Yonago Acta medica 1996;39:143–150

Reevaluation of Full-Width Tenotomy of Four Rectus Muscles Combinedwith Transscleral Pars Plana Cyclocryoapplication for Intractable Neovascular Glaucoma
Akihiko Tamai, Atsushi Yamasaki, Masao Nagata, Kyutaro Ito, Junji Hamamoto,
Shigeru Takagi, Yuji Sasaki, Kimiko Kawai, Machiko Inoue, Ryoko Ishihara,
Takeshi Kumagami, Go Ishino and Masayuki Funada*
Department of Ophthalmology, Faculty of Medicine, Tottori University, Yonago 683 and*Department of Ophthalmology, Yoka Municipal Hospital, Hyogo 667, Japan
We reevaluated full-width tenotomy of 4 rectus muscles combined with transcleral pars
plana cyclocryoapplication for intractable neovascular glaucoma. Fifteen patients (15eyes) with advanced, uncontrollable neovascular glaucoma resulting from various causes
were treated with the new surgical procedures. The visual acuity ranged from no lightperception to hand motion. As the surgery was intended to disrupt all the anteriorciliary arteries in the rectus muscles, we added the cyclocryoapplication to the site ofinsertion before resuturing of the severed muscles, with the aim of interrupting therecanalization of the fully cut ciliary vessels. The patients were followed up for 6 to 78
months, average 55.7 months. At the end of follow-up, all 15 eyes had no light perception.
The intraocular pressure level decreased from the preoperative level of 53.7 ± 13.4mmHg (mean ± SD) to 13.0 ± 5.3 mmHg without additional medical therapy. The
decrease was significant (P < 0.0001). The intraocular pressure remained below 10mmHg in 5 eyes, one of which became phthisic. Prominent rubeosis iridis regressed orappeared to regress in the 15 eyes. All patients felt comfortable. No patients complainedof ocular pain, headache or vomiting after surgery. The findings reconfirm that thecurrent surgical procedure is beneficial and effective in the management of
uncontrollable neovascular glaucoma with extremely poor vision.
Key words: anterior ciliary arteries; 4 rectus muscles; full-width tenotomy; neovascular glaucoma;
transscleral pars plana cyclocryoapplication

Medication and surgical treatment for eyes suffering from rubeosis iridis and neovascularglaucoma have always been problematic. Topical cycloplegics and corticosteroids relievepain, but do not control the glaucoma (Drews,
1974; Kanski and McAllister, 1989). Carbonic
anhydrase inhibitors decrease intraocular pressure, but rarely provide satisfactory control.
Regarding surgical procedures for neovascularglaucoma, angle vessel or panretinal photocoagulation appears to be beneficial before fibrovascular tissue has significantly closed theangle. However, once neovascular glaucoma
has been established, these therapies are usuallyineffective (Wand et al., 1978; Fukuda et al.,
143

1980; Suguro et al., 1987). Modified conventional filtration surgery and artificial filtering
shunts are considered by some (Sinclair et al.,
1982; Schocket et al., 1985; Kanski and
McAllister, 1989) to be preferential treatments
for eyes with rubeosis iridis and neovascularglaucoma. Cyclodestructive procedures including cyclocryotherapy, transscleral neodymium:
YAG (yttrium aluminum garnet) laser cycloablation and cyclophotocoagulation ab externo
are usually indicated when all hope of salvaging
useful vision is lost, but rarely provide satisfactory control (Krupin et al., 1978; Wesley andKielar, 1980; Kanski and McAllister, 1989;
Hamano et al., 1992; Inaba et al., 1994).

A. Tamai et al.

Table 1. Subject patients with advanced, uncontrollable neovascular glaucoma
PatientNo.

Age(year)

Sex

Side(eye No.)

Cause

1 E. M.
72
M
L ( 1)
2 K. A.
71
F
R ( 2)
3 Y. E.
61
F
L ( 3)
4 F. S.
64
M
R ( 4)
5 M. T.
85
F
R ( 5)
6 Y. K.
67
F
L ( 6)
7 Y. T.
81
M
L ( 7)
8 K. I.
75
M
L ( 8)
9 T. H.
68
M
L ( 9)
10 K. T.
76
M
R (10)
11 N. T.
61
F
L (11)
12 N. S.
52
M
R (12)
13 M. F.
59
F
L (13)
14 M. E.
70
F
R (14)
15 H. K.
62
M
L (15)
Mean ± SD
68.3 ± 8.8
F, female; L, left eye; M, male; R, right eye.

