Glaucoma Part 4

FRANK C. TODD, M.D.,

Minneapolis.

It is very difficult for one of limited experience to discuss a subject presented so ably by Lieutenant Colonel Elliot to whom we are indebted for the sclero-corneal trephine operation. He has already over a period of a little over four years performed over 900 trephinings, and has made a most careful subsequent study of the results of those operations on as many cases as he had the opportunity to observe.

Anyone who has read Colonel Elliot's book on the sclera-corneal trephining operation will be struck with the fact that he has not only had a tremendous experience in ophthalmic surgery, but that he has made the best of that unusual opportunity, and that to a foundation of a careful training he has added the experience of twenty-two years of hard painstaking work.

I have recently had the privilege of entertaining Colonel Elliot in my own city, where I had the opportunity of a.s.sisting him and hence closely observing his technique in eighteen trephinings. It has since been my duty, and responsibility I may add, to care for those eighteen eyes. For two years I have been doing the Herbert tongue flap, or a similar operation. The results have been highly satisfactory thus far and similar to those following the trephining operation, which operation I have performed in a number of cases during the past ten months. My conclusions as to these two operations are favorable to the trephining operation because the Herbert tongue flap operation is much more difficult, and hence less certain than the Elliot trephining operation.

The time for discussion does not permit a detailed statement of the results nor experiences in the handling of these trephining cases. Of the entire number five totally blind eyes were trephined. Tension was reduced in all but one. In that one hemorrhage occurred at the time of the operation. One of these blind eyes had not been totally blind longer than a few weeks. Hand movement vision developed in this eye. Another eye totally blind one year has thus far developed perception of light.

Of the cases with varying degrees of vision from hand movements to six-ninths all but one have either remained the same or shown some improvement. The one exception was an eye having six-ninths vision. A small b.u.t.ton hole iridectomy was made; prolapse of the iris into the wound occurred four days later requiring incision. Upon incision of the prolapse intra-ocular hemorrhage occurred, causing nearly total blindness for two weeks. Vision is clearing fast and it remains yet to be seen what the final results may be. One buphthalmic eye trephined by myself gave good results.

I have as yet seen no cases of remote infection, but the report of Axenfeld and some others would indicate that this occurred following the Lagrange as well as the trephining operation, the then bulging conjunctiva having become eroded and infection having taken place through the eroded conjunctiva as shown when stained with flourescin.

The opinion, not yet conclusive, that I have thus far formed as a consequence of my experience and the information obtained from others of greater experience is as follows:

First: That in those cases of chronic glaucoma in which iridectomy has been of benefit in preventing or r.e.t.a.r.ding the oncoming of blindness, the result has apparently been secured by reason of the fact that filtration has been produced, and not merely because a piece of iris has been removed.

Second: That in chronic glaucoma (in acute glaucoma iridectomy has proven a satisfactory operation) when the progress of the disease cannot be arrested by non-surgical treatment (an even in some of these, where, for instance the patient cannot be kept under observation or will not carry out the treatment) some form of operation intended to produce filtration should be performed.

Third: The Elliot sclero-corneal trephining operation carefully performed in accordance with the author's technique in the light of our present knowledge seems to be the best and safest operation to produce that result.

Fourth: That to glaucoma may be added buphthalmos and staphyloma, as diseases often capable of relief by trephining and indeed toward the relief of which trephining is the best form of operation yet presented.

Fifth: That the results secured when the operation is well done and the after care is properly followed out are satisfactory, in that the operation in a large proportion of cases apparently permanently lowers the tension to normal or below normal, relieves pain, prevents the oncoming blindness (otherwise inevitable) and in many cases causes an improvement in the acuity of vision, in the visual field. And in occasional cases of blindness of not too long duration, it restores some vision, occasionally to a marked degree.

Sixth: That it is not a simple nor easy operation and should, therefore, be performed only by an operator well trained in ophthalmic surgery. The careful and skillful technique of the originator of the operation perhaps accounts for his greater success in its results and those who perform the operation should follow his technique and be capable of handling complications that may later arise.

In conclusion, Mr. President, I wish to say that we ophthalmologists the world over are indebted to Lieutenant Colonel Elliot not alone for his contributions to our knowledge, but for his persistence against precedent and criticism in establis.h.i.+ng the facts upon which rest the foundation for the success of his operation, and for so emphasizing the great importance of this epoch-making achievement.

