• • • • New Approach For The Surgical Correction Of Myopia Jose lo Barraquer, M .O., Sogota, Colombia

SURGICAL CORRECTlON OF AMETROPIAS

When in 180 Fukala' suggested for severe cases of rnyopia the extl'action of the lens, he achieved, for the first time, the old wish of patients and surgeons, of correcti ng my-opias by means of surgery.

In 1903 Muller' performed the first scleral resections in order to shorten the rnyopic eyeball.

In 1949 J. 1. Barraquer3 l'essected a corneal ring and sutured the wound in arder to ftat-ten the cornea and thus correct rnyopia.

He also included interlamellar lens of dif­ferent kinds and used g rafts of different sizes, to correct ametropia. He intl'oduced the name of "Refractive Keratoplasty."

Ridley. R." in 1951 inserted 3n acrylic lens between the iris and posterior capsule lens to correct aphakia.

In 1953 Sato, T.o does inclslOlls on the cornea; these incisions retracted and moru-fied the cornea's shape. He used this method to correct myopia and astigmatismo

In 1953 Strampelli ' uses t he first anterior chamber ¡ens to correct high ametropias.

In 1954 Malbran, J.' reinforced the myopic eyeball with a strap of fascia lata in order to shorten it.

In 1958 J. I. Barraquer' obtains corneal tissue lens to achieve with them autokerato-plasties, lamel lar anterior homokeratoplas-ties and interlamellar inclusions to correct rnyopia, hypennetropia and astigmatismo

Bases of the Refractiva Karatoplasty Corneal affections oiten determine a per-

manent change of eye refraction due to an alteration of the cornea's curvature. S ince the cornea is the organ with the greatest re-fractive power in the eye and s ince it ¡s, at the sarne time the most accessible one, it seems logical that if we want to modify the ocular refraction by means of surgery, \Ve should act upon it.

Our last 15 years of research have been specially directed towa"ds finding a method that would enable us to modify at will the curve of the anterior face of the cornea

After many experiments on animals with several techniques, we have chosen as the most adequate, the anterior lamellar ke rato-plasty with a dioptric powered graft (Fig. 1) and the inclus ion of lamellar corneal ti s-

Int erl:ullinar ind usian af len" al "rarnea l parenlluinu", to increue Of di crease Ihe coro nea l rnd iul curvaLure.

~ ,...,. figure 1 . Interl o me llar inclus ion of o corneol tiuue le ns. A-Posi tive. B-Negotive.

sue lenses into the cornea (Fig. 2). We have named KERATOMILEUSIS' the

first techn ique, from the Greek roots {}EPccTOEul)",,> Co rnea, and Up-~Af.TBi,> chiseHng. The second Keratopbakia,' from Greek {}EP O:: TOEiS1J'> co rnea, and q>o::'70'> lens.

Figure 2 . Lomellor Grofts. A- Wilhout opticol power. B- With positive power. C-With negative power.

SURGICAL CORRECTION OF MYOPIA Being interested in correcting myopia, we

shall speak only of Keratomi leus is, that in the actual state seems to be the most ade­quate technique for thi s purpose.

In this case, as the cornea of the eye to be operated is healthy, it does not require a

without compromising its transparency.3,8,9 Figure 3 . Neuma tic f Íltotion Ring (Schemoticl.

gl'aft or donor material, as it is enough with the change of the refractive power of the patient's own cornea.

Technique of Keratomlleusls

Under local 01' general anesthesia, the Collybry Speculum is placed, the eyeball fixed wilh a pneumatic ring (Fig. 3) which is adapted to the anterior segment of the eye, by means of suction . The anterior face of lhe ring is flat to guide a small electrokera­tome (new model (Fig. 4)) that when

Figure 4. Microkeralome.

adapted and run OVer the flat surface oE the ring, pedorms a 8 mm. diameter and 0.25 mm. thick circular keratectomy (Fig. 5).

The ressected cornea has the shape of a parallel-faced meniscus; the posterior face is changed in radius by means of a turning radius machine and following the already eslablished rules of turning contael lenses (Fig. 6) . To make this procedure possible, lhe cornea must be hardened by freezing. Before freezing it, it is submerged and im-

..

Figure 5. Microkerolome in mol ion (Schemolic).

Figure 6. Scheme of Keralomileusis. A-Kera ledomy. S-Chiseling of Ihe corneo. C-Resulls of Ihe operation.

pregnated with a 10% GliceJ'OI solu tion, to pl'otect it fl'om freezing and thawing dam-ages.

This solution al so contains 0.5-1 % Creen Sulfo Solution which dyes the corneal tissue fol' a better visual control during pl'ocessing.

The lathe (Fig. 7) has a device s imilar lo

Figure 7. Rod ius lurning machine wilh freezing device.

the fl'eezing micl'otome's plate. The turlling does not present any difficulties for a Contact Lens Expert ; it i8 performed with a diamond culter at 1.800 revolutions.

Once chi seled, the negative corneal ti ssue lens is withdrawn Ít"om tbe lathe and quickly thawed in saline solu tion at 37' Centigrade. It is then washed, replaced and fixed in its bed with a contael len s sutured to the cornea.

The post operative CQurse has no peculiar-ities and is similar to that of the lamellar keratoplasty with the advantage of being an autoplasty (Fig. 6).

We briefly sketch here the pecul ia r con­ditions oí the cornea that have allowed cor-neal surgel'y to be several decades in ad-vance of other types of surgery. R omoplasty (R . Power 1875) . Heteroplasty (P . P ayrau 1957 ) and now a change of a main f unction (the refraction) in a noble organ (the cor­nea) performed wh ile thi s organ is separated f rom the human body.

