AS AN introduction to this paper I can do no better than quote extensively from an editorial by Edward Jackson in the February American Journal of Ophthalmology. He has expressed so clearly my deepest convictions in regard to this subtle disease, which has too often ended in blindness for the want of early recognition or of a properly regimented care.
“Glaucoma has been defined as increase of intra-ocular tension, with the causes and effects of that increase; a very good definition of the word. It is not certain that a better definition can be given today. It fixes attention on the central fact-increased intra-ocular pressure. But of the essential causes of such increase we still have only guesses, speculations, and unproved hypotheses.
“The successful operations that have been done for glaucoma, scleral tapping, anterior or posterior sclerotomy, iridotomy, incision of the ciliary body, cyclodialysis, Lagrange sclerectomy, Elliot trephining, iris inclusion, or iridotasis, present a confused picture.
“Knowledge of the effects of glaucoma has convinced all that it is a serious disease, that it is dangerous to neglect; but inclines one to think that little can be done to prevent the disastrous result. Without the stimulus of hope, we are not likely to put forth our best efforts.
“Some cases of glaucoma recover without treatment, some reach a permanent recovery after the use of miotics. If these cases were all reported with the same minute detail as we use to report the pathologic changes in the eyes that have to be enucleated, glaucoma would not be regarded as always hopeless.
“When a case does get well, it is apt to be regarded with doubt as to the permanence of the cure, or the correctness of the diagnosis. In the use of Laquer, glaucoma was held in check by miotics for more than five years; and then cure by operation gave good vision, which continued for more twenty years, to the end of his life”.
In this one sentence describing the case of Laquer, is embodied the ideal for which we are all striving. How to obtain this result is the question about which has received all the controversy of preoperative care, methods of operative procedure and postoperative regimen. Rules of procedure cannot always be followed, due to extenuating circumstances surrounding many cases and because of the inability to obtain consent to operate at the time of election. However, I feel that any case in which the fields of vision and the degree of tension cannot be kept in safe bounds by instillation of miotics four time a day, should be persuaded to resort to some operative procedure.
The patient or relatives responsible for their welfare should be taken in confidence and be made answerable for any delay. On the other hand the risks of operation should not be minimized but the greater danger of postponement should be properly stressed. When this has been settled, the grave decision of choice of procedure falls to the surgeons lot. The fact that there are so many methods, with their numerous modifications, is proof that no one of them is always satisfactory at the moment or in the later results.
If it often stated “that operation with which you are most confident of results is the operation for you,” but is not this confidence but the product of ones personal experience, subject to the peculiarities of each case and the familiarity with the technic used? However, as perfection is never attained, one is justified in constantly weighing each new operative method in the light of difficulties found in the old.
During twenty-eight years of experience I was bound to develop certain definite opinions, which may have been due only to my personal temperament or to the circumstances surrounding the care of certain cases. For example, after seeing a number of operators do the cyclodialysis operation and after becoming enthusiastic about this procedure as I witnessed it in Millers clinic in Vienna, I tried it out on my return in 1924. Two cases had marked reaction with increased tension just after operation, and another too soon had to be re-operated. The fault may have been mine, but I cannot help having had an aversion for this procedure ever since.
Though I have done many iridectomies with excellent results, especially in the first year of practice, I am still convinced that to place the incision in the proper angel at the root of the iris is most difficult. This dis almost impossible with a very shallow anterior chamber and an eyeball under high tension, unless a posterior sclerotomy is a first resort. This led me to be most enthusiastic over the Elliot trephine, but a number of large hideous- looking blebs and one infection four years after operation forced me to conclude that the perfect procedure was still to be found. Lagrange with scissors or punch has often been very successful; however, some cases have too long a postoperative inflammatory stage to give the greatest feeling of security.