Proliferative diabetic retinopathy
Unknown
Unknown
Proliferative diabetic retinopathy
Unknown
Central retinal vein occlusion
Unknown
Unknown
Unknown
Senile disciform macular degeneration
Unknown
Unknown
Proliferative diabetic retinopathy
Proliferative diabetic retinopathy
Central retinal vein occlusion

Since 1985, after observing and considering
the mechanism of the anterior segment ischemia associated with strabismus surgery (Girard
and Beltranena, 1960; McKeown et al., 1989;
Kanski and McAllister, 1989), we have carriedout a new surgical treatment, consisting of fullwidth tenotomy of 4 rectus muscles combinedwith transscleral pars plana cyclocryoapplica-tion, for patients with advanced, uncontrollable
neovascular glaucoma and extremely poor vision, with beneficial and effective results(Tamai et al., 1988, 1990, 1992; Hosogi et al.,1990). We reevaluate herein the favorable results achieved by these techniques in other patients with intractable neovascular glaucoma.

Table 2. Visual acuity of 15 eyes before and after surgery
Eye
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Mean

Visual acuity
BeforeAfter

No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
Hand motion
Light perception

No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception
No light perception

144

Monthsfollowed
78
78
76
76
72
66
62
61
61
60
56
43
31
10
6
55.7

Rectus muscle tenotomy in neovascular galucoma

Fig. 1. View of the operation. A 360˚ peritomy of the conjunctiva is first made 2 mm posterior and parallelto the limbus (a). Then, the superior rectus muscle is hooked using a muscle hook (b) and a 5-0 catgut
mattress is placed on both sides at the end of the superior rectus tendon (c). Under these conditions, a fullwidth, superior rectus tenotomy is performed (d, e). The other 3 rectus muscles are tenotomized one by one
in the same way. Transscleral cyclocryoapplication is performed at each insertion by using a retinal probe of
the Amoils Cryo Systems: 20 to 30 s, –65˚C, a total of 15 spots with 3 rows of 5 applications (f). Then, thesevered muscles are individually resutured at the insertion points (g). Finally the conjunctiva is interruptedly
closed with 8-0 virgin silk (h).

145

A. Tamai et al.

Table 3. Intraocular pressure of 15 eyes before and after surgery
EyeNo.

Intraocular pressure (mmHg)
BeforeAfter*
Difference

Pairedt-test

1
44
10
–34
2
56
16
–40
3
40
8
–32
4
38
15
–23
5
59
8
–51
6
45
16
–29
7
40
26
–14
8
46
13
–33
9
46
15
–33
10
72
18
–54
11
50
16
–34
12
76
12
–64
13
55
8
–47
14
80
6
–74
15
58
8
–50
Mean ± SD
53.7 ± 13.4
13.0 ± 5.3–40.8 ± 15.8 P < 0.0001* No subsequent medical treatment of neovascular glaucoma was required.
** 20.0% of 5 hypotonic eyes below 10 mmHg and 6.7% of all 15 eyes.

Subjects and Methods
Between July 1989 and June 1995, 15 patients(15 eyes) with neovascular glaucoma weretreated with the new surgical procedures foruncontrolled intraocular pressure and associated ocular pain, headache and vomiting, withthe consent of the subject patients. Intraocularpressure was measured with a Goldmann application tonometer attached to a slitlamp biomicroscope (Carl Zeiss Co., Ltd., Japan, Tokyo,
Japan). The operated eyes ranged between
having no light perception and the ability to detect hand motion. The age of the patients at surgery was 68.3 ± 8.8 years (mean ± SD). Neovascular glaucoma occurred in 4 eyes of the 4patients with proliferative diabetic retinopathy,
in 2 eyes of the 2 patients with central retinal
vein occlusion and in 1 eye of the 1 patient with
senile disciform macular degeneration. The
other 8 eyes of the remaining 8 patients had
undetermined disorders (Table 1). The lengthof follow-up ranged from 6 to 78 months, average 55.7 months (Table 2).
Details of our surgical procedures have been
fully described elsewhere (Tamai et al., 1988,

