EXPERIENCES W I T H PLEOPTICS 51

14. Girard, L. J., Fletcher, M. C , Tomlinson, E., and Smith, B.: Results of pleoptic treatment of sup­pression amblyopia. Am. Orthop. J., 12:12-31, 1962.

15. von Noorden, G. K. : Pathophysiology of amblyopia: Diagnostic and therapeutic principles of pleoptics. Am. Orthop. J., 10 :7-16, 1960.

16. Ehrich, W., and Piening, O . : Faktoren die für die Dauerresultate der pleoptischen Behandlung entscheidend sind. Klin. Monatsbl. Augenheilk., 135:394-400, 1959.

17. Richter, S.: Erfahrungsbericht über pleoptische und orthoptische Behandlungsmethoden. Klin. Monatsbl. Augenheilk., 137:155-160, 1960.

18. von Noorden, G. K.: Sensory and motor factors in amblyopia. Am. Orthop. J., in press. 19. Hamilton, B.: Orthoptics and its relationship to pleoptics and centroptics. Am. Orthop. J., 13 :95-

103, 1963. 20. Bangerter, Α . : Orthoptische Behandlung des Begleitschielens. Pleoptik. X V H I Conc. Ophth. Bél­

gica, 1:105-144, 1958.

T H E L A G R A N G E - F O R O N I O P E R A T I O N F O R G L A U C O M A *

ARCHIMEDE BUSACCA, M . D . Säo Paulo, Brazil

For the past 20 years I have performed a personal modification of the Lagrange-For-oni operation in selected cases of glaucoma. From Foroni I adopted the ab externo in­cision of the sclera.t A full iridectomy is es­sential for success. Gonioscopic examinations convinced me of a direct relationship between the amplitude of the iridectomy and the ex­tent of the corneoscleral incision that re­mains patent to guaranty a communication between the anterior chamber and the cystoid cicatrix. If only a basal iridectomy is done, a goniosynechia eventually becomes established that involves the zone of incision and leaves free solely the sector that corresponds to the small iridectoiny. The final appearance of the Lagrange operation then is frequently like that of the Elliot procedure. Furthermore, with only a basal iridectomy it is almost im­possible to avoid subsequent posterior syn-echiae over the sector where the dilator muscle has been cut. In the sequence, the subjacent pupillary border assumes a horizontal posi-

*This paper, submitted to T H E J O U R N A L in French, was translated by James E. Lebensohn, M.D., Chicago.

t Foroni: Ann. Ottal., 1913.

tion, like the chord of an arc, and its reac­tion to mydriatics is minimal.

PREOPERATIVE DETAILS

A preliminary study with the slitlamp mi­croscope aids in correctly estimating the width of the limbic region in the operative area, that is, the distance between Schwal-be's line and the distal extremity of the lim­bic zone as indicated by the termination of the vascular plexus. Theoretically, the ideal incision into the anterior chamber should be through the posterior part of the scleral trabecula. On the evening before surgery, the skin is disinfected, the conjunctival sac irrigated, eserine and an antibiotic ointment are separately instilled, the eye is occluded with a sterile pad and a coagulant is injected subcutaneously.

The immediate operative preparation in­cludes instillation of eserine to obtain maxi­mal contraction of the pupil, irrigation of the conjunctival sac, surface anesthesia, aki­nesia and anesthesia with procaine-epineph­rine embracing retrobulbar injection and minimal injections in the superior limbic area under the conjunctiva and in the epi-

52 A R C H I M E D E BUSACCA

Fig. 1 (Busacca). Bellied lid knife. (Enlarged 1 :1.5 in the reproduction.)

sclera. Cotton pledgets are avoided and, in­stead, a clear operative field is maintained by the assistant with a fine stream of artifi­cial aqueous poured from an undine to which may be added an antibiotic if desired.

Instruments. In addition to the standard armamentarium for the Legrange procedure, I use the following special instruments:

a. T w o small bellied lid scal]5els (fig. 1 ) , one of which is extremely sharp for the sclerectomy incisions, the other slightly dulled for dissection of the conjunctiva. Though one may use a corneal dissector, I prefer for this purpose the convex blade or point of the knife.

b. A forceps of my own design, made by Invirnizzi of Rome (fig. 2 ) . This for­ceps holds the conjunctival flap firmly in its rounded curve and so avoids the possibility of perforation by the points. A strong grasp is maintained by the serrated sides which ap­proximate accurately throughout the extent of the curve and not just at the points as is customary.

