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Operative Failures for Chronic Simple Glaucoma*
O P E R A T I V E F A I L U R E S FOR CHRONIC S I M P L E GLAUCOMA* A HISTOL« GIC STUDY BRITTAIN
F. PAYNE,
M.D.
New York A study of eyes removed after operative failures for chronic simple glaucoma shows that ideal surgical relief has not been de vised as far as the laboratory is concerned. The examination of approximately 100 op erated eyes with glaucoma at the New York Eye and Ear Infirmary showed at least three characteristics: (1) Adhesions between the iris and the cornea; (2) closure of new filtration channels with fibrosis ; and (3) inflammation of the uvea. Synechias between the anterior surface of the iris and the posterior surface of the cornea are composed of such dense connec tive tissue that permanent separation by op eration is almost impossible. The artificial filtration channel or channels become closed by the proliferation of connective tissue, despite an. iris inclusion in the operative wound. Progressive iridocyclitis usually re quires enucleation. Operations for glaucoma which illustrate the general microscopic findings of all globes sent to the laboratory for study are iridectomy, iridencleisis, and trephination. These eyes show in common the following characteristics. 1. Pathologic changes in the corneal epi thelium. 2. Thinning of the cornea and sciera. 3. Inflammation at the limbus. 4. Shallowness of the anterior chamber. 5. Adhesions of the iris to the cornea and lens. 6. Inflammation of the iris and ciliary body. 7. Changes in the crystalline lens. * Presented at the III Pan-American Congress of Ophthalmology, Havana, Cuba, January 4 to 10, 1948. From the Department of Pathology, New York Eye and Ear Infirmary and the N e w York University College of Medicine.
8. Pathologic depression of the optic nerve. 9. Atrophy of the ganglion cells of the retina. 10. Unusual findings in the vitreous body. The object of this paper is to show the causes of failures in the usual operations performed for the relief of chronic simple glaucoma. In order to show the histologie changes in the disease, it is necessary to re view briefly the microscopic anatomy of the normal globe. T H E NORMAL EYE
The eye is composed of a comparatively avascular fibrous tunic consisting of the cornea and sciera, both a millimeter or less in thickness, enclosing the uvea and the transparent contents of the globe. The
Fig. 1 (Payne). Normal globe. ( A )
Iris angle.
966
BRITTAIN F. PAYNE
Fig. 2 (Payne). Normal angle of the iris (A) enlarged.
Fig. 3 (Payne). Subacute glaucoma with shallow anterior chamber and peripheral anterior synechias.
lamina cribrosa is a continuation of the sciera to form a meshwork across the optic canal. A section of the cornea shows that it con sists of five layers and from without inward they are: the epithelial layer, Bowman's membrane, the stroma, Descemet's mem brane, and the endothelium. The normal cornea contains no blood vessels nor medullated nerve fibers. Corneal epithelium is unique in that it is visible throughout its five layers, including its most superficial squamous cells. Bowman's layer is a thin, homogenous, acellular layer lying immedi ately internal to the epithelium and serving as a basement membrane for it. It gradually fuses into the underlying stroma and be comes one of its components. The stroma consists of layers of specialized connective tissue, so interlaced that clean separation is impossible, and it forms nine tenths of the thickness of the cornea. Descemet's mem brane has an inner cuticular and an outer elastic component and is quite resistant to trauma or disease. The innermost endothelial lining consists of a single layer of flat tened cells which become quite thin over the
pectinate processes and the anterior surface of the iris. T H E LIMBUS CORNEAE
The limbus is a concentric segment meas uring 0.75 mm. anteroposteriorly at the junction of the cornea and sciera, and con taining characteristics of each. The fibrous tunic is reduced in thickness in this area by the indentation of the scierai sulcus exter nally and the scierai-furrow internally. The external sulcus is filled in with fine, loose aerolar connective tissue permeated by blood vessels which end in small capillary loops at the corneal margin. The surface is covered with thickened stratified squamous epithe lium, which is arranged in folds and is un dergoing transition to bulbar conjunctival epithelium. The scierai furrow or the inter nal depression of the limbus is filled in with a meridional meshwork of endothelialcovered strands known as the ligamentum pectinatum. Schlemm's canal is in close re lation to the outer bounds of the furrow. Anterior ciliary veins connect with the drainage channels which transport aqueous from the anterior chamber.