It is because we respect his wisdom gained by incessant study and experience in a country where climatic conditions are such that a man of ordinary energy would have failed to do even average work that we so readily welcome the teaching of this enthusiastic evangelist.

His pilgrimage to our country will be the means of starting many in this new field, and we shall soon be able to draw more definite and final conclusions from our own experiences.

Operations Other than Scleral Trephining for the Relief of Glaucoma

BY

CASEY A. WOOD, M.D.,

Chicago.

In this paper I shall say a few words about the large number of operative procedures that, apart from trephining, or, preferably, _trepanation_, have been urged in the treatment of the various forms of glaucoma. Their name is legion and among them we find peripheral iridectomy; anterior sclerotomy; irido-sclerotomy; scleriritomy; de Wecker's dialysis of the iris; Hanc.o.c.k's division of the ciliary muscle; the incision of the iridian angle of de Vincentiis; sclero-cyclo-iridic puncture; the Sterns-Semmereole _sclerotomia antero-posterior_; the _transfixio iridis_ of Fuchs; Antonelli's peripheral iritomy; Holth's formation of a cystoid cicatrix; Hern's operation; Terson's sclero-iridectomy; Abadie's ciliarotomy; Ballantyne's incarceration of iris method; Ma.s.selon's small equatorial sclerotomy; Simi's equatorial sclerotomy; Galezowski's sclero-choriotomy; excision of the cervical ganglion; removal of the ciliary ganglion; Querenghi's operation of sclero-choriotomy; Bettremieux's simple anterior sclerectomy; Heine's cyclodialysis; Herbert's wedge-isolation operation; Verhoeff's operation with a special sclerotome; Holth's sclerectomy with a punch-forceps; Walker's hyposcleral cyclotomy; posterior sclerotomy; T-shaped sclerotomy; and last but not least the Lagrange form of sclerectomy with its various modifications by Brooksbank James, myself and others.

In addition to the foregoing list--which is by no means complete--there are several combinations of operations, as, for example, the Fergus trephining operation, which is really a combination of a sclero-corneal trepanation and a cyclodialysis.

So far as it is practicable there is a certain amount of wisdom in comparing the results of an operative procedure with others with which it is brought in compet.i.tion, and I believe we are even now in a position to form at least some idea of the comparative value of the three methods that comprise the great majority of interventions made use of by ophthalmic surgeons at the present time. I refer to _iridectomy_, the _Lagrange operation_, and the _Elliot operation_. So far as regards the last named procedure, I congratulate this Society that it has had an opportunity of seeing a demonstration and hearing a discussion by the famous ophthalmic surgeon who perfected it.

As regards the others let me recommend to you the complete description of them given by Posey in _A System of Ophthalmic Operations_.

Let us consider the first of the three procedures just mentioned--_iridectomy_--introduced by von Graefe. The mechanism of its mode of cure is best studied in cases of acute primary glaucoma, when there is apposition of the periphery of the iris to the cornea. In these acute cases there is probably only a mere _apposition_, and the blocking up of the sclero-iridian angle is largely mechanical. Here the root of the iris is readily removed in its entirety and a really peripheral iridectomy is easily done. When, however, a true _adhesion_ between corneal and iridic tissue takes place the filtration angle is not so easily opened. True peripheral adhesions are not readily broken up or separated, and the iridectomy is, for that reason at least, not effective. Moreover, this form of anterior synechia (resulting from a true union of iris and cornea) is so intimate that the iris root is, by the iridectomy, torn away only at the sclero-iridian angle at the anterior border of the adhesion--and does not open up a channel into Schlemm's ca.n.a.l. It is not, therefore, difficult to understand why iridectomy alone in any of the forms of chronic glaucoma fails to open up the true filtration s.p.a.ces and does not provide a drain that permits of an escape of fluid from the posterior chamber through the loose tissue that surrounds it into the ca.n.a.l of Schlemm. Treacher Collins found, after a careful examination of eyes upon which iridectomy had been performed for glaucoma, that it is extremely rare for the initial section to pa.s.s through the pectinate ligament, while Schlemm's ca.n.a.l invariably escapes. Moreover, since the sclero-corneal incision is uniformly oblique, the position and extent of the external wound does not always furnish evidence of the character of the internal wound. In all likelihood many cases of relief or cure following iridectomy are those due to the formation of cystoid scars or minute fistulae, rather than as a result of the removal of a portion of the iris periphery.