Some years back I became enamoured with the iridotasis operation for mild inflammatory and especially non-inflammatory types of glaucoma. It was easily done and seemed all that could be desired. In older cases where the iris is thin and atrophic this operation does not always produce sufficient drainage since the scleral scar closes this newly formed outlet. In order to prevent this and to make the operation applicable also to he more severe types of this disease, I have resorted to punching out piece of sclera from the edge of the wound before drawing the iris between its edges.
The operative technic is as follows: A horizontal conjunctival incision about 12 mm. in length is made about 8 mm. above the cornea. This is dissected down toward the corneoscleral junction, being sure to get all the tissues down to the sclera in the lower center of the flap, in order that the punched-out area will have sufficient covering and remain loosely overlying for good absorption of seeping aqueous. Then at the center, close to the cornea, a scratch incision with a Graefe cataract knife is slowly made, trying to keep each scratch the same depth. The scratch is about 5-6 mm. in length and so placed that it enters the anterior chamber near the root of the iris. Eventually some point will prick through and a few drops of aqueous appear.
Thus the tension is gradually lowered and the incision enlarged by knife or scissors. It length should be only long enough to allow the grasping of the iris near the pupillary margin. Next the punch, thin side down, is pressed under the edge of the sclera at the center of the wound and a piece punched out. The size of the punched-out area depends, as in the trephine or Lagrange operation, upon the judgment of the operator. The iris is now grasped with small curved forceps as near the pupillary margin as possible and gently withdrawn with pigment side uppermost. This is now left with the center filling the gap in the sclera made by the punch.
The conjunctiva is gently replaced and, if all the operative area is well covered and if moving the upper lid up and down a few times does not disturb the flap, sutures may be dispensed with, though often one or two may be found necessary. If there is a return of tension on the second or third week, as sometimes happens, massage and temporary use of myotics have in my experience always tided over this period. As you see, I have by this procedure attempted to make the iridotasis operation adaptable to all forms of glaucoma. The incision is easily made without danger of injuring either the ciliary body or crystalline lens. As neither the root of the iris nor the iris itself is incised there is little trauma to delicate tissues prone to prolonged reaction. Lastly, it produces the greatest amount of drainage with the minimum danger of secondary infection.
I shall now briefly report the four worst cases I have seen of late years and the results obtained by this method.
Mrs. M.E.; she had received a traumatic injury of left side of head in June, 1931. Was unconscious for two to three days, after which she had intense pain and blindness in left eye. Pain and blurred vision developed in right eye. Was treated at another hospital, where left eye was operated on in March of the following year. As both eyes were worse after the operation, she would not give her consent to have the right eye operated on and she left the hospital against advice. Later was led into the Homoeopathic Dispensary with both eyes in state of acute inflammatory glaucoma. The right eye had tension of 65 McLean, with small pupil, very shallow anterior chamber and marked injection of the conjunctiva of both eyeball and lids. The left and a tension of 75 and the iris was tangled up in a mass of exudate and broken-down less substance.
Apparently, an operative traumatic cataract was present. There was a chemosis of the bulbar conjunctiva and a superficial ulceration at the center and edges of the cornea at three oclock. The latter was probably due to the attempt of the patient to instil drops is her own eyes. Intense pain and blindness had again led the patient to seek aid at a hospital. The previously described operation was done on the right eye on May 7, 1932. As I could not obtain consent to enucleate the left eye, I was forced to attempt to save what I could.
As a large iridectomy had originally been performed, a fair incision under a conjunctival flap made it possible to remove the debris and lens substance. The reaction of this eye was stormy but subsided in two weeks, leaving what was feared, in the beginning, a soft blind eye. This resolved into a non-inflammatory phthisis bulbae. However, the right eye made a most satisfactory recovery with an almost normal field and 20/20 vision with glass correction. Though I have taken the tension many times since, it had remained from 30 to 40 McLean without the use of myotics.