OPERATIVE FAILURES FOR CHRONIC GLAUCOMA T H E SCLERA
The sclera is that portion of the fibrous tunic which extends from the limbus corneae to the optic canal. It is composed of dense connective tissue and varies in thick ness from 1 mm. at the posterior pole to 0.5 mm. beneath the insertions of the extraocular muscles. For descriptive purposes, the sclera has three layers : the loose, mildly vascular episcleral connective tissue; the dense, almost avascular, areolar connective tissue forming the middle and greater thick ness of the structure; and the inner or "la mina fusca" which is only differentiated from the middle layer by chromatophores in its interspaces. The lamina cribrosa is a weblike continua tion of scierai fibers across the optic canal. It contains collagenous and elastic fibers in termingled with glial components. Normal horizontal sections through the optic nerve show that there is continuity in curvature of the cribriform plate corresponding to that of the sclera. It is evident that it is the weakest portion of the fibrous tunic and will be first to become distended by pressure from within the globe. T H E UVEA
The uvea consists of the choroid ciliary body and iris. The choroid may be described as the vascular layer lying just internal to the lamina fusca of the sclera. It is com posed of three ill-defined series of blood vessels as follows: An outer layer of largesized blood vessels, a middle layer of inter mediate-sized vessels, and an internal layer composed of a single row of capillaries ad jacent to the lamina vitrea of the choroid. Interspersed between these various layers of blood vessels are chromatophores and a fine reticulum of connective tissue and endothelial elements. The ciliary body is composed essentially of the same layers as the choroid, but differs in that the ciliary muscle is interposed. The ciliary muscle is made up of three parts;
967
an inner circular series of fibers connected with outer meridional fibers by a series of radiating fibers. The ciliary muscle gives size and shape to the ciliary body. Internal to the muscle layers are the continuations of the vascular choroidal layers with the excep tion of the choriocapillaris. The pigment epithelium is a continuation of the pigment epithelium of the retina and the ciliary epi thelium is the same as the retina reduced to a single layer of the nonpigmented cells. The principal blood and nerve supply is from the long posterior ciliary vessels and nerves. The iris may be divided into an anterior or mesodermal portion and a posterior or ectodermal derivative. The former consists of three ill-defined layers: the endothelium, the anterior border layer, and the vessel layer. The posterior portion of the iris is composed of a dilator pupillae and the pig ment epithelium of the iris. The anterior endothelium is peculiar in that its surface is abruptly broken at the margins of the crypts and aqueous is permitted to come into di rect contact with the stroma. The anterior border layer is characterized by a slight con densation of the fibrous tissue beneath the endothelium. The number of chromato phores contained in this layer determines the color of the iris, the more chromato phores, the darker the iris. The vessel layer of the stroma of the iris is composed of delicate, loose connective tissue supporting numerous blood vessels, which appear to have thickened walls. No elastic fibers are found in the iris except in the walls of the blood vessels and at its union with the cil iary body. The constrictor and dilator pu pillae muscles are derivative of the pigment epithelium and the latter forms the outer lead or the ectodermal portion of the iris. The constrictor is easily seen in most prepa rations but the dilator is thin and obscured by the pigment epithelium or the inner leaf of the iris. The circulation is through the radicals from the greater arterial circle, which lies in the anterior part of the ciliary
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BRITTAIN F. PAYNE
body and is supplied by the long posterior and anterior ciliary vessels. T H E RETINA
The retina is a thin transparent structure composed of nine layers, the outermost be ing the rods and cones and the innermost being the internal limiting membrane. It lies in apposition but not attached to the pig-
sels emerge. The fibers arrange themselves in the interstices of the cribriform plate and just posterior to it they assume medullation and become arranged into bundles. Pos terior to the globe, the nerve is covered by the pial and durai sheaths, with the arach noid lying between. At approximately 15 mm. posterior to the globe, the central reti nal vessels enter the nerve at right angles and proceed forward in its center to appear in the depression of the papilla. The bundles are so arranged that regular rows of nuclei from the septa follow a course parallel to the long axis of the nerve. The blood supply is from the vessels of the sheaths, the central vessels, and the circle of Zinn. CONTENTS OF THE NORMAL GLOBE
Fig. 4 (Payne). Iridectomy operation (A) shows stump of iris extending toward apex of cornea, adhesions remain.
