Part 10

"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 1/2 mm. thick, 11/2 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.

Dr. Casey A. Wood's Paper on Operations Other than Scleral Trephining for the Relief of Glaucoma

Discussion,

ALBERT E. BULSON, JR., M.D.,

Fort Wayne.

Increasing belief in Colonel Elliot's view that trephining should be the operation of choice in any form of glaucoma, makes it difficult to consider operations other than trephining in anything but a spirit of disfavor.

Until recently the decision as to the kind of operative procedure to be employed for the relief of glaucoma has depended on the form and stage of the disease, and the amount and character of the vision of the affected eye. Many operators still hold that an iridectomy is the most valuable of all operations for acute inflammatory glaucoma, and not a few hold that the operation has a decided place in the treatment of simple glaucoma. The operation is not without difficulties, and one is inclined to agree with Elliot who says that "The man who can make a 'finished iridectomy' quietly and cleanly has graduated as an ophthalmic operator." The difficulties of an iridectomy are especially pronounced in those cases in which the anterior chamber is extremely shallow and the iris is pressed against the cornea. It is in such cases that the success of the operation is increased by the addition of posterior sclerotomy and the intelligent use of miotics prior to the performance of the iridectomy. Even then the permanent results of the iridectomy will be modified in proportion to the success secured in freeing the filtration angle and opening Schlemm's canal by thorough removal of the root of the iris.

The failure of many apparently well executed iridectomies may be attributed to the fact that the iris is not removed to the extreme root, and the remaining stump is sufficient to block the drainage. This is especially apt to be the case in chronic glaucoma where the iris is adherent to the cornea, and in efforts to free the filtration angle by an iridectomy the iris is torn off in front of the adhesion and the filtration angle is not opened.

As Elliot has pointed out, iridectomy is most open to attack on the ground of safety. We have to take into account the large scleral wound made, and the fact that this lies close to the ciliary body. The sudden release of all tension and the simultaneous weakening of the supports of the lens and vitreous body create very unfavorable conditions under which to make the crucial step of the operation.

The poor results following an iridectomy in chronic glaucoma have led to the devising of many substitute operations, of which those tending to the production of a filtering scar are now preferred, and, experience shows, hold out the most hope of bringing about long continued relief. It even is considered probable that the effects of an iridectomy which brings about more or less permanent reduction in the intra-ocular pressure is due to the formation of a filtering scar which augments whatever results may have been secured in the attempt to open up the drainage into the canal of Schlemm.