- Email: [email protected]
Glaucoma—Sclerectomy, External and Suprachoroidal Drainage
1146
NOTES, CASES, INSTRUMENTS
GLAUCOMA—SCLERECTOMY, EXTERNAL AND SUPRACHOROIDAL DRAINAGE OTIS R. WOLFE, M.D.,
RUSSELL M.
WOLFE, L T . (M.C.) A.U.S., AND PIERRE GEORGARIOU,
M.D.
Marshalltown, Iowa No one surgical technique can meet all requirements of glaucoma. For acute glaucoma we still rely on basal iridectomy. For the wide-angle noninflammatory types, seen early, we have favored the Elliot trephine. For protracted glaucoma not yielding to those mentioned we have preferred our Seton drainage technique.1 A sclerectomy with the aid of the punch has also frequently been used. In addi tion we have reported two cases operated on by the Troncoso method.2 Since 1920, in selected cases of cataract surgery in which glaucoma was coexistent, the senior author has used a modified punch sclerectomy.3 The technique is essentially the same as here described except that for cataract we employ a larger corneal sec tion. The results have impressed us very favorably, especially when glaucoma and cataract were coexistent. Frequently ten sion is considerably reduced following intracapsular extraction alone, but more especially if combined with this method. Consequently, when miotics fail to con trol the tension we have more and more favored early intracapsular extraction plus the sclerectomy, rather than pre liminary iridectomy and extracapsular ex traction.4 Surgery, of a cyclodialysis type, for the purpose of obtaining suprachoroidal drainage, if it could be maintained, seems nearest to the ideal. In the narrowangle type of glaucoma, with a history of clinical evidence of uveal disease, we have been highly impressed with the results of this modified Lagrange technique per formed to obtain both external filtration and suprachoroidal drainage. In 14 cases
of the narrow-angle type in which the lens was clear, or nearly clear, we have used the technique described herein. These were cases with advanced surgical indications.* A broad conjunctival flap is dissected down to the limbus under Tenon's cap sule if possible. Two silk sutures are placed first through the conjunctiva, then anchored in the sclera very close to the limbus and laid to one side. A keratome incision is made at the limbus (fig. 1). This incision is enlarged by Wilder scis sors along the limbus from the 10:30- to the 1:30-o'clock position. If the lens is to be extracted, the corneal incision is car ried on with the scissors from 3 to 9 o'clock. The silk suture is then passed from underneath through the conjunc tival flap exactly at the junction of the cornea and conjunctiva. A loop is made on each side and laid aside. Next the cyclodialysis is performed, sweeping the angled Green iris repositor from 10:30 to 1:30 o'clock (fig. 2). In performing a cyclodialysis, it is well to remember the histology of the ciliary body. In the choroid, the delicate lamellae of the epichoroid permit a potential space to exist, the perichoroidal space. Ante riorly, the lamellae disappear into the ciliary muscle so that there is no peri choroidal space in the region of the ciliary body. The width of the ciliary body, ac cording to Salzmann,5 is 4.6 mm. to 5.2 mm. nasally, and 5.6 mm. to 6.3 mm. temporally. However, one should allow about 8 mm. from the limbus to be certain of extending beyond the ora serrata. It is probably not enough, then, merely to detach the ciliary body from the scleral spur. Anatomy of the iris shows it arises not from scleral spur or limbus but from the anterior end of the ciliary body, so a * Four additional patients have been satisfac torily operated on since this paper was sub mitted for publication.