ment epithelium, a single layer of cells sepa rating it from the choroid. The retina is an chored only at the ora serrata and around the margin of the optic disc. It has a dual blood supply, the inner five layers receiving nutrition from the central artery and accom panying vein. The outer four layers are sup plied by the choriocapillaris. The optic nerve begins with the papilla, a flat round projec tion just inside the globe measuring 1.5 mm. in diameter. It lies 1 mm. below and 3 mm. nasally to the posterior pole of the eye and corresponds to the intraocular portion of the nerve. The elevation is caused by an ac cumulation of nonmedullated nerve fibers from the ganglion cells of the retina. A cen tral depression lies on the surface. It is in this depression that the central retinal ves
The contents of the globe are aqueous hu mor, the crystalline lens, and the vitreous body. Under normal conditions, the aqueous does not appear in sections. The lens is often distorted in the process of fixation and staining. The vitreous may be displaced or compressed. In the presence of glaucoma, all three of these elements may show definite findings which contribute to the pathologic picture. The aqueous may show albuminous changes with cells and fibrin in suspension, the lens may be pushed forward and swol len, and the vitreous may contain fragments of pigment and other evidences of degen eration. IRIDECTOMY OPERATIONS
An eye (fig. 4) demonstrating most of the usual microscopic findings after un successful iridectomy operations shows gen eralized thinning of the fibrous tunic with edema and absence of the corneal epithe lium. The operative wound is closed by dense connective tissue in which some of the iris pigment remains. The stump of the iris extends toward the center of the cornea and is adherent to it, showing that the synechia is just as extensive as it was be fore the operation was performed. In other words, the normal iris angle is not restored
OPERATIVE FAILURES FOR CHRONIC GLAUCOMA
and the adhesions are not relieved. Further study of the specimen shows con siderable edema and round-cell infiltration at the limbus which extends into the op erative wound. The cornea is somewhat thinner than normal and the epithelium is undermined in the periphery, swollen and absent over the center. Bowman's membrane is intact except in the region of the limbus,
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A ^^ ^ H^ — I— L
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sure and fixation. The retina shows destruc tion of the ganglion cells, edema, and cystic degeneration. The crystalline lens has been removed but its enlarged and forward dis placed capsule remains. A fragment of iris lies on the anterior surface of the lens. Careful study of this specimen indicates that the iridectomy failed to create a new drainage channel and the synechias were
^ Tj
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969
/ -
# 1
V Fig. 5 (Payne). Iris inclusion (A) in operative wound; (L) crystalline lens; (S) anterior synechias.
