Chapter 5
The following hypothesis is based upon Fischer's edema theory of glaucoma and the relation of the circulation of the eye and orbit and that of the nose and the accessory sinuses, the minute anatomy of which is not as yet thoroughly understood. However, sufficient work has been done to make it appear that the lymph channels which drain the eyes and orbits empty into the same main channel as do those which drain the sinuses. Admitted for sake of argument that such is the case, then disease either acute or chronic of one or more of the sinuses with the accompanying inflammatory reaction, congestion and stasis, will cause an increased amount of fluid to be taken care of by the lymph channels draining these sinuses. This will in turn cause flooding of the common lymph channel, producing a stagnation in the flow of fluid from the orbits and eyes at the junction with the main channel, with backing up of the fluid within these channels and retention of the waste products within the orbits and eyes; thus will be brought about conditions most favorable (to quote from Fischer's theory of glaucoma) "to an abnormal production or accumulation of acid in the eye. In consequence of this abnormal acid content the hydration capacity of the ocular colloids is raised and glaucoma results, not because water is pushed into the ocular colloids, but because these suffer changes which make them suck in water from any available source."
This hypothesis also might suggest why the subconjunctival injection of sodium citrate in addition to alkalinizing the ocular contents, may be effective in reducing tension, _i. e._, the amount of fluid injected beneath conjunctiva may overcome the stagnation in the lymph passages, flush out these channels and improve ocular elimination.
Fischer in a personal letter says:
"You have two possibilities for the production of glaucoma with sinus disease: A toxic factor due to poisons being carried into the eye; and second, interference with a proper blood supply to the eye through compression of the efferent or afferent blood vessels supplying the eye from edema of the tissues about the eye consequent upon the sinus infection. Either is associated with the production of substances which increase the hydration capacity of the ocular colloids."
If such is the case why could not the existence of pyorrhea and blind 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 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.