Mrs. A.T., admitted January 1, 1934. Five weeks prior to this she had intense pain in right eye and head, and as nose began to discharge, was treated for sinus disease by her country physician. Later, left eye began to ache and then patient found she could not see from the right, and the left was rapidly becoming blurred. She called in another physician, who sent her at once to the hospital. At the time of arrival she could only distinguish light. Both pupils were dilated. Eserine oil drops were used every two hours during the night in conjunction with hot compresses. At time of admission to operation room the next morning the tension was 90 and 95 McLean.
In this case, due to the every shallow anterior chamber and high tension, I used the scratch incision with the Graefe cataract knife in both eyes. This made it possible to have the tension released slowly and all danger of injury to the lens was avoided. A medium-sized piece of sclera was punched out and the iris drawn into the area. No sutures were used.
Light massage was found necessary a few times while a day during October and November in the right eye only, when for some unknown reason tension rose to 55 McLean. Prior and since then, the tension has been on the average 35 in the right and 30 in the left. Vision at the end of January was 20/40 in both eyes, and by the end of February, 20/30 right and 20/20 left, where it has remained since then. There is a little contraction of the field of the right eyes.
Mrs. A.O., admitted January 10, 1934. Had been under treatment for non-inflammatory glaucoma three years before my seeing her. Complaints of periods when vision is hazy and specks before eyes. Tension found to be right eye 50 and left 40 McLean. Cupping of both nerve heads was present and the visual field of the right contracted to 15 degrees on the nasal side-less than 20 at 0 and 180, while at 90 it was 30 (Cut I). The left eye had a contraction in the 45 meridian extending within 5 degrees of center.
The vision for both eyes was, with best correction, half of the 20/30 line and a consciousness of lost nasal fields. The iridotasis punch operation was performed as previously given, without difficulties. As the conjunctival flap would not stay in place when operating on left eye, one stitch was used. Vision in February was found to be 20/30 for both eyes and in March 20/20 on half. The tension for a short period has been up to 50 first in one eye and then in the other, but not since, July, 1934, has there been any increase above 49 in either.
Mr. T.C.O., admitted April 29, 1934. I saw him first March. 7, 1934, when he was led into my office. It was a case of non-inflammatory glaucoma. He could not count fingers with the right eye, being able only to distinguish light. The left eye and vision of 20/100, which with correction could be brought up to 20/70. The tension was 55 and 60 respectively. While he was at the office, eserine and pilocarpine reduced the tension to 45 and 50. In a week the tension was brought to 40 and 45 but the field in the only eye with which he could see was so reduced that he could hardly get about without a guide.
Nevertheless his acuity of central vision had come up to 20/30. The next week he was knocked down by an auto and was in the hospital for a few days. His vision after this was 20/50 and the tension 55 and 70. Myotics were used every two hours and on return visit the tension 55 and 70. Myotics were used every two hours and on return visit the tension was 50 in both eyes with vision still only 20/50 in the good eye. The described operation was performed without any untoward results.
The vision in June was 20/40-one-half in the only seeing eye-but the field was still too small to allow any freedom of navigation. In fact, when taken in July, it had changed about from the temporal to the nasal side. During that month, having contracted a cold, both eyes became inflamed and the tension rose to 45 and 50. This returned to normal in two weeks but the patients one bad eye still remained inflamed and a chronic iritis developed.
When last seen in September, 1934, the left eye was as normal as such an eye ever could expect to be, i.e., tension 35, on inflammation, fields the same as previous with vision of 20/30/ The right eye was still in a chronic state of irritation.
I have reported these most unfavorable cases where I resorted to a punching out of a piece of the scleral side of the wound prior to doing the regular procedure in iridotasis in order to show its advantages over the trephine or Lagrange operation. I have a number of patients on whom the orthodox iridotasis was performed who have to resort to myotics either constantly or at intervals. I cannot but feel that if a small piece of sclera had been removed there would not have been a return of tension a year or so following the operation. At least it facilities drainage at the time and prolongs the period when scar tissue can thwart the original intent of the operator.