where pannus is beginning to form. A mem brane is forming on the anterior surface of the iris, and the endothelium is covered with a thin layer of round cells, fibrin, and pigment particles. The sciera is thinner than normal and shows little of importance. The iris is characterized by atrophy, broad an terior peripheral synechias, and chronic in flammation. The iris stump extends far an terior to the filtration angle which has been closed by adhesions. The membrane form ing on the anterior surface of the iris, and contributing to the adhesions, has firmly sealed any possible connection with the nor mal drainage spaces. The ciliary body shows atrophie and inflammatory changes, and the choroid is flattened to a mere line by pres-
undisturbed. The presence of inflammation contributed to the loss of the eye. IRIDENCLEISIS OPERATION
An eye (fig. 5) removed after an unsuc cessful iris inclusion operation shows atrophie uveal tissue in the operative wound, a shallow anterior chamber, and definite lens changes. The fibrous tunic is distended and thinner than normal. The epithelium shows signs of edema and bullouslike formation near the operative wound. A more intensive examination of the sec tions shows that the iris is included in the bleb and that filtration is possible. There is sufficient space between the conjunct!val flap
970
BRITTAIN F. PAYNE
and the iris for aqueous drainage. Unfortu nately, the iris shows signs of chronic in flammation and firm diagonal adhesions, which unite the root.of the iris to the base of the flap. Instead of acting as a filtration "wick," the iris forms a firm band which dams the aqueous behind it. There is no re lief from increased intraocular pressure, which accounts for distention of the globe and formation of bullae on the cornea.
vessels with extravasations into the loose connective tissue. A small hemorrhage lies adjacent to the ciliary body. Diffuse lymphocytic infiltration and fibrotic changes com plete the picture. The iris on the side oppo site is drawn taut by its adhesion to the dis placed lens. It is atrophie and diffusely in filtrated with lymphocytes. The ciliary.body shares in the atrophie changes just men tioned.
Fig. 6 (Payne). Unsuccessful trephining operation showing (T) operative wound. The crystalline lens has moved in the di rection of the filtration cicatrix. It is saved from complete dislocation,by a firm adhe sion of the pupillary area of the iris to its anterior capsule. The iris itself is almost diamond shaped in cross section and shows evidence of nuclear sclerosis. Some of the contraction of the lens cortex is due to hardening agents. Displacement of the lens is a fairly common finding after operations for glaucoma. Most of the inflammatory changes in this specimen are in the vicinity of the operative wound. There is congestion of the blood
The eventual loss of this eye was due to the bandlike adhesion of the iris across the mouth of the operative wound, displacement of the lens, distention of the globe, and bullous keratitis. TREPHINATIONS
Eyes (figs. 6 and 7) enucleated after un successful trephinations may be illustrated by the description of a typical "failure." The specimen shows that ' the anterior chamber is shallow, the crystalline lens is swollen, and the operative wound is closed by fibrous tissue. The cornea is irregular in
OPERATIVE FAILURES FOR CHRONIC GLAUCOMA thickness. The epithelium is slightly under mined by new blood vessels and connective tissue at the limbus. The stroma is moder ately infiltrated in the periphery. Descemet's membrane is curled in itself near the op erative wound, and the endothelium is cov ered with a thin layer of fibrin. The opera tive wound is closed by dense connective tis
971
the eye was due to fibrotic changes in the wound and close approximation of the lens. CONCLUSIONS
1. Common pathologic changes are pres ent in eyes removed after operative fail ures for chronic simple glaucoma. 2. Comparing the histology of normal
Fig. 7 (Payne). Operative failure after trephining operation, (T) showing herniation of crystalline lens. sue containing fragments of pigment, lymphocytes, and new blood vessels. The filtering cicatrix contains fresh hemorrhage. The iris is atrophie and is closely adherent to the cornea and lens on the unoperated side. An iridotomy has been performed as is shown by a part of the iris lying in the wound. The ciliary body and the choroid show atrophie changes with congestion of the blood vessels. The retina is undergoing degenerative changes with diffuse hemor rhage in its innermost layers. The crystal line lens shows cortical cataractous changes with nuclear sclerosis. The lens is in close relation to the filtration wound. The loss of
eyes with that in chronic simple glaucoma may show the causes of operative failures. 3. Failure of the iridectomy operation may be due to persistence of synechias and not removing the iris at its roots. 4. Iris-inclusion operations may be closed by the iris itself. 5. Trephinations may become closed by fibrotic and inflammatory changes. 6. Specimens reviewed in the laboratory are operative failures. 7. Successful operations for glaucoma are not reviewed in the laboratory and far exceed the "failures." 17 East 72nd Street (21).
