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.
