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Subconjunctival Cortisone in Iris-Inclusion Surgery
NOTES, CASES, INSTRUMENTS SUBCONJUNCTIVAL CORTISONE IN IRIS-INCLUSION SURGERY GEORGE J. W Y M A N , M.D.,
AND E.
E.
HOLLINGSHEAD, D.V.M. Peoria, Illinois
Since one of the effects of cortisone is to inhibit the production of fibroplastic prolif eration, it would seem to be indicated in any filtering operation for glaucoma, where fi brous tissue is especially undesirable. We have been using cortisone drops topically fol lowing iris inclusion with no noticeable ef fect. Having used cortisone subconjunctivally for various eye conditions it was thought worth while to run a controlled ex periment on dogs. The following experiment was then performed. ANIMAL
EXPERIMENT
Four puppies, weighing about five pounds each, were anesthetized with intravenous nembutal. A conjunctival flap was dissected down to the limbus and the anterior chamber entered with a keratome. The iris was pulled out, a portion cut off, and the remaining iris pillar was left in the wound. The conjunctiva was sutured with a running 5-0 plain gut suture. Identical op erations were done on all of the eyes. At the completion of the procedure, the right eye of each dog received a subconjunctival injection of cortisone containing 25 mg. per cc. The usual amount injected was about 0.3 of a cc. Every two or three days thereafter, under topical anesthesia, an injection of cortisone solution was made with a fine needle under the flap in the right eyes, and the results observed. The dogs were killed at two, four, six, and eight weeks and both eyes were re moved for sectioning. Unfortunately, the eyes were excised with considerable neighboring tissue and cellodion fixation was not good. As a result the sec tions had to be switched to paraffin and final sections were so distorted that they were of
no value. Hence, only clinical observations will be recorded. Without exception all the eyes receiving the cortisone injections were more congested and showed more corneal edema than the controls. This is at variance with the idea of inhibition of inflammatory reaction by the drug. At the end of the 10 days, three of the eyes had an open wound as evidenced by the solu tion leaking from it and in one eye this per sisted for three weeks. The haziness of the cornea vanished by the end of the first five days in all of the injected eyes. At two weeks, when the first dog was killed, the cortisone-treated eye had a firm adherent mass at the operative site with the inclusion area itself not well demarcated. The control eye on the contrary had a clean iris prolapse with a slight bleb. By the fourth week, when the second dog was killed, the treated eye had a firm nodule at the site of the surgery and considerable scarring of the conjunctiva about it so that on injection of the solution it was difficult to get into the immediate area. The next four weeks only made the findings more evident, as the untreated eyes, although not showing active filtering scars, had clean prolapses cov ered with conjunctiva and a minimum of re action or new vessels. The treated eyes, on the contrary, had much new scar tissue, ad herence of conjunctiva to sclera, and new vessels. CONCLUSION
As a result of using subconjunctival cor tisone after iris-inclusion operations in dogs, the amount of vascularization and fibrous tissue proliferation in the treated eyes was definitely and without exception much more marked than the control eyes. Subconjuncti val cortisone would appear contraindicated after any type of filtering operation. 744 Jefferson Building (2). Acknowledgement is made to Merck & Company who contributed the Cortone in the experiment.
AND E.
E.
HOLLINGSHEAD, D.V.M. Peoria, Illinois
Since one of the effects of cortisone is to inhibit the production of fibroplastic prolif eration, it would seem to be indicated in any filtering operation for glaucoma, where fi brous tissue is especially undesirable. We have been using cortisone drops topically fol lowing iris inclusion with no noticeable ef fect. Having used cortisone subconjunctivally for various eye conditions it was thought worth while to run a controlled ex periment on dogs. The following experiment was then performed. ANIMAL
EXPERIMENT
Four puppies, weighing about five pounds each, were anesthetized with intravenous nembutal. A conjunctival flap was dissected down to the limbus and the anterior chamber entered with a keratome. The iris was pulled out, a portion cut off, and the remaining iris pillar was left in the wound. The conjunctiva was sutured with a running 5-0 plain gut suture. Identical op erations were done on all of the eyes. At the completion of the procedure, the right eye of each dog received a subconjunctival injection of cortisone containing 25 mg. per cc. The usual amount injected was about 0.3 of a cc. Every two or three days thereafter, under topical anesthesia, an injection of cortisone solution was made with a fine needle under the flap in the right eyes, and the results observed. The dogs were killed at two, four, six, and eight weeks and both eyes were re moved for sectioning. Unfortunately, the eyes were excised with considerable neighboring tissue and cellodion fixation was not good. As a result the sec tions had to be switched to paraffin and final sections were so distorted that they were of
no value. Hence, only clinical observations will be recorded. Without exception all the eyes receiving the cortisone injections were more congested and showed more corneal edema than the controls. This is at variance with the idea of inhibition of inflammatory reaction by the drug. At the end of the 10 days, three of the eyes had an open wound as evidenced by the solu tion leaking from it and in one eye this per sisted for three weeks. The haziness of the cornea vanished by the end of the first five days in all of the injected eyes. At two weeks, when the first dog was killed, the cortisone-treated eye had a firm adherent mass at the operative site with the inclusion area itself not well demarcated. The control eye on the contrary had a clean iris prolapse with a slight bleb. By the fourth week, when the second dog was killed, the treated eye had a firm nodule at the site of the surgery and considerable scarring of the conjunctiva about it so that on injection of the solution it was difficult to get into the immediate area. The next four weeks only made the findings more evident, as the untreated eyes, although not showing active filtering scars, had clean prolapses cov ered with conjunctiva and a minimum of re action or new vessels. The treated eyes, on the contrary, had much new scar tissue, ad herence of conjunctiva to sclera, and new vessels. CONCLUSION
As a result of using subconjunctival cor tisone after iris-inclusion operations in dogs, the amount of vascularization and fibrous tissue proliferation in the treated eyes was definitely and without exception much more marked than the control eyes. Subconjuncti val cortisone would appear contraindicated after any type of filtering operation. 744 Jefferson Building (2). Acknowledgement is made to Merck & Company who contributed the Cortone in the experiment.