Monthsfollowed
78
78
76
76
72
66
62
61
61
60
56
43
31
10
6
55.7

Remarks

Phthisis bulbi**

1990, 1992; Hosogi et al., 1990), and only themain points will be outlined below, as demonstrated in Fig. 1.
We performed full-width tenotomy on the 4
rectus muscles to disrupt all the anterior ciliaryarteries in the muscles on 15 eyes in the 15
patients under local anesthesia. The tenotomy
was done by instillation of 0.4% oxybuprocainehydrochloride and by retrobulbar injection of
2% xylocaine (Figs. 1d and 1e). Although thesevered muscles were resutured at the insertion
points, transscleral cyclocryoapplication wasadded at each insertion before resuturing, withthe aim of interrupting the recanalization of the
fully cut ciliary vessels. A single-freeze-thaw
technique (lasting 20 to 30 s) was used at -65˚Cwith a retinal probe (2.5 mm diameter) from the
Amoils Cryo Systems (Konan Keeler Ltd.,
Osaka, Japan). The 15 eyes received 15 applications at each insertion (a total of 15 spots with
3 rows of 5 applications) (Fig. 1f). All eyes
received topical antibiotics and corticosteroids
after the operation for at least 1 week. No subsequent antiglaucoma medication was applied.

146

Rectus muscle tenotomy in neovascular galucoma

from the preoperative level of 53.7 ± 13.4mmHg (mean ± SD) to 13.0 ± 5.3 mmHg without any subsequent medical treatment. The decrease was statistically highly significant by thepaired t-test (P < 0.0001). The intraocularpressure remained below 10 mmHg in 5 eyes
(33.3% of the 15 eyes), one of which became
phthisic (20.0% of the 5 hypotonic eyes and6.7% of the 15 eyes) (Table 3).
Prominent rubeosis iridis with secondary
angle-closure glaucoma, Stage IV in the classification of Fukuda and others (1980), was observed in all 15 eyes before surgery through slitlamp biomicroscopic and gonioscopic examinations. Final examination revealed that theneovascularization of the iris in Stage IV had
regressed in 7 eyes (46.7% of the 15 eyes) andappeared to regress in 8 eyes (53.3%) (Table 4).
Figure 2 presents the preoperative situationof the left eye in Patient 3. Prominent dilated
rubeosis iridis is visible. Figure 3 presents the
postoperative situation of the left eye in the patient. This photograph was taken 1 month after
surgery. The remarkable regression of the rubeosis iridis is obvious.
All patients were comfortable. No patientscomplained of ocular pain, headache or vomiting after surgery, although the grade of severity
had been different for each patient before surgery (Table 5).

Table 4. Rubeosis iridis of 15 eyes before
and after surgery
EyeNo.

Rubeosis iridis
BeforeAfterMonthsfollowed

1
Stage IV* Regressed
78
2Stage IV Regressed
78
3Stage IV Regressed
76
4Stage IV Appeared to regress
76
5
Stage IV Regressed
72
6Stage IV Regressed
66
7Stage IV Appeared to regress
62
8
Stage IV Appeared to regress
61
9Stage IV Appeared to regress
61
10
Stage IV Appeared to regress
60
11Stage IV Appeared to regress
56
12
Stage IV Regressed
43
13Stage IV Appeared to regress
31
14
Stage IV Appeared to regress
10
15
Stage IV Regressed
6
Mean
55.7
*Stage IV in the classification of Fukuda and others(1980).

Results
At the end of follow-up, 13 eyes having no lightperception before surgery (86.7% of the 15 eyestreated) remained unchanged after surgery. No
light perception was observed postoperatively
in 1 eye having hand motion (6.7%) and in 1 eye
having light perception before surgery (6.7%),
indicating that all 15 eyes had no light perception after surgery (Table 2).
The intraocular pressure level decreased

Fig. 3. Postoperative condition of Patient 3 (lefteye), 1 month after surgery.

Fig. 2. Preoperative condition of Patient 3 (left eye).

147

A. Tamai et al.

Table 5. Subjective complaints of 15 patients before and afte surgery
Patient
No.

Ocular pain
BeforeAfter

Headache
BeforeAfter

1 E. M.
++–++–
2 K. A.
++–++–
3 Y. E.
++–++–
4 F. S.
+–+–
5 M. T.
++–++–
6 Y. K.
++–++–
7 Y. T.
++–++–
8 K. I.
++–++–
9 T. H.
++–++–
10 K. T.
+++
–
+++
–
11 N. T.
++–++–
12 N. S.
++–++–
13 M. F.
++–++–
14 M. E.
++–++–
15 H. K.
++
–
++
–
Mean
Severity indexes (+++, ++, +, ±): no complaint is indicated as –.

