Vitreous surgery as a supplement to anterior segment surgery

Selected vitreous surgery techniques can provide effective and safe means of supplementing anterior segment surgery for correction or avoidance of many problems. In my experience, the guillotine or piston action vitrectomy instruments are more effective and safer than those which have a rotating or oscillating action. Pars plana vitreous surgery has added a new dimension to anterior segment surgery. There is reason to hope that the future will bring further refinements of instrumentation and surgical technique and more precise knowledge of the indications and limitations of this type of surgery.

[Convergent strabismus with eccentric fixation in a case of persistent pupillary membrane]

Case report of a now 9-year-old boy with a pronounced persistent pupillary membrane in both eyes combined with amblyopia and eccentric fixation in the right eye and a convergent squint. After surgery removing the persistent pupillary membrane in both eyes at the age of 4 years, pleoptics and orthoptics were applied. Visual acuity and eccentric fixation did not improve. Strabismic surgery was carried out with good cosmetic result. Aetiologically, one can assume a deprivation by the persisting pupillary membrane.

Argon laser treatment for medically unresponsive attacks of angle-closure glaucoma

Seven patients with medically unresponsive attacks of angle-closure glaucoma were successfully treated with the argon laser. Three methods may be used either singly or in combination to cut short an attack: (1) peripheral iridoplasty, (2) pupilloplasty, and (3) laser iridectomy. Laser treatment is preferable to and safer than intraocular iridectomy in such cases. Pilocarpine, which increases the axial length of the lens and shallows the anterior chamber, may worsen angle closure by increasing the pupillary block. An enlarged lens or forward movement of the lens may be a significant factor in medically unresponsive attacks. The routine use of copious amounts of pilocarpine should be avoided in treating angle-closure glaucoma.

Vitrectomy methods in anterior segment surgery

We have used vitrectomy instrumentation and techniques to treat a variety of conditions affecting the anterior segment, including: 1) an occluded or inadequate pupillary space, 2) complications of vitreous in the anterior chamber, 3) epithelial ingrowth, 4) complicated lens surgery, and 5) total hyphema. The vitrectomy methods provided controlled excision of intraocular tissues under optimum visualization using a closed-eye system with normal intraocular pressure and the ability to use techniques such as intraocular diathermy. Our experience has been favorable in this series of 117 cases. Of these, 104 cases (89%) were anatomically successful, 70 eyes (60%) had a significant postoperative improvement in vision. The detailed results of vitrectomy surgery for anterior segment disorders are presented for each indication.

Acute aphakic pupil block glaucoma: an alternative surgical approach

In a series of 7 cases of acute aphakic pupil block glaucoma a surgical approach designed to break adhesions between the iris and the anterior hyaloid face was uniformly successful. Reasons for the success of the method are discussed and comparisons made with other surgical approaches.

Capsulotomy technique in the presence of an anterior chamber lens

A modified Sato technique has proved to be a highly successful and atraumatic method of posterior capsulotomy in the presence of an anterior chamber lens. The lens remains undisturbed and iris-ciliary body, vitreous-retinal traction is avoided.

[Lasermicrosurgery of the flattened anterior chamber (author's transl)]

The method of laser-microsurgery for restoration of lost anterior chamber in aphakic pupillary block and malignant glaucoma is once more reported. The problems of the flattened anterior chamber are discussed. Principle, technique, and indication of laser-coagulation of the iris are demonstrated. A short discussion of the method, description of late observations and instructions for postoperative treatment are given. In each of the 23 eyes this dangerous postoperative complication could be abolished in a simple manner without any risk. This operation must be considered as the method of choice.

[Results of transpupillar vitrectomy (author's transl)]

Vitreous prolapse in cataract surgery or during the extraction of a dislocated lens; corneal dystrophy in aphacic eyes due to corneo-vitreous contact and vitreous invading the anterior chamber following perforating injury proved to be valid indications for partial transpupillary vitrectomy. In malignant glaucoma, in postoperative wound rupture following cataract extraction, in open-sky-surgery of the anterior segment of aphacic eyes and in other particular conditions, transpupillary vitrectomy may also be considered. The transpupillary approach is not indicated in retinal detachment, unless prepupillary vitreous incarceration pulling up of the retina is obvious. Transpupillary vitrectomy can be performed without much harm to the eye even in children, if indicated (congenital cataract, congenital on traumatic lens dislocation, perforating lens injury). In general the results of transpupillary vitrectomy are good. Longterm complications are relatively rare. Experiences on 208 eyes are reported in particular.

Pars plana vitrectomy. Vitrectomy technique in anterior segment surgery

Instrumentation and techniques developed primarily for vitreoretinal surgery were used to treat 20 eyes with an occluded or inadequate pupillary space and 5 aphakic eyes with complications caused by formed vitreous in the anterior chamber. A pars plana approach was used in 19 eyes and a limbus approach was used in 6 eyes. In every eye an adequate pupillary space was provided and all formed vitreous was removed from the anterior segment. No intraoperative complications occurred. This new approach to selected cases of anterior segment surgery offers several advantages over conventional techniques. A larger number of cases and longer period of follow-up are necessary to further define the specific indications and limitations of this technique.

Argon laser photomydriasis

Argon laser photomydriasis was used to enlarge 20 miotic pupils in 18 open-angle glaucoma patients, with beneficial visual results in patients properly selected before treatment. During eight months of observation, significant complications such as persistent iritis and lens changes did not occur. An increase in intraocular pressure occasionally occurred shortly after treatment, but chronic exacerbation of underlying glaucoma was not observed. Argon laser iris photocoagulation in rabbit eyes showed localized atrophy of the iris sphincter and stroma within the treatment zones. Discrete, anterior lens opacities occurred only at high-power levels, and these appeared to be nonprogressive during the eight-week observation period.

[Lasermicrosurgery in glaucoma (Lasertrabeculopuncture I1LTP], tangential irisbasecoagulation [TLC], removal of miosis and shifting of pupils) (author's transl)]

The long-term results of Lasertrabeculopuncture (LTP) and of tangential irisbasecoagulation (TIC) according to experience of 4 years are presented and critically discussed in comparison with the reports of other authors. The removal of miosis and the shifting of displaced pupils in glaucomatous and cataract eyes is demonstrated. The long-term results of other interventions in glaucoma by lasermicrosurgery are announced.

Argon laser photocoagulation of iris abnormalities

Argon laser photocoagulation of various iris abnormalities has been performed successfully. The destruction of iris cysts, the obliteration of blood vessels in iridocyclitic membranes prior to surgical discission, the correction of updrawn and deformed pupils, the mydriasis of pupils in patients debilitated by the miosis of antiglaucoma medication, and the production of iridotomies have been accomplished and are described along with the indications, photocoagulation techniques, results, and complications attendant to these particular procedures.