I shall not quote Hare's elaborate methods for determining these various points because they do not belong to a paper of this character, but I quote his admirable advice because it emphasizes what I believe to be an essential in the treatment of chronic glaucoma, exclusive of operative work, that is, the intelligent co-operation of the oculist and the internist.

Some such thought was in the mind of Ibershoff, who quotes Sterling and Henderson's views that the rate of secretion depends upon and varies with the difference in the blood pressure and the tension of the eyeball, and that the specific gravity of the secretion increases directly with the blood pressure and inversely with the ocular tension. Should the blood pressure be very high, paracentesis, for example, would apparently not be the proper procedure, and the resulting difference produced between the blood pressure and the eye tension would cause a rapid reformation of fluid with higher specific gravity and higher osmotic coefficient. The proper procedure in these circumstances is first properly to reduce the blood pressure, or what I have, quoting Hare, ventured to call the over plus pressure.

4. The relation of osmosis, lymphagogue activity, absorption of edema, capillary contractility and decreased affinity of ocular colloids for water to the reduction of increased intra-ocular tension. We are all familiar with the attention which was directed some years ago to the statements coming from French clinics that the treatment of glaucoma should include the administration of osmotic substances as adjuvants in the reduction of increased intra-ocular tension. Particularly was this treatment advocated by Cantonnet in the administration of daily doses of 3 grams of chlorid of sodium, preceded, of course, by a careful urinary examination and the estimation of the amount of urine and its contained chlorids. Carefully this dose was increased in proper circumstances to 15 grams per diem, and in Cantonnet's original paper good results were achieved in 12 of the 17 patients so treated. I have myself experimented somewhat, not with the administration of sodium chlorid by the mouth, but with the introduction by the bowel of fairly large quantities of physiologic salt solution in patients with glaucoma whose quantity of urinary secretion was markedly below the normal, and in one or two startling instances, which have been reported, achieved success in the rapid reduction of the intra-ocular tension when by this technic the urine secretion rose to the normal amount. To be sure, myotics were also used, but these myotics were insufficient, totally so in the two instances noted prior to the enteroclysis.

Very interesting are the observations on the subconjunctival injections of various substances, notably the citrate of sodium, because of its power of decreasing the affinity of ocular colloids for water. This method of treating increased intra-ocular tension, introduced, as you know, by Thomas and Fischer, has met with confirmation from a number of sources in spite of the fact that Happe's experimental study failed to confirm Fischer's observations; indeed, he even reports in several instances a rise of tension.

As you will remember, the strength of ordinary crystallized sodium citrate in water should be from 4.05 to 5.41 per cent. Of this five to fifteen minims are injected, the eye having been previously cocainized and adrenalinized. With frequent injections the weaker of the two solutions is mixed with 2 to 4 parts of physiologic salt solution. These authors in no sense claim to cure glaucoma, but to ameloriate it and reduce the tension. Weekers has used the salts of calcium, 3 grams a day, with success in so far as lowering of tension is concerned, although it must be stated, as a reviewer of his work has said, that his recommendation of this drug in these respects is poorly supported. On the other hand, Tristiano seems to have proved that calcium chlorid is capable of lowering ocular tension and clinically may be used as an adjuvant in the treatment of glaucoma for this purpose, largely because he believes that he has proven that it facilitates the absorption of edema. Darier has reported that a single subconjunctival injection of a milligram of iodate of sodium has cleared the cornea and lessened the intra-ocular pain in glaucoma.

What shall be said in regard to certain medicinal agents which stimulate the lymphagogue activity of the eyeball in their relation to the reduction of intra-ocular tension, notably of dionin? Toczyski's experiments with this drug on the normal eye indicate that it produces first a rise of tension, which shortly falls to the normal and sometimes below it, the tension being high as long as the primary narrowing of the pupil is maintained, but more than one author, particularly A. Senn, holds an opposite view and reports acute glaucoma following its instillation into a chronic glaucomatous eye. He believes that dionin not only does not reduce the tension but hinders the filtration through the anterior lymph channels by the pressure of the edema which is produced on the veins and by the increased secretion of the ciliary processes. In spite of this statement, most of us must agree with Karl Grossman's observations that certainly in acute and particularly in chronic secondary glaucoma, this is a most valuable agent, especially if it is combined with holocain, which Paul Knapp in his well-known research has proved can reduce the tension even of the normal eye. I cannot think that anybody who has systematically used dionin with holocain, the former in gradually increasing strength, beginning with 2 per cent and going up to 8 per cent, in various types of acute glaucoma, particularly of the secondary variety, can fail to have noted a favorable influence.