Discussion
The posterior ciliary arteries in itself produce
no important changes in the anterior segment(Virdi and Hayreh, 1987) and the majority ofblood flow to the anterior segment is carried by
the anterior ciliary arteries (Wilcox et al., 1980).
Therefore, interruption of the anterior ciliaryarteries during a rectus muscle tenotomy isgenerally accepted as the cause of the anterior
segment ischemia which follows strabismus
surgery (Girard and Beltranena, 1960; Wilcox
et al., 1980; Vird and Hayreh, 1987; McKeownet al., 1989). The pathogenesis of anterior segment ischemia is not completely understood,
but is presumably related to some perturbationof the blood supply to the anterior segment, resulting in iridocyclodestruction (McKeown etal., 1989). The anterior segment ischemia associated with strabismus surgery may decrease
uveal blood flow and obliterate capillary circulation at the iris and ciliary processes, producing a decrease in active and passive aqueous
secretions (McKeown et al., 1989; Kanski and
McAllister, 1989).
Since 1985, after observing and considering
the mechanism of the anterior segment ischemia (Girard and Beltranena, 1960; McKeown etVomiting
Before
After
+
+
±
±
++
+
+
+
+
++
++
++
+
++
++

–
–
–
–
–
–
–
–
–
–
–
–
–
–
–

Monthsfollowed
78
78
76
76
72
66
62
61
61
60
56
43
31
10
6
55.7

al., 1989; Kanski and McAllister, 1989), we
have carried out the new surgical treatment inpatients with advanced, refractory neovascularglaucoma resulting from various causes andonly allowing vision to range from the inability
to perceive light to the ability to perceive handmotion (Tamai et al., 1988, 1990, 1992; Hosogi
et al., 1990), as mentioned above.
In our present study, 15 patients (15 eyes)with advanced, intractable neovascular glaucoma had no light perception in 13 eyes andhand motion in the other 2 eyes before surgery.
In glaucoma patients with no useful vision, thecontrol of associated ocular pain, headache orvomiting is usually more important than thecontrol of elevated intraocular pressure (Tamai
et al., 1988, 1990). Our new surgical techniqueprovided relief from the subjective complaints,
especially persistent ocular pain without enucleation or retrobulbar alcohol injection (Tamai
et al., 1988, 1990, 1992; Kanski and McAllister,
1989; Hosogi et al., 1990). This result suggeststhat sensory nerves or pain receptors in the eyeball are likely to degenerate with the anterior
segment ischemia derived from the surgery(Awaya et al., 1989). In the present study, nopatients complained of ocular pain, headache or148

Rectus muscle tenotomy in neovascular galucoma

even vomiting either after surgery. All subject
patients felt comfortable after surgery.
The preoperative intraocular pressure(53.7 ± 13.4 mmHg) significantly decreased (P< 0.0001) postoperatively to 13.0 ± 5.3 mmHg
without any subsequent medical treatment, andprominent rubeosis iridis regressed or appeared
to regress postoperatively in the 15 eyes in thepresent study.
Although just 1 eye became phthisic at theend of follow-up in this survey, the relatively
high incidence of late serious complications,such as hypotony defined as less than 10 mmHg
and phthisis bulbi, may be caused by excessive
destruction of the ciliary body by these cyclodestructive procedures (Tamai et al., 1988,
1990, 1992; Hosogi et al., 1990). The combined transscleral pars plana cyclocryoapplication
might influence the ciliary processes and the
peripheral retina (Kurpin et al., 1978; Wesley
and Kieler, 1980; Tamai et al., 1988, 1990,
1992; Kanski and McAllister, 1989). Therefore, we believe that there is a need to develop
other modified forms of our procedures for eyeswith vision potential, i.e., tenotomy of 3 or 4 rectus muscles without cyclocryoapplication andsimultaneous recession (Awaya et al., 1989) oradvancement of the severed muscles (Tamai etal., 1992).
In conclusion, various types of operation for
neovascular glaucoma rarely provide satisfactory control (Kurpin et al., 1978; Wand et al.,
1978; Fukuda et al., 1980; Wesley and Kieler,
1980; Sinclair et al., 1982; Schocket et al.,
1985; Kanski and McAllister, 1989; Hamano etal., 1992; Inaba et al., 1994), but the results obtained in the present study reconfirm the previous evaluation that the current surgical procedure is beneficial and effective in the management of uncontrollable neovascular glaucoma
with extremely poor vision (Tamai et al., 1988,
1990, 1992; Hosogi et al., 1990).