F. PAYNE,
M.D.
New York A study of eyes removed after operative failures for chronic simple glaucoma shows that ideal surgical relief has not been de vised as far as the laboratory is concerned. The examination of approximately 100 op erated eyes with glaucoma at the New York Eye and Ear Infirmary showed at least three characteristics: (1) Adhesions between the iris and the cornea; (2) closure of new filtration channels with fibrosis ; and (3) inflammation of the uvea. Synechias between the anterior surface of the iris and the posterior surface of the cornea are composed of such dense connec tive tissue that permanent separation by op eration is almost impossible. The artificial filtration channel or channels become closed by the proliferation of connective tissue, despite an. iris inclusion in the operative wound. Progressive iridocyclitis usually re quires enucleation. Operations for glaucoma which illustrate the general microscopic findings of all globes sent to the laboratory for study are iridectomy, iridencleisis, and trephination. These eyes show in common the following characteristics. 1. Pathologic changes in the corneal epi thelium. 2. Thinning of the cornea and sciera. 3. Inflammation at the limbus. 4. Shallowness of the anterior chamber. 5. Adhesions of the iris to the cornea and lens. 6. Inflammation of the iris and ciliary body. 7. Changes in the crystalline lens. * Presented at the III Pan-American Congress of Ophthalmology, Havana, Cuba, January 4 to 10, 1948. From the Department of Pathology, New York Eye and Ear Infirmary and the N e w York University College of Medicine.
8. Pathologic depression of the optic nerve. 9. Atrophy of the ganglion cells of the retina. 10. Unusual findings in the vitreous body. The object of this paper is to show the causes of failures in the usual operations performed for the relief of chronic simple glaucoma. In order to show the histologie changes in the disease, it is necessary to re view briefly the microscopic anatomy of the normal globe. T H E NORMAL EYE
The eye is composed of a comparatively avascular fibrous tunic consisting of the cornea and sciera, both a millimeter or less in thickness, enclosing the uvea and the transparent contents of the globe. The
Fig. 1 (Payne). Normal globe. ( A )
Iris angle.
966
BRITTAIN F. PAYNE
Fig. 2 (Payne). Normal angle of the iris (A) enlarged.
Fig. 3 (Payne). Subacute glaucoma with shallow anterior chamber and peripheral anterior synechias.
lamina cribrosa is a continuation of the sciera to form a meshwork across the optic canal. A section of the cornea shows that it con sists of five layers and from without inward they are: the epithelial layer, Bowman's membrane, the stroma, Descemet's mem brane, and the endothelium. The normal cornea contains no blood vessels nor medullated nerve fibers. Corneal epithelium is unique in that it is visible throughout its five layers, including its most superficial squamous cells. Bowman's layer is a thin, homogenous, acellular layer lying immedi ately internal to the epithelium and serving as a basement membrane for it. It gradually fuses into the underlying stroma and be comes one of its components. The stroma consists of layers of specialized connective tissue, so interlaced that clean separation is impossible, and it forms nine tenths of the thickness of the cornea. Descemet's mem brane has an inner cuticular and an outer elastic component and is quite resistant to trauma or disease. The innermost endothelial lining consists of a single layer of flat tened cells which become quite thin over the
pectinate processes and the anterior surface of the iris. T H E LIMBUS CORNEAE
The limbus is a concentric segment meas uring 0.75 mm. anteroposteriorly at the junction of the cornea and sciera, and con taining characteristics of each. The fibrous tunic is reduced in thickness in this area by the indentation of the scierai sulcus exter nally and the scierai-furrow internally. The external sulcus is filled in with fine, loose aerolar connective tissue permeated by blood vessels which end in small capillary loops at the corneal margin. The surface is covered with thickened stratified squamous epithe lium, which is arranged in folds and is un dergoing transition to bulbar conjunctival epithelium. The scierai furrow or the inter nal depression of the limbus is filled in with a meridional meshwork of endothelialcovered strands known as the ligamentum pectinatum. Schlemm's canal is in close re lation to the outer bounds of the furrow. Anterior ciliary veins connect with the drainage channels which transport aqueous from the anterior chamber.