NOTES, CASES, INSTRUMENTS
1147
Figs. 1 to 4 (Wolfe, Wolfe, and Georgariou). Modified Lagrange sclerectomy with cyclodialysis. Fig. 1. A broad conjunctival flap dissected well down to the limbus under Tenon's capsule and episclera if possible. Two scleral sutures are inserted in sclera near limbus at the 1- and 11-o'clock positions. A keratome incision is made at the limbus and completed with scissors from 10:30 to 1:30 o'clock. For cataract the scissors section is to 3 and 9 o'clock. Fig. 2. The curved end of the Green iris repositor is inserted under the scleral margin of the section and the ciliary body is separated from its insertion at the scleral spur. For glaucoma the corneal section extends only from about 10 :30 to 1:30 o'clock, and not so large as illustrated in figures 1, 2, 4, and 5. Fig. 3. The straight end of the marked Green iris repositor is then inserted and the ciliary body
1148
NOTES, CASES, INSTRUMENTS
true cyclodialysis would not touch the iris. T o be certain of contacting the perichoroidal space, the dissection must be carried back behind the ora serrata. Only then may one be certain of having per formed a true cyclodialysis. However, following the use of the angled Green iris repositor (fig. 3) the straight end is employed to complete the cyclodialysis (fig. 4 ) . T h e straight tip has lines every 2 mm. from the tip to help in estimating depth. If the lens is to be removed it is done at this time intracapsularly. Then the scleral lip of the wound is picked up with a hook and a sclerectomy is i per formed with a Holth punch, to accom plish a modified Lagrange operation. D r . Ramon Castroviejo also uses such a punch technique. 6 Any scleral tags are cut smooth. If the iris bulges it is merely snipped without the forceps. ( A com plete iridectomy is performed for the
cataract extraction.) T h e two looped su tures are then d r a w n up and tied. F o u r to six additional conjunctival sutures are used to obtain better closure. A n underand-over continuous watertight suture can be utilized for this last step. Post operative hyperemia has been moderate. Dressings on the second day demonstrate external filtration under the flap with partially restored anterior chambers and abated tension. Only one patient had pro longed hypotension. SUMMARY
This is a preliminary report of a method of modified Lagrange sclerectomy combined with cyclodialysis to obtain suprachoroidal drainage plus external filtration. T h e technique is essentially the same with or without cataract extraction. In 18 cases the method has given satis factory results, and its wider use seems to be indicated in selected cases.
REFERENCES 1
Wolfe, O. R., and Blaess, M. J. Seton operation in glaucoma. Amer. Jour. Ophth., 1936, v. 19, May, no. 5. Wolfe, O. R., and Wolfe, R. M. Troncoso magnesium implant and Seton operation used on the same patient. Amer. Jour. Ophth., 1940, v. 23, Aug., no. 8. 3 Wolfe, O. R. Intracapsular extraction of cataract by the Barraquer method. Jour. Iowa State Med. Soc, 1925, Nov. . Barraquer cataract operation (modified). Trans. 35th annual meeting of Amer. Acad. Ophth. and Otolaryn., 1930, pp. 259-270 and 467-468. 4 Wolfe, O. R., and Wolfe, R. M. Barraquer technique in incipient cataract and glaucoma. Jour. Intern. Coll. of Surg., 1943, July-August. 5 Salzmann, M. The anatomy and histology of the human eyeball in the normal state (transl. E. V. L. Brown), 1912, p. 107. "Castroviejo, Ramon. Personal observation. 2
is dissected free of the sclera to a point just beyond the ora serrata, thus assuring contact with the perichoroidal space. Repositor has graduated scale every 2 mm. to gauge depth. An iridotomy or iridectomy is performed as indicated. Fig. 4. Either preceding or at this stage a silk scleral suture is passed through the corneal flap at the exact junction of cornea and conjunctiva, is looped and laid aside. By holding the scleral lip with a hook, a modified Lagrange sclerectomy is performed with Holth punch. (If cataract is removed, the sclerectomy is the last step before closing flap.) Fig. 5. Schematic. The two scleral limbal sutures are drawn up and tied. Where a broad conjunctival flap is used a double-needled suture is brought out through the conjunctiva at the limbus instead, as illustrated in figures 3 and 4. Additional conjunctival or a continuous watertight suture is used. Black dot indicates site of sclerectomy giving external drainage. Dotted line indi cates area of cyclodialysis.