References
1 Awaya S, Miyake Y, Miura M, Okuda N. Simultaneous recession of four recti for rubeotic glaucoma. Nippon Ganka Kiyo 1989;40:2349–2350(in Japanese with English abstract).

149

2 Drews RC. Symposium. Glaucoma. Corticosteroid management of hemorrhagic glaucoma.
Trans Am Acad Ophthalmol Otolaryngol 1974;
78:334–336.
3 Fukuda M, Yamada Y, Tsukimoto N, Maekubo K.
Effects of trabeculectomy and panretinal photocoagulation of neovascular glaucoma. Rinsho
Ganka 1980;34:563–570 (in Japanese with English abstract).
4 Girard LJ, Beltranena F. Early and late complications of extensive muscle surgery. Arch Ophthalmol 1960;64:576–584.
5 Hamano K, Toyoguchi A, Yamamoto K, Goto H,
Usui M. Cyclophotocoagulation ab externo.
Ganka Rinsho Iho 1992;86:2381–2385 (in Japanese).
6 Hosogi K, Ueno H, Takahashi T, Yasuoka K,
Kuzume K, Tamai A, et al. Tenotomy of four rectus
muscles for neovascular glaucoma. Rinsho Ganka
1990;44:793–798 (in Japanese with English
abstract).
7 Inaba I, Inoue T, Takemoto Y, Ichioka H. Modified cyclophotocoagulation ab externo in the treatment of neovascular glaucoma. Nippon Ganka
Kiyo 1994;45:948–951 (in Japanese with English
abstract).
8 Kanski JJ, McAllister JA. Glaucoma. A color
manual of diagnosis and treatment. London:
Butterworths, 1989:66–147.
9 Krupin T, Mitchell KB, Becker B. Cyclocryotherapy in neovascular glaucoma. Am J Ophthalmol 1978;86:24–26.
10 McKeown CA, Lambert HM, Shore JW. Preservation of the anterior ciliary vessels during extraocular muscle surgery. Ophthalmology 1989;96:
498–507.
11 Schocket SS, Nirankari VS, Lakkanpal V,
Richards RD, Lerner BC. Anterior tube shunt toan encircling band in the treatment of neovascularglaucoma and other refractory glaucomas. Ophthalmology 1985;92:553–562.
12 Sinclair SH, Aaberg TM, Meredith TA. A pars
plana filtering procedure combined with lensectomy and vitrectomy for neovascular glaucoma.
Am J Ophthalmol 1982;93:185–191.
13 Suguro K, Isobe M, Yamamori O. Effect of laser
goniophotocoagulation on neovascular glaucoma. Rinsho Ganka 1987;41:1245–1248 (inJapanese with English abstract).
14 Tamai A, Matsumoto Y, Ueno H, Kishi S,
Takahashi T, Yano K, et al. A new surgical treatment of neovascular glaucoma. A preliminary
report of 4 rectus muscle tenotomies. Ganka
Rinsho Iho 1988;82:2280–2284 (in Japanese).
15 Tamai A. Hosogi K, Ueno H, Matsumoto Y. The
effects of 4 rectus muscle tenotomies combinedwith transscleral pars plana cyclocryoapplication
on intractable neovascular glaucoma. Yonago
Acta Med 1990;33:85–94.

A. Tamai et al.

16 Tamai A, Osada K, Nakao H, Sasaki Y, Shimada K,
Murata Y, et al. Full-width tenotomy of four rectus
muscles for intractable neovascular glaucoma. In:
Shimizu K, ed. Current aspects in ophthalmology.
Amsterdam: Elsevier Science Publishers B. V.
(Biomedical Division), 1992:1436–1439.
17 Virdi PS, Hayreh SS. Anterior segment ischemia
after recession of various recti. An experimental
study. Ophthalmology 1987;94:1258–1271.
18 Wand M, Dueker DK, Aiello LM, Grant WM.

Effects of panretinal photocoagulation on rubeosis iridis, angle neovascularization, and neovascular glaucoma. Am J Ophthalmol 1978;86:332–
339.
19 Wesley R, Kielar RA. Cyclocryotherapy in treatment of glaucoma. Glaucoma 1980;3:533–537.
20 Wilcox LW, Keough EM, Connolly RJ, Hotte
CE. The contribution of blood flow by theanterior ciliary arteries to the anterior segment in
the primate eye. Exp Eye Res 1980;30:167–174.

(Received August 19, Accepted September 18, 1996)

150