The best brief tabulation of the results obtained by iridectomy, in glaucoma, is to be found in Weeks' textbook on _Diseases of the Eye_, page 417: "Sulzer reports as follows: Acute glaucoma, 149 cases; improved, 72.5 per cent; serviceable vision preserved, 11.3 per cent; vision impaired at once, 4.08 per cent; very little vision, 12.12 per cent.

"Zentmeyer and Posey: In simple glaucoma central vision increased in 60 per cent; remained the same in 20 per cent; diminished in 20 per cent.

"WyG.o.dski: Inflammatory glaucoma, 37 cases; improvement, 76 per cent; unimproved, 5 per cent; deterioration, 19 per cent. Sub-acute (chronic inflammatory), 147 cases; improvement 10 per cent; unimproved (condition the same as before iridectomy), 40 per cent; deterioration, 30 per cent; blindness, 20 per cent. Cases operated on at an early stage gave 85 per cent of good results. Simple glaucoma, 104 cases; improvement, O.96 per cent; condition as before, 10.5 per cent; deterioration, 52 per cent; amaurosis, 36.5 per cent.

"Hahnloser and Sidler: One hundred seventy-two eyes observed not less than ten years after operation; acute inflammatory, 31 eyes; good results, 64 per cent; relatively good, 13 per cent; blind 23 per cent; chronic inflammatory, 37 eyes; good result, 29.9 per cent; relatively good, 27 per cent; blind, 43 per cent; simple glaucoma, 76 eyes; good results, 42 per cent; relatively good, 28.9 per cent; blind, 28.9 per cent."

As far as the _Lagrange procedure_ is concerned, you will remember that after eserinization an oblique incision is made through the sclera by means of a narrow Graefe knife and a large conjunctival flap secured.

This is obtained by making a peripheral section of the sclero-corneal margin with the knife and, as soon as the edge of the knife reaches the upper limit of the anterior chamber, it is turned backward and brought out through the sclera obliquely. The conjunctival flap thus formed is turned back over the cornea, and the fragment of sclera that is left attached to the cornea is removed by means of a fine pair of delicate curved scissors. Following this an iridectomy is performed. The conjunctival flap is now replaced and a bandage applied.

This operation opens a large filtration pa.s.sage for the intra-ocular fluids and the prompt healing of the wound with its mucous covering prevents prolapse of the iris.

Under no circ.u.mstances must iris be left between the lips of the wound.

Although Lagrange advocated iridectomy in all cases in his first communication, he no longer judges the procedure to be necessary in all instances, reserving it for cases in which for any reason, such as hypertension, prolapse is to be feared.

While Lagrange holds that it is necessary to open the anterior chamber, Bettremieux thinks that a removal of but a portion of the thickness of the sclera suffices. His procedure is as follows: After raising a flap of conjunctiva from the neighborhood of the limbus a medium sized needle, curved and flattened towards its point and firmly grasped in a needle holder, is thrust superficially into the sclera tangentially to the upper edge of the cornea, so as to become fixed in the capsule of the eyeball. A small shaving of the sclera, about mm. thick, 1 to 2 mm. broad and from 2 to 3 mm. long, is then excised by means of a narrow Graefe knife. The scleral slip is then freed from the conjunctiva at each end and the mucous membrane brought together over the wound by fine catgut sutures.

As you are well aware, numerous operators regard the Lagrange operation as superior to the iridectomy of von Graefe because they believe there is filtration through the newly formed tissue between the lips of the operative wound. Among those of many observers the conclusions of Ballantyne may be quoted: "The results of sclerectomy vary according to the degree of hypertension of the eye operated on. Three varieties of cicatrix are distinguishable according to the amount of sclera excised: (1) that in which there is mere thinning of the sclera owing to the excised portion not reaching the posterior surface of the cornea (conjunctiva smoothly covers the cicatrix); (2) that represented by a subconjunctival fistulette, due to excision of the whole thickness of the sclera, in an eye with moderate tension (the conjunctiva lies smoothly over the cicatrix); (3) the fistulous cicatrix with an ampulliform elevation of the overlying conjunctiva, resulting from excision of the whole thickness of the sclera in an eye the seat of high tension. In cases of high tension, even a simple sclerectomy will allow ample filtration, owing to the gaping of the wound, while in cases without elevation of the tension, sclerectomy will be quite ineffectual.