NOTES, CASES, INSTRUMENTS
GLAUCOMA—SCLERECTOMY, EXTERNAL AND SUPRACHOROIDAL DRAINAGE OTIS R. WOLFE, M.D.,
RUSSELL M.
WOLFE, L T . (M.C.) A.U.S., AND PIERRE GEORGARIOU,
M.D.
Marshalltown, Iowa No one surgical technique can meet all requirements of glaucoma. For acute glaucoma we still rely on basal iridectomy. For the wide-angle noninflammatory types, seen early, we have favored the Elliot trephine. For protracted glaucoma not yielding to those mentioned we have preferred our Seton drainage technique.1 A sclerectomy with the aid of the punch has also frequently been used. In addi tion we have reported two cases operated on by the Troncoso method.2 Since 1920, in selected cases of cataract surgery in which glaucoma was coexistent, the senior author has used a modified punch sclerectomy.3 The technique is essentially the same as here described except that for cataract we employ a larger corneal sec tion. The results have impressed us very favorably, especially when glaucoma and cataract were coexistent. Frequently ten sion is considerably reduced following intracapsular extraction alone, but more especially if combined with this method. Consequently, when miotics fail to con trol the tension we have more and more favored early intracapsular extraction plus the sclerectomy, rather than pre liminary iridectomy and extracapsular ex traction.4 Surgery, of a cyclodialysis type, for the purpose of obtaining suprachoroidal drainage, if it could be maintained, seems nearest to the ideal. In the narrowangle type of glaucoma, with a history of clinical evidence of uveal disease, we have been highly impressed with the results of this modified Lagrange technique per formed to obtain both external filtration and suprachoroidal drainage. In 14 cases
of the narrow-angle type in which the lens was clear, or nearly clear, we have used the technique described herein. These were cases with advanced surgical indications.* A broad conjunctival flap is dissected down to the limbus under Tenon's cap sule if possible. Two silk sutures are placed first through the conjunctiva, then anchored in the sclera very close to the limbus and laid to one side. A keratome incision is made at the limbus (fig. 1). This incision is enlarged by Wilder scis sors along the limbus from the 10:30- to the 1:30-o'clock position. If the lens is to be extracted, the corneal incision is car ried on with the scissors from 3 to 9 o'clock. The silk suture is then passed from underneath through the conjunc tival flap exactly at the junction of the cornea and conjunctiva. A loop is made on each side and laid aside. Next the cyclodialysis is performed, sweeping the angled Green iris repositor from 10:30 to 1:30 o'clock (fig. 2). In performing a cyclodialysis, it is well to remember the histology of the ciliary body. In the choroid, the delicate lamellae of the epichoroid permit a potential space to exist, the perichoroidal space. Ante riorly, the lamellae disappear into the ciliary muscle so that there is no peri choroidal space in the region of the ciliary body. The width of the ciliary body, ac cording to Salzmann,5 is 4.6 mm. to 5.2 mm. nasally, and 5.6 mm. to 6.3 mm. temporally. However, one should allow about 8 mm. from the limbus to be certain of extending beyond the ora serrata. It is probably not enough, then, merely to detach the ciliary body from the scleral spur. Anatomy of the iris shows it arises not from scleral spur or limbus but from the anterior end of the ciliary body, so a * Four additional patients have been satisfac torily operated on since this paper was sub mitted for publication.
