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.
Dr. Wood has referred to several of the many substitutes for iridectomy
that have been proposed, and it is unnecessary to enumerate them again
or to attempt to point out their good or bad features. It is sufficient
to say that for the average operator and the larger per cent of cases,
the operation which is easiest to perform, is attended with the least
risk and offers the best hope of permanent results should be the one of
choice. Sympathectomy has failed to secure a place in ophthalmic
surgery, sclerotomy has not been found adequate, and cyclodialysis is
not sufficiently simple of execution or permanently beneficial in its
results to give it prominence.
Of the operations proposed for the formation of a filtering cicatrix,
those of Elliot and Lagrange are justifiably the most popular. Those of
us who have had the pleasure of seeing the trephining operation done by
Col. Elliot are impressed with the fact that the operation, even in the
hands of its originator, is not, when properly done, uniformly easy of
performance. It does, however, offer the advantage of carrying with it
the minimum amount of risk, and the apparently permanent results secured
justify the ophthalmologist in acquainting himself with the technique of
the operation, for, as pointed out by Sydney Stephenson and others, "the
technique is responsible for success or failure." Furthermore, there is
no sufficient reason why the field of usefulness of the operation should
be confined to the chronic forms of glaucoma, and Col. Elliot
unhesitatingly recommends trephining as safer and more efficient than
any other operative procedures at present employed for the relief of
acute glaucoma.
The success of the Lagrange operation, which, like the Elliot operation,
aims to produce a fistulous communication between the anterior chamber
and the sub-conjunctival area, depends upon securing the removal of a
relatively large section of all of the layers of the scleral and corneal
lip of the wound, so that a permanent opening, covered by the replaced
conjunctival flap, is made. Unlike the trephine operation which was
evolved from it, the Lagrange operation requires the same kind of an
opening of the eyeball as required for a well executed iridectomy, and a
properly placed section entirely in scleral tissue, with a good sized
conjunctival flap, are elements which enter into the ultimate success or
failure of the procedure.
Aside from the dangers incident to a wide incision in the neighborhood
of the ciliary body and the possibility of accident to the lens or
vitreous body, or of intra-ocular hemorrhage, there is for the average
operator the added difficulty and danger in removing a piece of sclera
of the exact size required. The technique of the operation is even more
difficult and exacting than in the performance of the trephine
operation, and it also compares unfavorably in safety.
The advisability of removing the conjunctival flap, as advocated by Dr.
Wood, as a modification of the Lagrange operation, may be seriously
questioned, for aside from the fact that apparently no advantages in
aiding permanent filtration are added, there is, added to the objections
to the Lagrange operation already mentioned, the very serious
disadvantage of subjecting the area at the root of the iris to infection
for a prolonged period of time. The advantages of the protection
afforded by a conjunctival flap far outweigh the disadvantages of a
remotely possible interference of drainage by the blocking of the open
wound with conjunctival tissue. The fortunate experience of Dr. Wood in
not having infection in a wound which remains open and unprotected for
variable lengths of time is not likely to be the experience of any
considerable number of operators, and probably will not always be the
experience of Dr. Wood. Furthermore, the possibilities of damage by
hemorrhage from the choroidal or retinal vessels, delayed formation of
the anterior chamber and adhesion of the capsule of the lens to the
wound, and the injurious effects of even slight trauma subsequent to the
operation, including loss of vitreous, are increased by omitting the
conjunctival flap.
The modern operation for the relief of glaucoma, by which a filtering
scar is produced which permits escape of liquid from the anterior
chamber, is the one which apparently holds out the most hope of
permanently relieving the condition. While success will depend always to
a certain extent upon the personal equation, yet it seems now that for
a large majority if not all of the cases we are justified in abandoning
all other operations than trephining, notwithstanding the verdict of
Elschnig and others that fistula forming operations eventually will be
discarded in favor of iridectomy and cyclodialysis.
Late or secondary infection, not unknown following iridectomy, may
follow the trephine operation, and already some fifteen or sixteen cases
have been reported. But while this possibility is a real danger, which
improved technique may greatly minimize (Col. Elliot has not seen a case
of secondary infection in an experience of over 1200 trephining cases of
his own and a large number of others performed by his assistants and
pupils) the ultimate verdict must rest with results as compared with
other measures. At present, as pointed out by Meller, whose statistics
Dr. Wood has cited, trephining heads the list of remedial measures for
the relief of glaucoma, and it has the advantage of being applicable to
any form of the disease, to be relatively free from danger, either
immediate or remote, and to produce the highest percentage of favorable
results. The addition of an iridectomy in every case of trephining does
not unduly complicate the operation and has much to commend it in
offering the patient every possibility of relief.
INDEX
PAGE
ETIOLOGY AND CLASSIFICATION OF GLAUCOMA,
_Edward Jackson, M.D._ 9
ETIOLOGY AND CLASSIFICATION OF GLAUCOMA,
Discussion, _Francis Lane, M.D._ 28
PATHOLOGY OF GLAUCOMA,
_John Elmer Weeks, M.D._ 37
PATHOLOGY OF GLAUCOMA,
Discussion, _E. V. L. Brown, M.D._ 57
CONCERNING NON-SURGICAL MEASURES FOR THE
REDUCTION OF INCREASED INTRA-OCULAR TENSION,
_George Edmund de Schweinitz, M.D._ 61
CONCERNING NON-SURGICAL MEASURES FOR THE
REDUCTION OF INCREASED INTRA-OCULAR TENSION,
Discussion, _Nelson Miles Black, M.D._ 101
TREPHINING FOR GLAUCOMA,
_Robert Henry Elliot, M.D._ 107
TREPHINING FOR GLAUCOMA,
Discussion, _Frank C. Todd, M.D._ 113
OPERATIONS OTHER THAN SCLERAL TREPHINING
FOR THE RELIEF OF GLAUCOMA,
_Casey A. Wood, M.D._ 121
OPERATIONS OTHER THAN SCLERAL TREPHINING
FOR THE RELIEF OF GLAUCOMA,
Discussion, _Albert E. Bulson, Jr., M.D._ 141