OPERATIVE FAILURES FOR CHRONIC GLAUCOMA T H E SCLERA
The sclera is that portion of the fibrous tunic which extends from the limbus corneae to the optic canal. It is composed of dense connective tissue and varies in thick ness from 1 mm. at the posterior pole to 0.5 mm. beneath the insertions of the extraocular muscles. For descriptive purposes, the sclera has three layers : the loose, mildly vascular episcleral connective tissue; the dense, almost avascular, areolar connective tissue forming the middle and greater thick ness of the structure; and the inner or "la mina fusca" which is only differentiated from the middle layer by chromatophores in its interspaces. The lamina cribrosa is a weblike continua tion of scierai fibers across the optic canal. It contains collagenous and elastic fibers in termingled with glial components. Normal horizontal sections through the optic nerve show that there is continuity in curvature of the cribriform plate corresponding to that of the sclera. It is evident that it is the weakest portion of the fibrous tunic and will be first to become distended by pressure from within the globe. T H E UVEA
The uvea consists of the choroid ciliary body and iris. The choroid may be described as the vascular layer lying just internal to the lamina fusca of the sclera. It is com posed of three ill-defined series of blood vessels as follows: An outer layer of largesized blood vessels, a middle layer of inter mediate-sized vessels, and an internal layer composed of a single row of capillaries ad jacent to the lamina vitrea of the choroid. Interspersed between these various layers of blood vessels are chromatophores and a fine reticulum of connective tissue and endothelial elements. The ciliary body is composed essentially of the same layers as the choroid, but differs in that the ciliary muscle is interposed. The ciliary muscle is made up of three parts;
967
an inner circular series of fibers connected with outer meridional fibers by a series of radiating fibers. The ciliary muscle gives size and shape to the ciliary body. Internal to the muscle layers are the continuations of the vascular choroidal layers with the excep tion of the choriocapillaris. The pigment epithelium is a continuation of the pigment epithelium of the retina and the ciliary epi thelium is the same as the retina reduced to a single layer of the nonpigmented cells. The principal blood and nerve supply is from the long posterior ciliary vessels and nerves. The iris may be divided into an anterior or mesodermal portion and a posterior or ectodermal derivative. The former consists of three ill-defined layers: the endothelium, the anterior border layer, and the vessel layer. The posterior portion of the iris is composed of a dilator pupillae and the pig ment epithelium of the iris. The anterior endothelium is peculiar in that its surface is abruptly broken at the margins of the crypts and aqueous is permitted to come into di rect contact with the stroma. The anterior border layer is characterized by a slight con densation of the fibrous tissue beneath the endothelium. The number of chromato phores contained in this layer determines the color of the iris, the more chromato phores, the darker the iris. The vessel layer of the stroma of the iris is composed of delicate, loose connective tissue supporting numerous blood vessels, which appear to have thickened walls. No elastic fibers are found in the iris except in the walls of the blood vessels and at its union with the cil iary body. The constrictor and dilator pu pillae muscles are derivative of the pigment epithelium and the latter forms the outer lead or the ectodermal portion of the iris. The constrictor is easily seen in most prepa rations but the dilator is thin and obscured by the pigment epithelium or the inner leaf of the iris. The circulation is through the radicals from the greater arterial circle, which lies in the anterior part of the ciliary
968
BRITTAIN F. PAYNE
body and is supplied by the long posterior and anterior ciliary vessels. T H E RETINA
The retina is a thin transparent structure composed of nine layers, the outermost be ing the rods and cones and the innermost being the internal limiting membrane. It lies in apposition but not attached to the pig-
sels emerge. The fibers arrange themselves in the interstices of the cribriform plate and just posterior to it they assume medullation and become arranged into bundles. Pos terior to the globe, the nerve is covered by the pial and durai sheaths, with the arach noid lying between. At approximately 15 mm. posterior to the globe, the central reti nal vessels enter the nerve at right angles and proceed forward in its center to appear in the depression of the papilla. The bundles are so arranged that regular rows of nuclei from the septa follow a course parallel to the long axis of the nerve. The blood supply is from the vessels of the sheaths, the central vessels, and the circle of Zinn. CONTENTS OF THE NORMAL GLOBE
Fig. 4 (Payne). Iridectomy operation (A) shows stump of iris extending toward apex of cornea, adhesions remain.