OPERATION

1. Preparation of conjunctival flap. A curved incision, made with scissors, starts at the vertical meridian five to eight mm. from the limbus and gradually lessens this inter­val to two to three mm. as the incision ter­minates on either side at the 10:30- and l:30-o'clock positions (fig. 3 ) . T o obtain the thickest possible flap, the conjunctiva is dis­sected to the limbus by pressing the dull points of the scissors against the sclera. At the proximity of the limbus, the dissection against the sclera is continued with the sharp knife. With the base of the flap held by for­ceps, the operator heaves up a bit o f epi-sclera till the transparent cornea is revealed. The base of the flap now consists of con­junctiva and limbic episclera. Usually a

Fig. 2 (Busacca). Curved forceps for grasping the conjunctival flap, (a) Opened to show the serrated zone, (b) Closed and in profile. (Enlarged 1 :1.5 in the reproduction.)

whitish curved line, notched by mother-of-pearl points, marks the breaks of the epi­scleral fibers along the limbic periphery (fig. 3 - A ) . After grasping the flap at this level, which assures a secure fixation, the dissec­tion is continued until a luniform area of cornea is uncovered of about two-mm. ex­tent in the vertical meridian. A suture passed through the center of the free border of the conjunctival flap allows the assistant to ex­ert the desired traction during sclerectomy and iridectomy and later serves as the first of the final conjunctival sutures.

2. Sclerotomy ab externo. A curved line is incised at 1.0 to 1.5 mm. from the un­covered cornea (fig. 3 - B ) . While fixation of the globe is effected with the forceps at the very base of the flap, the scleral incision is

LAGRANGE-FORONI O P E R A T I O N 53

Figs. 3 and 4 (Busacca). (3) Di­agram of tlie first stage of the operation. ( A ) Curved line of sec­tion of episcleral fibers participat­ing in the make-up of the limbic area. (B) Line of incision through sclera. (C) Extremity of scleral in­cision. (4) Sclerectomy. ( A ) Line along base of flap cut for excision of corneoscleral crescent.

Fig. 3 Fig. 4

deepened with the knife inclined very slightly forward. Penetration of the anterior chamber is followed by a hernia of the iris which is re-posited with a spatula and the incision is com­pleted to correspond with the length of the exposed luniform corneal area. A spatula then checks the entirety of the incision.

3. Sclerectomy. The rim of the sclerocor-neal lunula is seized with the teeth of an iris forceps at the 12-o'clock position. While the assistant pulls the conjunctival flap forward and slightly downward by the attached su­ture, the sharp scalpel cuts through the sclerocorneal lunula along the base of the flap (fig. 4 - A ) and the crescent is removed.

4. Iridectomy. Blood in the anterior cham­ber is gently irrigated out but a residual coagulum is ignored as it is speedily ab­sorbed. With the flap held down by the as­sistant, the iris is grasped at the sphincter, pulled out and a full iridectomy matching the sclerectomy is made in two steps with a DeWecker scissors. After the first snip, an iridodialysis is performed by tearing the iris from its base and the second snip is then executed.

5. Disengagement of the base of the iris pillars. This is imperative as they are almost always wedged in the incision.

6. Conjunctival sutures. The conjunctival flap is replaced on the sclera and fixed by one

suture at the apex and two on each side. 7. Final toilette. Atropine is instilled, some

antibiotic ointment is deposited in the con­junctival sac and both eyes are patched.

COMMENTARY ON TECHNIQUE

The limbic injection not only enhances the local anesthesia but the associated conjunc­tival edema facilitates the dissection. The in­jection should be given just a minute or two before surgery lest the pupil become too di­lated at the stage of iridectomy. Rarely the injection precipitates a sudden pupillary di­latation, probably from the entrance of the anesthetic mixture into the anterior chamber via an aqueous vein.

The conjunctival incision that delimits the flap must not touch the limbus; otherwise, if cicatricial adhesions ensue, the filtering cica­trix will be blocked completely at its periph­ery. Bleeding should be controlled by the ap­plication of epinephrine or a local coagulant, never by cautery, since cauterization evokes the formation of dense cicatricial bands which either block filtration or produce an exaggerated projection of the cystoid zone. Even though accidental perforation of the flap rarely occurs, the scalpel for dissection of the conjunctiva should not be too sharp. On the other hand, for the incision ab ex­terno the blade must have a perfect edge.

54 A R C H I M E D E BUSACCA

The incision of the sclera should be deep­ened gradually in its entire extent so that an equal depth is attained throughout when the anterior chamber is penetrated. A s said be­fore, the ideal incision should be through the posterior part of the trabecula. A too-for­ward inclination of the knife will cause the incision to swerve from the trabecula and the blade may slide between the corneal stroma and Descemet's membrane. A too-backward incision may strike the ciliary body and in­stitute grievous secondary complications.

The full iridectomy should include an iri-dodialysis of the root of the iris over a large sector. A s already noted, I have observed a direct relationship between the amplitude of the iridectomy and the extent of the corneo­scleral incision that remains patent for the establishment of communication between the anterior chamber and the filtering cicatrix. Without iridodialysis, the base of the iris in the zone of the scleral incision becomes ad­herent eventually to the trabecula or to the posterior surface of the cornea. A basal iridectomy allows only a very restricted pas­sage between the anterior chamber and the cystoid cicatrix.

