As a large iridectomy had originally been performed, a fair incision under a conjunctival flap made it possible to remove the debris and lens substance. The reaction of this eye was stormy but subsided in two weeks, leaving what was feared, in the beginning, a soft blind eye. This resolved into a non-inflammatory phthisis bulbae. However, the right eye made a most satisfactory recovery with an almost normal field and 20/20 vision with glass correction. Though I have taken the tension many times since, it had remained from 30 to 40 McLean without the use of myotics.
Mrs. A.T., admitted January 1, 1934. Five weeks prior to this she had intense pain in right eye and head, and as nose began to discharge, was treated for sinus disease by her country physician. Later, left eye began to ache and then patient found she could not see from the right, and the left was rapidly becoming blurred. She called in another physician, who sent her at once to the hospital. At the time of arrival she could only distinguish light. Both pupils were dilated. Eserine oil drops were used every two hours during the night in conjunction with hot compresses. At time of admission to operation room the next morning the tension was 90 and 95 McLean.
In this case, due to the every shallow anterior chamber and high tension, I used the scratch incision with the Graefe cataract knife in both eyes. This made it possible to have the tension released slowly and all danger of injury to the lens was avoided. A medium-sized piece of sclera was punched out and the iris drawn into the area. No sutures were used.
Light massage was found necessary a few times while a day during October and November in the right eye only, when for some unknown reason tension rose to 55 McLean. Prior and since then, the tension has been on the average 35 in the right and 30 in the left. Vision at the end of January was 20/40 in both eyes, and by the end of February, 20/30 right and 20/20 left, where it has remained since then. There is a little contraction of the field of the right eyes.
Mrs. A.O., admitted January 10, 1934. Had been under treatment for non-inflammatory glaucoma three years before my seeing her. Complaints of periods when vision is hazy and specks before eyes. Tension found to be right eye 50 and left 40 McLean. Cupping of both nerve heads was present and the visual field of the right contracted to 15 degrees on the nasal side-less than 20 at 0 and 180, while at 90 it was 30 (Cut I). The left eye had a contraction in the 45 meridian extending within 5 degrees of center.
The vision for both eyes was, with best correction, half of the 20/30 line and a consciousness of lost nasal fields. The iridotasis punch operation was performed as previously given, without difficulties. As the conjunctival flap would not stay in place when operating on left eye, one stitch was used. Vision in February was found to be 20/30 for both eyes and in March 20/20 on half. The tension for a short period has been up to 50 first in one eye and then in the other, but not since, July, 1934, has there been any increase above 49 in either.
Mr. T.C.O., admitted April 29, 1934. I saw him first March. 7, 1934, when he was led into my office. It was a case of non-inflammatory glaucoma. He could not count fingers with the right eye, being able only to distinguish light. The left eye and vision of 20/100, which with correction could be brought up to 20/70. The tension was 55 and 60 respectively. While he was at the office, eserine and pilocarpine reduced the tension to 45 and 50. In a week the tension was brought to 40 and 45 but the field in the only eye with which he could see was so reduced that he could hardly get about without a guide.
Nevertheless his acuity of central vision had come up to 20/30. The next week he was knocked down by an auto and was in the hospital for a few days. His vision after this was 20/50 and the tension 55 and 70. Myotics were used every two hours and on return visit the tension 55 and 70. Myotics were used every two hours and on return visit the tension was 50 in both eyes with vision still only 20/50 in the good eye. The described operation was performed without any untoward results.
The vision in June was 20/40-one-half in the only seeing eye-but the field was still too small to allow any freedom of navigation. In fact, when taken in July, it had changed about from the temporal to the nasal side. During that month, having contracted a cold, both eyes became inflamed and the tension rose to 45 and 50. This returned to normal in two weeks but the patients one bad eye still remained inflamed and a chronic iritis developed.
When last seen in September, 1934, the left eye was as normal as such an eye ever could expect to be, i.e., tension 35, on inflammation, fields the same as previous with vision of 20/30/ The right eye was still in a chronic state of irritation.
CONCLUSIONS.
I have reported these most unfavorable cases where I resorted to a punching out of a piece of the scleral side of the wound prior to doing the regular procedure in iridotasis in order to show its advantages over the trephine or Lagrange operation. I have a number of patients on whom the orthodox iridotasis was performed who have to resort to myotics either constantly or at intervals. I cannot but feel that if a small piece of sclera had been removed there would not have been a return of tension a year or so following the operation. At least it facilities drainage at the time and prolongs the period when scar tissue can thwart the original intent of the operator.