The results obtained (Fig. 8) in the /irst

Figure 8. The resu lh of o case in Keralom ileusis. A- Befor!! the opero lio n. S-After the operol ion. The flo lnen of Ihe cornea is evidenl.

operated cases are explained in the tables. The oldest case was operated in Octobe r 1963. These tables were made to be presented in P aris during the month of May and for this reaSOD, actually the observation times are longer and the resul ts are still the same or ha ve impl'oved.

T ABLA I Re.ultados expresados en e quivalentel .déricos

Caso R efracción R efracción Preoperatorla Postoperatoria Mese s

1 -11 ,75 - 1,50 6

2 - 14,50 -0,3 7 5

3 -15,00 - 4 ,50 5

4 -5 ,50 +0,62 4

5 - 8,75 N eutro 3

T ABLA I A Resultados ."prelado, en equivalent •• etféricoJ

Caso Refracción Refracción Preoperatorla Postoperatorla Meses

8 -17,00 -2,75 3

9 - 9 ,00 -1 ,50 3

10 -16,75 _3 ,25 3

11 - 7 ,75 +0,50 2'"

12 - 7 ,00 - 2 ,00 2

..

T ABLA 11 Modificación del promedio oftalmométrico

Caso Preoperatorlo Postoperato rlo Modificación

1 43.2 5 3 6 ,00 7,25

2 45,00 3 9,00 6 .00

3 4 7,00 4 0 ,1 2 6 .88

4 41 ,00 3 5 ,12 5 .88

5 47,7 39,50 8 ,25

T ABLA 11 A Modificación del promedio oftalmométrico

Caso P reope ratorio Posloperatorlo M od lflcacl6 n

8 44,37 36,25 8,12

9 4 5 ,75 41 ,00 4,75

10 45,00 36,50 8 ,50

11 43.00 37,00 6 ,00

12 46,00 4 2,50 3,50

T ABLA 111 Agudeza visual con corrección

Caso P reoperatoria Postoperatorla Observacion es

1 ~edos 30 c ms 0 ,33 Ortotro pla Esotropla)

2 B"edos 30 c ms 0,30 Ortotropla Esotropla)

3 0,05 0 ,10 54 anos

4 0 ,3 3 0 ,80

5 P .L. 0.20

TABLA 111 A Agudeza visual con corrección

C aso P reoperatoria Postoperatorla Observaciones

8 0 ,50 0,62

9 0.05 0 ,05 . En ple6ptica (Exotropla)

0,20 10 0.40

11 0 .05 0 ,05 En ple6ptlca (Exotropla)

0 ,50 12 0,4 0

F rom the study of these cases we arrived to the fo!1owing concJusions : 1) Approximate cor rection can be obtained

of rnyopic anisometropias. 2) The f unctional recuperation of ambliopic

eyes can be achieved.

.. 3) The possibility of correcting in the near correct less serious refractive el't'ors.

future all kinds of refl'3ctive el'1'01'8 with aCCUl'acy and li ttle l'isk.

Naturally, we must bear in mind that my­opia is a degenerative iIIness and that the described technique, even ii it can correct the ref1'3ctive e1'l"01'8 in a more 01' less com­plete way, cannot stop the degenera ti ve pl'ocess Di the rnyopia.

In the actual state Di tbe operation, its indication is Myopic Anisometropia associ­ated 01' not to ambliopia and strabismus.

It is to hope that the increase oi our ex­perience, wiII enable us to enlarge prog¡'es­sively these indications and, in a ne31' future.

Referencos

1. FukHln, W. U SflO): O¡)erntive 8ehandlung der Myo¡lie durch A Ilhnkie. Arch. F. Ophthal. 36. 230.

2. MuUer (1903): Klin. Mon. r. Aug. 3. Ba¡'¡'aquer, J. 1. (l949): Qucl'atolJlustia rerractiva.

EE.n,OO. (Instituto BarraQuel') . 2, 10. 4. Ridley, H. (1961): lntra Ocular Aerylie Lensell . Tl·R II S.

Opht.hal. Soc, U .K .. 71. 617. S Sato. T. {I958 1 : A new lIurgical apprOllcn to rnyop ia.

Am, J. Opht.h .. 36, 823. 6, Strurnl)elli. B. (J(53): SoI'lJOrtabi li tn di len ti acr!­

liche in camera ant.eriore IIclla !l fnehia e nei viú di re­(mziolle. Atti . Soc. orllll. 1.0mb. 8, 292,

7. Mulbran, J . (1964): Unn nueva orientllcion qu lrur. gica contra h~ Miopia. Areh . Soc. Ortal. 1[is l). Amer. 11 , 116.

8. Barraquer, J. J. (1958): Met.hod fo r cutting Inmellnr g l'ufta in frozen COI'nen, New orientation for refractive surgery. Areh. Soc. Amer. ortal. Ol>tom. 1, 271.

!1. Barraquer, J . T. (1963): Modifieacion de la relra celon por medio de inc lull iones int.racorneales . A I·ch. Soc . Amel'. Oftal. O¡)wm, 4, 229.

Lfmture delivered a.t. Tite First. lnternutional Con/erenee 01l Myopia, New York, N. Y., September 10-1$. 1961,. sPQ?lsored by t.lte Myopia Research Foundation, ¡nc., 415 Lexingtou Ave., New York, N. Y. 10017.

Pl'inted as a gitt by Tite ProfessionaZ Prese, Ine .. Chicago, lll.