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; Hancock'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; Masselon'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 competition, 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 canal. 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 spaces 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 canal 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 pass through the pectinate ligament, while Schlemm's canal 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.
"Wygodski: 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 passage for the intra-ocular fluids and the prompt healing of the wound with its mucous covering prevents prolapse of the iris.
Under no circumstances 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 ½ mm. thick, 1½ 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 Association 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 massage 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 associated with a quiet uveitis or an iridokeratitis, 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 shields 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 pronounced, 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.
Quite recently several operators, who have been in a position to do so, have contrasted the results obtained by the Elliot method and those following the Lagrange procedure. Probably the most important of these observations is the experience of Meller (Die Sklerektomie nach Lagrange und die Trepanation nach Elliot) set forth in a paper read by him at the last meeting of the Deutsche Naturforscher und Aertze. In this report Meller gives an account of 389 sclerectomies following the usual Lagrange procedure. Twelve per cent of the cases were of acute glaucoma; 61.5 per cent of chronic inflammatory glaucoma, and 9 per cent of simple glaucoma. The rest of the operations were done in other forms of the disease. In more than half the cases the usual iridectomy was performed; in 30 per cent the procedure was peripheral; in 4 per cent there was no iridectomy. The patients were studied during a period of five years. In more than half the instances there was a pale, cystic, oedematous cicatrix; in 11 per cent the scar was ectatic, and in the remainder the field of operation was quite flat. The form of the scar was described in most instances, but it was not noticed that there was a definite relation between the cicatrical formation and the intra-ocular tension. In 70 per cent of the cases a good result followed the operation, but in 10 per cent the result was decidedly unsatisfactory. Cloudiness of the lens set in in 4 per cent of the cases, while posterior synechiae developed in the great majority of them. In 2.3 per cent the eye was attacked by iridocyclitis and in 3.4 per cent enucleation was found to be necessary. Six eyes became atrophic but were not, for various reasons, removed. One and three-tenths per cent of the eyes operated on were lost from late infection. Vitreous was lost in 6.2 per cent. Two eyes became blind from expulsive hemorrhage. The large majority of these complications arose in the eyes operated on for chronic glaucoma. There were fewer eyes lost following the operation for glaucoma simplex than in the other forms of the disease. Recurrences were noticed in 11.3 per cent of all the cases; in simple glaucoma 14.3 per cent as against the acute and chronic forms with 6 per cent. A return of the glaucoma was noticed in 7 per cent of the pale, oedematous, post-operative scars, in 16 per cent of the flat cicatrices, and in 24 per cent of the ectatic variety. Considerable stress is laid upon the fact of the marked softness of the eyes after each operation. There were histological examinations made of the eyeballs in 11 cases, in which the position of the incision and excision, the development of the scar tissue, and the appearance of the complications were duly set forth. The operator then gave a history of over 178 trepanations after the Elliot method and compares them with the procedure of Lagrange. He concludes that the Elliot trephining operation is less dangerous, is more likely to be followed by the development of a cystic scar, and leads to loss of the eye in only 2.4 per cent of the eyes operated on. In Elliot's cases the percentage of relapse was more noticeable than in the Lagrange cases where no iridectomy was done. This observer concludes that the method of Elliot is to be preferred to that of Lagrange, and that in the former case iridectomy is an important factor in obtaining a favorable result. This being the case one cannot truthfully say that trephining alone can take the place of the old Graefe iridectomy. On the other hand, trephining may with advantage be employed instead of iridectomy for cases difficult or dangerous under the latter method.
Whatever difference of opinion was noticeable at the Vienna meeting, all of those present, especially Meller, the reader of the paper just quoted, were decidedly of the opinion that the Elliot operation is in every respect the one best adapted to buphthalmia, or congenital glaucoma.
In conclusion let me say that the acceptance or rejection of Colonel Elliot's procedure or any other operation is not to be decided by the percentage of iritis, secondary cataract, relapses, lost eyes, etc., but by deciding whether or not his procedure in the various forms of glaucoma gives the best results, including the preservation of comfortable eyes. In other words, we are seeking not the operation that will cure every case of glaucoma but the one which is capable, in the hands of the average ophthalmic surgeon, of relieving or curing most cases of that affection.