NOTES, CASES, INSTRUMENTS
1147
Figs. 1 to 4 (Wolfe, Wolfe, and Georgariou). Modified Lagrange sclerectomy with cyclodialysis. Fig. 1. A broad conjunctival flap dissected well down to the limbus under Tenon's capsule and episclera if possible. Two scleral sutures are inserted in sclera near limbus at the 1- and 11-o'clock positions. A keratome incision is made at the limbus and completed with scissors from 10:30 to 1:30 o'clock. For cataract the scissors section is to 3 and 9 o'clock. Fig. 2. The curved end of the Green iris repositor is inserted under the scleral margin of the section and the ciliary body is separated from its insertion at the scleral spur. For glaucoma the corneal section extends only from about 10 :30 to 1:30 o'clock, and not so large as illustrated in figures 1, 2, 4, and 5. Fig. 3. The straight end of the marked Green iris repositor is then inserted and the ciliary body
1148
NOTES, CASES, INSTRUMENTS
true cyclodialysis would not touch the iris. T o be certain of contacting the perichoroidal space, the dissection must be carried back behind the ora serrata. Only then may one be certain of having per formed a true cyclodialysis. However, following the use of the angled Green iris repositor (fig. 3) the straight end is employed to complete the cyclodialysis (fig. 4 ) . T h e straight tip has lines every 2 mm. from the tip to help in estimating depth. If the lens is to be removed it is done at this time intracapsularly. Then the scleral lip of the wound is picked up with a hook and a sclerectomy is i per formed with a Holth punch, to accom plish a modified Lagrange operation. D r . Ramon Castroviejo also uses such a punch technique. 6 Any scleral tags are cut smooth. If the iris bulges it is merely snipped without the forceps. ( A com plete iridectomy is performed for the
cataract extraction.) T h e two looped su tures are then d r a w n up and tied. F o u r to six additional conjunctival sutures are used to obtain better closure. A n underand-over continuous watertight suture can be utilized for this last step. Post operative hyperemia has been moderate. Dressings on the second day demonstrate external filtration under the flap with partially restored anterior chambers and abated tension. Only one patient had pro longed hypotension. SUMMARY
This is a preliminary report of a method of modified Lagrange sclerectomy combined with cyclodialysis to obtain suprachoroidal drainage plus external filtration. T h e technique is essentially the same with or without cataract extraction. In 18 cases the method has given satis factory results, and its wider use seems to be indicated in selected cases.
REFERENCES 1
Wolfe, O. R., and Blaess, M. J. Seton operation in glaucoma. Amer. Jour. Ophth., 1936, v. 19, May, no. 5. Wolfe, O. R., and Wolfe, R. M. Troncoso magnesium implant and Seton operation used on the same patient. Amer. Jour. Ophth., 1940, v. 23, Aug., no. 8. 3 Wolfe, O. R. Intracapsular extraction of cataract by the Barraquer method. Jour. Iowa State Med. Soc, 1925, Nov. . Barraquer cataract operation (modified). Trans. 35th annual meeting of Amer. Acad. Ophth. and Otolaryn., 1930, pp. 259-270 and 467-468. 4 Wolfe, O. R., and Wolfe, R. M. Barraquer technique in incipient cataract and glaucoma. Jour. Intern. Coll. of Surg., 1943, July-August. 5 Salzmann, M. The anatomy and histology of the human eyeball in the normal state (transl. E. V. L. Brown), 1912, p. 107. "Castroviejo, Ramon. Personal observation. 2
is dissected free of the sclera to a point just beyond the ora serrata, thus assuring contact with the perichoroidal space. Repositor has graduated scale every 2 mm. to gauge depth. An iridotomy or iridectomy is performed as indicated. Fig. 4. Either preceding or at this stage a silk scleral suture is passed through the corneal flap at the exact junction of cornea and conjunctiva, is looped and laid aside. By holding the scleral lip with a hook, a modified Lagrange sclerectomy is performed with Holth punch. (If cataract is removed, the sclerectomy is the last step before closing flap.) Fig. 5. Schematic. The two scleral limbal sutures are drawn up and tied. Where a broad conjunctival flap is used a double-needled suture is brought out through the conjunctiva at the limbus instead, as illustrated in figures 3 and 4. Additional conjunctival or a continuous watertight suture is used. Black dot indicates site of sclerectomy giving external drainage. Dotted line indi cates area of cyclodialysis.