I perform the iridectomy always after the sclerocorneal resection and never on the iris herniated in the incision. The herniated iris should be reposited even if it is somewhat traumatized thereby. This trauma is incon­sequential as the affected area is subse­quently excised. The reposition avoids an abrupt loss of aqueous that might cause the apices of the ciliary processes and the rim of the crystalline lens to dislocate toward the scleral incision. T o protect the anterior zonu­lar fibers the surgeon must exercise due care in the further manipulations required. When the Elliot operation includes resection o f the herniated iris, adhesions of the stump of the base of the iris or of the apices of the ciliary processes are frequent. If the pillars of the coloboma are wedged in the scleral incision, disengagement is necessary. According to my observations, the incarceration can provoke vexatious consequences although some main­

tain that, like iridencleisis, it aids in the for­mation of a filtering cicatrix. Whether this be so or not, I would still avoid the drawn-up pupil that incarceration produces.

In the Lagrange-Foroni operation, done according to the described technique, the re­sulting cystoid cicatrix is large and flat and a dark band corresponding to the sclerectomy is visible through the conjunctiva.

POSTOPERATIVE MANAGEMENT

The first dressing is done in 24 hours when the surgeon often finds the anterior chamber already reformed, the pupil fully dilated and only a slight hyphema. Minor in­flammatory reactions are readily controlled by a retrobulbar injection of cortisone or by irgapirine. Binocular occlusion is maintained for six to eight days. Should the anterior chamber be shallow, the pupil then is only partly dilated and the blood stays in the pupillary area, clinging to the border of the iris. If a flat anterior chamber persists, re­formation is facilitated by removal of the binocular bandage on the fifth day to allow ocular movement, instillation of dionin (five percent) to produce conjunctival edema and a drop of a strong miotic once or twice to induce motility of the iris which is com­pressed between the lens and the cornea. With this exception, the postoperative use of miotics is absolutely proscribed. The eye is kept atropinized for about two months, since cicatricial retraction is not completed till the sixth week. The contraction of the ciliary body efi^ected by atropine separates the apices of the ciliary processes from the lateral wall of the sinus camerularis and so tends to prevent them being nipped or en­closed in the scleral incision. However, ad­hesion of the extremity of some apices to the external wall o f the sinus camerularis is not always avoidable due to individual variations in the conformation of the ciliary body.

L A T E COMPLICATIONS

The one complication that may arise after several months is damming of the cystoid

LAGRANGE-FORONI O P E R A T I O N 55

Fig. 5 (Busacca). Diagram illustrating debridement of blocked cystoid cicatrix.

cicatrix. This results from firm adhesions of the conjunctiva to the sclera over the entire extent of the conjunctival incision or may be

sequential to dense cicatricial tissue formed about the cysts. I have observed such adhe­sions when bleeding from the episclera was controlled by cautery. Very elevated and thin-walled cysts may thus be formed, pre­senting the danger of perforation, even when neither side of the conjunctival incision strikes the limbus.

In these cases I perform a debridement of the cicatrix (fig. 5 ) . A small incision is made through the temporal side of the con­junctiva, five mm. from the adherent border. A curved scissors with dulled points is plied against the sclera to form a tunnel to the cicatricial band which is cut; then the cysts are cut through down to the limbus till the scissor points reach the adhesions at the nasal border which are likewise cut. After a lapse of some weeks the cystic mass flattens.

CP. 2813.

C O N T R I B U T I O N O F A N A T O M Y T O C L I N I C A L O P H T H A L M O L O G Y *

GEORGE K . SMELSER, P H . D . , AND VICTORIA O Z A N I C S , M . S .

New York

I am very grateful to you for allowing me to join in sharing your pleasure in the op­portunity which these new laboratories offer. I am glad for you, and I am glad for the laboratories, for they will house in these next years many exciting moments, and, with a little luck, very important ones.

It is scarcely necessary to emphasize the value of anatomic knowledge to clinical oph­thalmology. It is axiomatic that a physician and surgeon must have a thorough under-

* From the Department of Ophthalmology, Col­lege of Physicians and Surgeons, Columbia Uni­versity. This investigation was supported by grant 00492-10 from the Department of Health, Educa­tion and Welfare, Public Health Service, National Institutes of Health and by Research Career Award NB-K6-19, 609-01. This paper was pre­sented at the dedication of the Eye Research Laboratories of The University of Chicago, De­cember 16, 1964.

Standing o f the structures with which he deals. Currently, the increase in scientific re­search in this and other fields is so rapid and vast that the contributions cannot be satis­factorily sorted out or evaluated as they are reported. This rapid increase is occurring be­cause the value of basic scientific research to clinical medicine is widely recognized and, therefore, more workers are recruited to this effort. In addition, the advances in tech­nology greatly enhance the investigator's productivity.

N o one can determine the value of a spe­cific finding to clinical ophthalmology or, what is more important, what fields an in­dividual discovery may lead to. Perhaps it is more appropriate if we regard the contribu­tions of anatomy to ophthalmology as a con­tinuum, and consider the role it has been.