Lagrange therefore proposes the following rules of procedure: (a) If tensions is normal to +1, do sclerectomy without iridectomy, the amount of sclera excised being inversely proportionate to the degree of hypertension. (b) If tension is +1 to +3, do sclerotomy-iridectomy, the iridectomy being added to avoid entanglement of the iris. Lagrange does not recommend his operation for acute glaucoma. It is especially adapted for cases of chronic simple glaucoma."

During the past ten years or more I have been doing a modification of the Lagrange operation, the details of which (The Operative Treatment of Glaucoma with Special Reference to the Lagrange Method, _The Canadian Medical a.s.sociation Journal_, November, 1911) I have elsewhere published.

As stated in this paper I have modified the procedure to the extent of removing _all_ the conjunctiva attached to the borders of the operative wound. I admit that this intervention exposes the root of the iris and the ciliary body, but I have never yet had the slightest infection of the wound. I attribute this freedom from sepsis to careful cleansing of the conjunctival sac and to other pre-operative precautions, but especially to the use, before and after the operation, of White's ointment--a preparation of 1-3000 mercuric chloride in sterile vaseline.

One cannot use sublimate in such a strong _watery_ solution, but the vaseline seems to modify it and to allow of such slow absorption that it is not only a non-irritant but a most excellent antiseptic application in operations on the eye.

In any event the result of the Lagrange operation proper, as well as my modification of it, is to produce a drainage-oedema about the incisional wound which persists almost indefinitely. In many cases this swelling amounts to a bleb which may be increased by ma.s.sage of or pressure upon the eyeball. The efficacy of the operation in lowering intra-ocular tension is to some extent measured by the degree and the constancy of this epibulbar oedema; indeed, I suspect that the most successful examples are those in which sclera fistulae, minute or otherwise, form as a sequel of the operation.

My object in excising the conjunctiva about the sclero-corneal flap, is to delay union of the wound edges, to widen the bridge of loose cicatricial tissue between them, to prevent such a complete growth of the endothelium as would cover the wound and block the exit of fluids, and to insure intra-ocular rest.

In cases of _chronic_ increase of intra-ocular tension a.s.sociated with a quiet uveitis or an iridokerat.i.tis, when the patient exhibits traces of old synechiae, or where there is danger of their re-formation, I do not hesitate to use atropia as long as the wound of operation has not healed.

To the present time I have done 72 operations of the sort and have seen no reason to alter the opinion of it expressed in the article mentioned.

Whatever objection may in the future arise--and I freely confess that it _seems_ to be fraught with the dangers that many of my colleagues have pointed out as probable--I have so far not seen a single case of infection of the wound of operation. While I believe the anti-glaucomatous results to be excellent, I may also claim that the operation is of the simplest character; and it is easy of performance and the resulting filtration-scar is large and (perhaps) more permeable to the changed intra-ocular fluids than the quicker healing wounds of the usual Lagrange and Elliot procedures.

It is regarded by most operators as desirable that there should not be long delayed healing of the operative wound, and the fact that the conjunctiva covers the incision is often spoken of as an advantage, partly because it s.h.i.+elds the large open area produced by the Lagrange incision from infection.

My experience of this modified operation continues to be that it is necessary to clear the neighborhood of the operation wound entirely of conjunctiva. If the down-growth of epithelium into the operative wound is permitted the effects are by no means as p.r.o.nounced, and the eventual lowering of tension is not as permanent as they otherwise would be.

Another matter: I am satisfied that the delayed filling of the wound by connective tissue is desirable in most cases of _chronic_ glaucoma. A complete drainage of the intra-ocular fluids that results from long delayed union of the wound edges, allows the interior of the eye to regain, as far as possible, the _status quo ante_. On the other hand the comparatively early closure of the wound (or the termination of _free_ drainage and minus tension) tends to re-establish the _status glaucamatosus_. Whether these desirable results are to be realized or not will, of course, depend upon a future experience larger than I have yet had. This modification of the Lagrange operation seems to be a radical one and I do not expect its adoption until the results of an extended trial are carefully recorded and reported.