Part 9

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 assisting 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 button 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 retarding 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 establishing 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

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.