ment epithelium, a single layer of cells sepa rating it from the choroid. The retina is an chored only at the ora serrata and around the margin of the optic disc. It has a dual blood supply, the inner five layers receiving nutrition from the central artery and accom panying vein. The outer four layers are sup plied by the choriocapillaris. The optic nerve begins with the papilla, a flat round projec tion just inside the globe measuring 1.5 mm. in diameter. It lies 1 mm. below and 3 mm. nasally to the posterior pole of the eye and corresponds to the intraocular portion of the nerve. The elevation is caused by an ac cumulation of nonmedullated nerve fibers from the ganglion cells of the retina. A cen tral depression lies on the surface. It is in this depression that the central retinal ves
The contents of the globe are aqueous hu mor, the crystalline lens, and the vitreous body. Under normal conditions, the aqueous does not appear in sections. The lens is often distorted in the process of fixation and staining. The vitreous may be displaced or compressed. In the presence of glaucoma, all three of these elements may show definite findings which contribute to the pathologic picture. The aqueous may show albuminous changes with cells and fibrin in suspension, the lens may be pushed forward and swol len, and the vitreous may contain fragments of pigment and other evidences of degen eration. IRIDECTOMY OPERATIONS
An eye (fig. 4) demonstrating most of the usual microscopic findings after un successful iridectomy operations shows gen eralized thinning of the fibrous tunic with edema and absence of the corneal epithe lium. The operative wound is closed by dense connective tissue in which some of the iris pigment remains. The stump of the iris extends toward the center of the cornea and is adherent to it, showing that the synechia is just as extensive as it was be fore the operation was performed. In other words, the normal iris angle is not restored
OPERATIVE FAILURES FOR CHRONIC GLAUCOMA
and the adhesions are not relieved. Further study of the specimen shows con siderable edema and round-cell infiltration at the limbus which extends into the op erative wound. The cornea is somewhat thinner than normal and the epithelium is undermined in the periphery, swollen and absent over the center. Bowman's membrane is intact except in the region of the limbus,
I
f/i
\
*"
M:
A ^^ ^ H^ — I— L
• \
Wt
sure and fixation. The retina shows destruc tion of the ganglion cells, edema, and cystic degeneration. The crystalline lens has been removed but its enlarged and forward dis placed capsule remains. A fragment of iris lies on the anterior surface of the lens. Careful study of this specimen indicates that the iridectomy failed to create a new drainage channel and the synechias were
^ Tj
s—-^m ^^r
969
/ -
# 1
V Fig. 5 (Payne). Iris inclusion (A) in operative wound; (L) crystalline lens; (S) anterior synechias.
