NOTES, CASES, INSTRUMENTS 1289

CONJUNCTIVAL TRANSPLANT FOR THE TREATMENT

O F PTERYGIUM

JANOS MAJOROS, M.D. Kiskunhalas, Hungary

It is my opinion that, with the exception of the inner part of the bulbar conjunctiva which differs from other conjunctiva, con-junctival ingrowth is the chief cause of pterygium. It is, therefore, essential to keep the conjunctiva from creeping back onto the cornea after the removal of a pterygium. To accomplish this it is necessary to erect a bar­rier between the incision for the removed pterygium and the cornea. For this purpose I use the upper and outer part of the bulbar conjunctiva for transplantation, since it is well known that a pterygium never develops from this area.

After thorough scraping and cleansing of the pterygium wound, a conjunctival graft, about 5 by 5 mm. in dimension, is cut and placed at the recipient site. It is not necessary to suture either the donor site or the graft, but the patient should keep his eyes closed for 10 to 15 minutes after positioning of the graft to insure its staying in place.

Before the eye is bandaged, care must be taken to see that it is kept closed. The first postoperative dressing is two days later.

It is surprising how quickly the eye heals after this procedure. By the third or fourth day, there is little redness or injection. The donor site is frequently more inflamed than the eye itself. Healing may be speeded by the use of an eye bath.

On two occasions (out of more than 50 operations) the transplant has become ne-crotic and caused severe reaction. I do not know whether the graft was inverted before it was placed, or whether necrosis was due to a local anaphylactia.

This method of conjunctival transplanta­tion should prove useful in plastic repair of trachoma, epibulbar carcinoma, posttraumatic pterygoids, and recurrent pterygia. Alto­gether I have done 50 conjunctival trans­

plantations according to this technique with­out a recurrence. By using the outer part of the bulbar conjunctiva, one is also able to avoid the conspicuous graft of buccal mucosa. The cosmetic result with my procedure is excellent.

Hotvos-u. 17.

CORRECTION NECESSARY IN PRINCE'S RULE

MALVIN PROCTOR, M.D. Tuckahoe, New York

Most ophthalmologists measure the power or amplitude of accommodation by the use of the Prince rule or the Berens accommodation meter. In both of these instruments the near point is determined by sliding the target in toward the eye until it begins to blur. The position of the nearest point at which the print is still clear (marked in cm. and inches) is noted, and, alongside, the amplitude in diopters corresponding to this distance is given. The amplitude, as marked on the ruler, is found from the near point by dividing the distance, in cm., into 100. Thus, if the near point is 16 cm., the amplitude is 100 divided by 16, which gives 6.25 diopters.

Beach1 and all books on refraction teach that before finding the near point of accom­modation the eyes must be refracted and made emmetropic. The near point must be found with the correcting lenses before the patient's eye. But when the patient wears his correcting lenses, the amplitude, as shown on the Prince rule, is not the true amplitude in diopters.

Pascal2'3 has shown that there is a unit of accommodation for every corrected ametrope and that this unit is more than one diopter for the corrected hypermetrope and less than one for the corrected myope.

There are several formulas for this unit, but a very close approximation is that the unit is equal to 1 + 2dL diopters, "L" being the power of the lens worn by the patient and "d" the distance in meters between lens and

1290 NOTES, CASES, INSTRUMENTS

eye. For the usual position of the correcting lens, the whole system simplifies to adding four percent of L or deducting three percent of L. Thus, if L is plus (corrected hyperope) the unit is 1.00 plus 4/100 of L. If L is minus (corrected myope) the unit is 1.00 minus 3/100 of L.

For example, in a 4.0D. hypermetrope, the unit is 1.00 plus 4/100 of 4.00, equals 1.16D. In a 4.0D. myope, the unit is 1.00 minus 3/100 of 4.00, equals 0.88D. The near point gives the number of units of accommodation the patient has. So that, if the near point on the Prince or Berens rule is 16 cm. the patient has 6.25 units of accommodation. This is derived by dividing 1.00 by 16.

The value of the accommodation in diop-

COSMETIC CURE O F ALTERNATING SQUINT*

C. MARTIN-DOYLE, D.O. (OXON. ) Worcester, England

At the outset, I wish to make it clear that the type of case to which I am referring has been given up by the orthoptist without any hope of treatment producing simultaneous macular perception. The case may be one with or without refractive error, and the vision with or without glasses may be 6/6 or 6/9 in each eye. The patient usually has a marked preference for fixing with one eye, but this preference is sometimes absent and he may be equally happy with either eye. We are, therefore, considering the matter of cos­metic cure only.

At the Worcester Eye Hospital during the past few years different operations have been

* From the Worcester Eye Hospital.

ters is equal to 6.25 times the value of the unit. In the case of the 4.0D. hypermetrope the accommodation is 6.25 times 1.16, which equals to 7.25 diopters. In the case of the 4.0D. myope this equals to 4.00 times 0.88, which equals to 5.50 diopters.

It can be seen from these two illustrative cases that the dioptral number on the rule, which is 6.25 at 16 cm., is not correct for the patient whose amplitude is determined while he is wearing his glasses. The ophthalmolo­gist, who wishes to know the true amplitude of accommodation of his patient, must find the near point, which gives the number of accommodative units, and multiply this num­ber by the dioptral value of the unit.

66 Main Street.

performed with cosmetic cure as their aim, and the object of this article is to attempt to assess their respective values.

Broadly speaking the cases can be divided into two groups: (1) Those with an angle of more than 20 degrees with or without glasses, and (2) those with an angle of less than 20 degrees with or without glasses.

1. In this group, in which the angle is more than 20 degrees, the operation of choice would seem to be that of resection and recession. The procedure at this hospital has been to get an orthoptic report noting the measurement of the angle, and with which eye the patient prefers to fix. The re­section and recession operation is then done on the other eye, that is, the eye that usually squints. The amount of resection and reces­sion done has been in accordance with the appended table and, if these measurements are carried out at the operation, the results appear to be remarkably accurate.

REFERENCES

1. Beach, S. J.: Verified refraction: Near point test. J.A.M.A., 138:953 (Nov.) 1948. 2. Pascal, J.: Efficiency of the lens: A clinical concept. Arch. Ophth., 34:466 (Nov.-Dec.) 1945. 3. : A physiological unit of accommodation. Eye, Ear, Nose & Throat Monthly, 35 :3S4 (July)

1946.