Many authors, for example, Darier, Grandclement and others, are strong in their recommendation of adrenalin, particularly if this drug is added to the various myotic mixtures, and yet adrenalin is certainly not without danger in the treatment of glaucoma. McCallan has seen a number of instances of striking increase of intra-ocular tension following this instillation in the conjunctival sac. Harmon has had a similar experience, as also has Senn. It is possible that in these circumstances the solution was too strong. Should the rise of tension occur, and I have seen it myself, it is doubtless due to the fact that this drug dilates the pupil, which would be especially dangerous if the dilatation should occur before contraction of the ciliary vessels; also the narrowing of the ciliary veins by the adrenalin might by virtue of this narrowing obstruct the gate of outflow. I have never been able to persuade myself that, except as an adjuvant to operative work, there was any real therapeutic value in the instillation of adrenalin.

A word in regard to the effect of general narcosis on intra-ocular tension. Thus, Neuschuler has observed that narcosis causes an elevation of the intra-ocular tension of from 2 to 6 degrees as measured with Fick's tonometer. These observations were made while he was experimenting on irritation of the sympathetic as a method of producing increased intra-ocular tension. This is not in accord with Axenfeld's recent observations. It is well known, this observer points out, that after the period of excitation and muscular rigidity disappears, there is a lowering of blood pressure in chloroform narcosis and coincidently a sinking of the intra-ocular pressure. Not only this, the intra-ocular tension of normal eyes during this narcosis drops several millimeters. Only such eyes as have high hypertony, for example, in absolute glaucoma, are unaffected during chloroform narcosis. In the light of this observation it will be interesting to measure the tension both of normal and glaucomatous eyes during narcosis in a large series of cases, and if it is confirmed there will be an additional reason why in many circumstances general narcosis is advantageous in glaucomatous patients. Formerly I thought it was essential, if iridectomy was to be performed, lest some sudden movement on the part of the patient might bring the point of the knife in contact with the lens. I have rarely employed it in corneo-scleral trephining, and yet if there is this temporary reduction of intra-ocular pressure, it is not without a certain therapeutic value, and the matter is mentioned as a suggestion that additional observations along this line shall be made.



Dr. George Edmund de Schweinitz' Paper on Concerning Non-Surgical Measures for the Reduction of Increased Intra-ocular Tension

Discussion,

NELSON MILES BLACK, M.D.,

Milwaukee.

It seems almost useless to attempt any discussion of Dr. de Schweinitz' most terse and comprehensive paper. However, Dr. de Schweinitz mentioned the close relationship which should exist in the non-surgical treatment of increased intra-ocular tension between the internist and the ophthalmologist, but neglected to mention a corresponding relation which should exist between the rhinologist and the ophthalmologist, and possibly between the dental surgeon and the ophthalmologist.

I would like to refer to the now recognized close relationship which exists between disease of the nasal accessory sinuses and diseases of the eye. The definition of glaucoma found in Dr. Wood's system of therapeutics gives rise to an hypothesis as to why disease of the nasal accessory sinuses may be a factor in producing increased intra-ocular tension and why treatment directed toward obtaining free drainage from the sinuses gives good results in so many cases, especially if the relationship is recognized sufficiently early. "Glaucoma proper is essentially a damming or blocking of the drainage from the interior of the eye. The chief lymph stream flows from the posterior chamber past the margin of the lens, through the zonula of Zinn, beneath the iris, through the pupil into the anterior chamber, thence through the tissue at the junction of the iris and sclera into the circular canal of Schlemm and from this space into the external lymph channels. Obstruction to the steady escape of the intra-ocular fluids at any point in this drainage system or any undue increase of the fluids themselves may produce glaucoma. Probably the most important obstruction to the exosmosis is at the angle close to Schlemm's canal."

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 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.

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

THE END