|Year : 1967 | Volume
| Issue : 4 | Page : 131-134
Iridenclysis by folding of iris
Department of Ophthalmology, General Hospital, Udaipur, Rajasthan, India
|Date of Web Publication||21-Jan-2008|
S P Mathur
Department of Ophthalmology, General Hospital, Udaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mathur S P. Iridenclysis by folding of iris. Indian J Ophthalmol 1967;15:131-4
Amongst all the filtration operations for glaucoma, iridenclysis has been given the place of choice during the past two decades, although the operation was described by Herbert as early as 1903, and by Holth in 1907. For the present this operation has more or less completely replaced its immediate contemporary - namely trephining. This is because with a little care iridenclysis has achieved satisfactory results in more or less every type of glaucoma. Its particular indication has been mentioned by Kalt (1947) to be in secondary glaucoma, and by Arruga (1962) in glaucoma with aphakia and buphthalmos.
The purpose of this paper is to mention a method by which iris is placed through the scleral section in a fold in order to enclose a drainage channel lined by epithelium. This gives much better filtration than if the iris is placed flat.
| Steps of Operation|| |
Anesthesia-Xylocaine 4% instillation, Xylocaine 2% retrobulbar injection and facial block.
Operation-Lid sutures retract both lids, and a superior rectus stitch exposes the upper bulbar conjunctiva.
Conjunctival incision. A semi-circular incision is made 8 mm. above and concentric with the limbus [Figure - 1]. Smaller incision closer to the limbus limits the area of filtration, lifts the conjunctiva into a bleb like the one after trephining operation and is likely to cause irritation, astigmatism, and infection.
The conjunctival flap is undermined upto the limbus and reflected over the cornea. Bleeding points are pressed with an adrenalin swab. Cauterisation close to the limbus is avoided to prevent reaction and fibrosis.
The eye ball is fixed with a fixation forceps keeping one limb above and the other below the conjunctival flap at the limbus at 3 O'clock. This avoids necessity for the assistant to hold the conjunctival flap down.
An ab-externo incision is made 1 mm above the limbus and 3 to 5 mm. long, with a cataract knife directing the edge towards the pupil. Effort is made to reach the anterior chamber at the first attempt. Many attempts may cut the tissue in different planes, making the section ragged, which ultimately excites tissue reaction, and fibrosis resulting in poor filtration of the aqueous.
The iris is made to prolapse by pressing over the upper lip of the scleral section. It always comes out as a bulging prominance folded on itself, more so if the pupil is constricted by miotics pre-operatively.
In case the iris does not come out, a curved iris forceps is introduced into the anterior chamber, and the iris caught at the middle of the pupil and ciliary attachments [Figure - 3]. When pulled out, the iris will come folded on itself. The nasal end of this fold is cut with de-Wecker's scissors [Figure - 4]. The temporal portion is detached from the ciliary attachment, and iris is rotated by 90°, to be placed vertically on the sclera [Figure - 5].
The nasal pillar of the iris gets reposited into the anterior chamber by itself, or manipulated by the iris repositor. In the whole procedure iris is never touched more than once. The conjunctival flap is reposited over the iris and sutured [Figure - 5]. Care is taken not to stroke the iris from over the conjunctiva, because that is likely to injure and disorganise the tissue.
The conjunctival flap is stitched back into position by a continuous suture.
Sterile air is injected into the anterior chamber and under the conjunctival flap, and dressings applied with atropine and antibiotic drops.
Dressing is changed on alternate days. Atropine is used only when there is iritis and tenderness. Cortisone with antibiotic ointment was used after the third day. Conjunctival stitch is removed on the 5th day, and the patient is discharged on the tenth day. Massage to the eyes was never necessary.
| Observations|| |
During the last 3 years a total number of 499 eyes of chronic simple, acute congestive, and secondary glaucomas were operated by this method. After perfecting the technique, a sample batch of 74 eyes was observed in detail and followed for at least one year.
As control, 35 eyes with similar groups of glaucoma, were operated keeping all the steps of operation same as in the sample batch, except that the iris was placed flat in the scleral section, with epithelial surface facing the conjunctiva.[Table - 1]
Before operation all the cases were treated with miotics and Diamox for 24 hours in an attempt to normalise the tension.
| Discussion|| |
[Figure - 6] shows a sectional view of the iris fold under the conjunctiva. It may be noted that the iris is enclosing a definite space which is lined by epithelium, which forms a channel for the aqueous. In addition, the iris tissue will work as a wick by conducting aqueous through its body. It is therefore evident that a double passage has been made for the filtration of aqueous by this operation. In those methods in which iris is kept flat, the only passage for the aqueous is through the iris tissue. With minimum handling of the iris as described, satisfactory results can be achieved even when iris tissue is atrophic.
The need for handling the iris most gently is here emphasised, because in the later stages, the iris is atrophic and disintegrates more readily as when it is held with two forceps and torn as it is done in some places. This iris then cannot hold out like a tunnel for filtration.
The table of results clearly shows the better results obtained with fewer complications, by our modified technique.
Defects in the field of vision get reduced remarkably in majority of the cases, while in early cases they may even disappear completely after the operation. Importance should be given to a clean ab-externo scleral incision at the first attempt, as subsequent attempts invariably result in a ragged incision with a poorer filtration scar.
The presence of a folded iris in the wound prevents total escape of aqueous during the operation, and prevents damage to the lens. Introduction of air in the anterior chamber further helps in chamber reformation.
Post-operative hyphaema is the result of injury to the intrascleral plexus or to the ciliary body. This can happen only when the scleral incision in made too posteriorily. Precaution is therefore taken not to incise farther than 1 mm. behind the limbus, and to enter the anterior chamber slanting towards the pupil. A more anterior and vertical incision is suggested by Nirankari and Malhotra (1965), but this is likely to produce some astigmatism, although it may avoid hyphaema. Further this is also likely to injure the lens, iris and ciliary body [Stallard (1953), Mackie and Rubenstein (1954) and Agarwal (1958)].
We have achieved satisfactory results in cases of absolute glaucoma also by this operation in which we were reasonably sure of absence of a neoplasm. It may therefore be suggested that a trial be given to this operation before putting up the case for excision of the eye ball.
| Summary|| |
A method of placing the iris in a vertical fold under the conjunctiva, in iridenclysis operation is described. A double channel is formed for the aqueous filtration, one through the enclosed channel lined by the iris epithelium, and the other through the iris tissue which works like a wick. Advantages of this method over others are described.
| References|| |
Kalt, Arch. Ophthal. Paris, 1947, 7, p. 18.
Arruga, H. (1962). Ocular Surgery. Mc Graw Hill, p. 727.
Herbert, H. (1903) Trans. Ophthal. Soc. U.K. 23, 324.
Holt, S. (1907) Ann Oculist (Paris) 137, 345.
Nirankari M. !S., Malhotra G. S. (1965) Brit. J. Ophth. 49, 646.
Stallard H. B., (1953) Brit. J. Ophth. 37, 680.
Mackie E. G., and Rubenstein, E. (1954) Brit. J. Ophth. 38, 641.
Agarwal L. P. (1958) Ophthalmologica 135, 51.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
[Table - 1]