CORRESPONDENCE 481

"Concerning the operative procedure it­self, the following points should be ob­served :

"1 . The wound must be slanting so that the point of entrance is about one mm. out in the sclera and the internal wound just at the limbus. In this way it is possible to draw out the iris up to the point of its ciliary inser­tion; this seems to be necessary for a good result.

"2. Since the excised piece must be as large as possible, a broad, lance-shaped knife should be used.

"3 . The aqueous must be evacuated care­fully, because too sudden a release of the pressure may cause numerous hemorrhages.

"In the acute cases in which vision is lost almost immediately, iridectomy must be per­formed whenever possible in the first few days of the disease. The theory of the cura­tive effect of iridectomy is far less certain than the empirical fact. A decrease in the secretory surface of the iris might account for a reduction in the quantity of the fluid. After the marked change in our views on glaucoma produced by the first ophthalmo-scopic examinations, I felt that further in­vestigation was imperative. I hope that I have assisted in solving some of the difficulties and that some one better equipped will soon bring this difficult task to a happy conclu­sion."

* * * "Whatever is excellent is permanent." The

classic Graefe iridectomy has remained the most satisfactory therapy for acute glau­coma. When done in time it both relieves the attack and prevents further attacks. But in glaucoma simplex the results of iridectomy proved unpredictable. Certain cases which healed with a "cystoid cicatrix" (v. Graefe) allowed the aqueous humor to escape under the conjunctiva and responded with the ten­sion adequately reduced. Many surgeons reasoned that this effect could be attained more definitely by procedures designed spe­cifically for this end CCoccius, iris inclusion, 1859; de Wecker, bridge-sclerotomy, 1863;

Argyll-Robertson, scleral trephine, 1876). But nearly a half-century elapsed before such variations secured widespread profes­sional acceptance. In rapid succession then came the flap-sclerotomy of Herbert (1903), the sclerectomy of Lagrange (1905), the cyclodialysis of Heine (1905), the iriden-cleisis of Holth (1907), and the corneo­scleral trephining operations of Fergus and of Elliot (1909).

James E. Lebensohn.

CORRESPONDENCE SCLEROCLEISIS

Editor, American Journal of Ophthalmology :

I have read with interest the excellent paper on "Sclerocleisis" by Dr. A. B. Vicen-cio ( T H E JOURNAL, 42:402, 1956). May I mention that I have described previously a similar operation based on a scleral insert in the anterior chamber (Klinika Oczna, 13: 59, 1935). My paper was abstracted by Pro­fessor Lauber in the Zentralblatt fur die gesammte Ophthalmologie und ihre Grenzge-biete (34:328, 1935).

I stated that current fistulizing operations have certain limitations. Both corneoscleral trephination and iridencleisis are susceptible of secondary infection, and the latter opera­tion deforms the pupil. In my operation of sclerencleisis, filtration is effected by insert­ing two thin slices of sclera in the corners of the corneal wound. After dissection of the

Fig. 1 (Arkin) Fig. 2 (Arkin)

482 BOOK RF.VIFAVS

conjunctiva, as in the Elliot operation, two vertical sections of scleral tissue are elevated with a von Graefe knife, keeping the attach­ment at the limbus intact (fig. 1) . A kera-tome incision and iridectomy follow, after which the scleral slices are turned down with a spatula and manipulated through the cor-neal wound into the anterior chamber (fig. 2 ) . Ten cases of absolute glaucoma were thus operated. A permanent reduction in ocular tension occurred in two cases, a tem­porary reduction in one. Absolute glaucoma is seldom benefited, however, by any pro­cedure.

Dr. W . Reitsch described an identical operation under the same title, "Sclerenclei-sis" four years later (Klin. Monatsbl. f. Augenh., 102:326, 1939).

Will you kindly publish this note in T H E JOURNAL.

(Signed) Wiktor Arkin, Warsaw, Poland.

BURIED CORNEOSCLERAL GUT SUTURES

Editor, American Journal of Ophthalmology:

In reference to the excellent report on "The use of corneoscleral gut sutures" by Dr. Frederick Stocker in the November (1956) issue of T H E JOURNAL, I have used this tech­nique with minor variations adapted to the keratome incision for the past three years.

My associate, Dr. Richard Dennis, de­scribed the method in a paper before the New England Ophthalmological Society in 1954 and again in 1955. In October, 1956, T demonstrated the technique in a movie in Dr. Derrick Vail's instructional course at the Academy meeting. W e feel that this suture has great advantages and gives excellent re­sults.

(Signed) Howard F . Hill, Waterville, Maine.

BOOK REVIEWS GLAUCOMA : TRANSACTIONS OF T H E F I R S T

CONFERENCE. Edited by Frank W . Newell, M.D. New York, The Josiah Macy Jr. Foundation, 1956. 251 pages. Price: $4.50. This volume is a verbatim transcription of

a three-day conference on glaucoma held in December, 1955, under the auspicies of the Josiah Macy Jr. Foundation. The list of par­ticipants in the conference reads like a Who's Who in glaucoma: Barany, Becker, Chandler, Grant, Kinsey, Scheie, Shaffer, Sugar, and von Sallmann to mention a few. Dr. Peter C. Kronfeld was chairman of the meeting and Dr. Frank W . Newell, the sec­retary.

Three major topics were discussed, angle-closure glaucoma, central control of intra­ocular pressure, and physiologic and pharma-cologic factors influencing the resistance to aqueous outflow. The keynote of the con­ference was informality and this is reflected in the transactions where it is almost im­possible to find a thought carried through to completion without several interruptions. For example, a question put to Dr. Shaffer on page 18 leads to a fascinating discussion of the semantics of glaucoma which continues for the next 11 pages where Dr. Shaffer says (wistfully?) " I think we should go on to pupillary block mechanism." ( H e goes on only for three paragraphs before a new dis­cussion erupts.) This unpolished presenta­tion is charming in that it allows the imagi­native reader to feel he is sitting in on the conference. The section includes some inter­esting comment on the psychiatric aspects of glaucoma by Dr. Ripley, an analyst.

The second presentation is an elaboration of the ninth Proctor Lecture by Dr. von Sallmann and here the commentary by Barany aids greatly in clarifying some of Dr. von Sallmann's erudite remarks. Barany then closes the conference with a report of his work on the chemical anatomy of the chamber angle. This work is in the fore­front of glaucoma research and is fascinat-