abscesses about the roots of the teeth be the source of the toxic
factors mentioned by Fischer? Hence the suggested association of the
dental surgeon with the ophthalmologist in these cases of apparently
idiopathic increased intra-ocular tension.
It would be well to state here a cursory examination of the mouth will
not discover root abscesses any more than such examination will
discover non-suppurative sinus disease. A careful examination of each
tooth together with radiograms of the entire maxilla are absolutely
essential to determine their presence or absence.
Trephining for Glaucoma
BY
ROBERT HENRY ELLIOT, M.D.,
London, England.
Mr. President and Members of The Chicago Ophthalmological Society:
As the hour is late I propose to take up only the principal points in
connection with my subject and to deal with each one shortly.
First: The operation of trephining is suitable, not merely for chronic
cases, but for sub-acute and acute cases of glaucoma as well. I would
urge on your attention that, of all the operations dealing with
glaucoma, this one involves the minimum of surgical violence, and
should, therefore, in acute cases be the operation of choice. It is,
moreover, much safer than any other operation I know of, and is no less
certain in its results. I do not advise trephining in the secondary
glaucoma following intumescent cataract, for in such cases the
semi-fluid lens bulges into and blocks the trephine hole. Nor for
obvious reasons do I recommend it in cases where there is reason to
believe that a communication exists between the aqueous and vitreous
chambers.
Second: The object of trephining is to tap and permanently drain the
aqueous fluid from the anterior chamber of the eye into the
sub-conjunctival space; in doing so it is essential to avoid as far as
possible all interference with the uveal tissue. The purpose of an
iridectomy is to avoid the danger of the iris in the neighborhood of the
wound being drawn and impacted in the trephined hole. We have found in a
large number of cases in which an iridectomy has been omitted, that the
results have been in no way inferior to those in which a piece of iris
has been removed, provided always that no subsequent iris prolapse
takes place. In pursuance of our purpose to avoid uveal tissue, we split
the cornea, and place the trephine as far forward as such splitting will
allow, and we bear on the trephine in such a way that it cuts through on
the corneal edge of the wound first. This insures establishing our
fistula in the most anterior position possible, and, therefore, as far
away as possible from the ciliary body and the angle of the chamber.
Third: The difficulties of the operation. Far too much stress has been
laid on these. Trephining is an operation which can be performed by any
surgeon who is used to ophthalmic manipulations, and who has good sight.
It is essential that he should work in a good light. The necessary
technique can be acquired from a written description. It is not for a
moment necessary that the surgeon who wishes to learn trephining should
see the originator of the operation at work. If, however, he feels
diffident at undertaking the procedure until he has seen it done by
another, there are many centers in this country where the operation is
now being successfully performed. I would mention amongst those which I
have visited New York, Minneapolis, St. Louis, Nashville, Louisville,
Detroit and Chicago. I have seen results of trephining by American
surgeons which could not be bettered anywhere.
Fourth: I am sure that everybody will recognize the difficulties of
operating during such a tour as I am now making. I have so far in the
last month performed over seventy trephinings in ten cities, and in
twice as many clinics. To adapt one's self to different clinical
methods, different assistants and different nurses is so difficult that,
as you are aware, many distinguished surgeons refuse to work out of
their own clinics. One cannot expect the results of such a tour to be on
a par with those one obtains in one's own quiet daily surroundings. I
am, however, confident that you will make a generous allowance for
these difficulties, and I gladly welcome the suggestion that all the
cases which I have operated on in America be collected together and
reviewed as a whole.
Fifth: In conclusion I would like to express the pleasure with which I
listened to Dr. de Schweinitz' paper. I believed from the title that
there might be a wide divergence of opinion between us. I find to my
great relief that we are in absolute accord. I know, however, that there
are in America and elsewhere able men who consider that the medical
treatment of glaucoma should be pushed as long as possible. I cannot but
feel that this is a survival of the dread that most surgeons have felt
in recommending one of the older operations for glaucoma. We have now in
our hands a method so safe, so easy and so certain that I feel sure that
this dread will ere long pass away, and that the diagnosis of glaucoma
will then be followed by a very early operation. In India I have gone
farther than this, and where one eye has shown high tension, I have
frequently trephined both. The prophylactic use of the operation is more
than justified in that land of long distances and scattered medical aid,
and where the patient is not likely to return a second time for surgical
help. This prophylactic trephining is a proposition that I put before
you today for your consideration, reminding you at the same time that
glaucoma is practically invariably a bi-lateral condition. I have seen
even in America not a few people blind in both eyes who might have
retained the sight of the second eye had the surgeon advised a double
sclerectomy when he first saw the case, despite the fact that the second
eye was then to all appearances non-glaucomatous.
Dr. Robert Henry Elliot's Paper on Trephining for Glaucoma
Discussion,
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
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 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.