where pannus is beginning to form. A mem brane is forming on the anterior surface of the iris, and the endothelium is covered with a thin layer of round cells, fibrin, and pigment particles. The sciera is thinner than normal and shows little of importance. The iris is characterized by atrophy, broad an terior peripheral synechias, and chronic in flammation. The iris stump extends far an terior to the filtration angle which has been closed by adhesions. The membrane form ing on the anterior surface of the iris, and contributing to the adhesions, has firmly sealed any possible connection with the nor mal drainage spaces. The ciliary body shows atrophie and inflammatory changes, and the choroid is flattened to a mere line by pres-
undisturbed. The presence of inflammation contributed to the loss of the eye. IRIDENCLEISIS OPERATION
An eye (fig. 5) removed after an unsuc cessful iris inclusion operation shows atrophie uveal tissue in the operative wound, a shallow anterior chamber, and definite lens changes. The fibrous tunic is distended and thinner than normal. The epithelium shows signs of edema and bullouslike formation near the operative wound. A more intensive examination of the sec tions shows that the iris is included in the bleb and that filtration is possible. There is sufficient space between the conjunct!val flap
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BRITTAIN F. PAYNE
and the iris for aqueous drainage. Unfortu nately, the iris shows signs of chronic in flammation and firm diagonal adhesions, which unite the root.of the iris to the base of the flap. Instead of acting as a filtration "wick," the iris forms a firm band which dams the aqueous behind it. There is no re lief from increased intraocular pressure, which accounts for distention of the globe and formation of bullae on the cornea.
vessels with extravasations into the loose connective tissue. A small hemorrhage lies adjacent to the ciliary body. Diffuse lymphocytic infiltration and fibrotic changes com plete the picture. The iris on the side oppo site is drawn taut by its adhesion to the dis placed lens. It is atrophie and diffusely in filtrated with lymphocytes. The ciliary.body shares in the atrophie changes just men tioned.
Fig. 6 (Payne). Unsuccessful trephining operation showing (T) operative wound. The crystalline lens has moved in the di rection of the filtration cicatrix. It is saved from complete dislocation,by a firm adhe sion of the pupillary area of the iris to its anterior capsule. The iris itself is almost diamond shaped in cross section and shows evidence of nuclear sclerosis. Some of the contraction of the lens cortex is due to hardening agents. Displacement of the lens is a fairly common finding after operations for glaucoma. Most of the inflammatory changes in this specimen are in the vicinity of the operative wound. There is congestion of the blood
The eventual loss of this eye was due to the bandlike adhesion of the iris across the mouth of the operative wound, displacement of the lens, distention of the globe, and bullous keratitis. TREPHINATIONS
Eyes (figs. 6 and 7) enucleated after un successful trephinations may be illustrated by the description of a typical "failure." The specimen shows that ' the anterior chamber is shallow, the crystalline lens is swollen, and the operative wound is closed by fibrous tissue. The cornea is irregular in
OPERATIVE FAILURES FOR CHRONIC GLAUCOMA thickness. The epithelium is slightly under mined by new blood vessels and connective tissue at the limbus. The stroma is moder ately infiltrated in the periphery. Descemet's membrane is curled in itself near the op erative wound, and the endothelium is cov ered with a thin layer of fibrin. The opera tive wound is closed by dense connective tis
971
the eye was due to fibrotic changes in the wound and close approximation of the lens. CONCLUSIONS
1. Common pathologic changes are pres ent in eyes removed after operative fail ures for chronic simple glaucoma. 2. Comparing the histology of normal
Fig. 7 (Payne). Operative failure after trephining operation, (T) showing herniation of crystalline lens. sue containing fragments of pigment, lymphocytes, and new blood vessels. The filtering cicatrix contains fresh hemorrhage. The iris is atrophie and is closely adherent to the cornea and lens on the unoperated side. An iridotomy has been performed as is shown by a part of the iris lying in the wound. The ciliary body and the choroid show atrophie changes with congestion of the blood vessels. The retina is undergoing degenerative changes with diffuse hemor rhage in its innermost layers. The crystal line lens shows cortical cataractous changes with nuclear sclerosis. The lens is in close relation to the filtration wound. The loss of
eyes with that in chronic simple glaucoma may show the causes of operative failures. 3. Failure of the iridectomy operation may be due to persistence of synechias and not removing the iris at its roots. 4. Iris-inclusion operations may be closed by the iris itself. 5. Trephinations may become closed by fibrotic and inflammatory changes. 6. Specimens reviewed in the laboratory are operative failures. 7. Successful operations for glaucoma are not reviewed in the laboratory and far exceed the "failures." 17 East 72nd Street (21).