^ fiU^ldfiiSQi^ QA S ^'^ - (pre?'/ j^ 14. <--■ ^rj^ SCLERO-CORNEAL TREPHINING IN THE OPERATIVE TREATMENT OF GLAUCOMA ROBERT HENRY gLLIOT, M.D., B.S.Lond., Sc.D.Edin., FJl.C.S.Eng., etc., LlEUT.-COLONEL, I. M.S. SUPERINTENDENT OF THE GOVERNMENT OPHTHALMIC HOSPITAL, MADRAS ; PROFESSOR OF OPHTHALMOLOGY IN THE MEDICAL COLLEGE, MADRAS; HON. FELLOW OF THE AMERICAN ACADEMY OF OPHTHALMOLOGY; AND HON. MEMBER OF THE MINNESOTA ACADEMY OF OPHTHALMOLOGY, OF THE CHICAGO OPHTHALMO- LOGICAL SOCIETY, AND OF THE DETROIT OPHTHALMOLOGICAL CLUB. First Edition, 1913. Second Edition, 1914. LONDON: George Pulman & Sons, Limited, The Ophthalmoscope Press, OPTO To E. C. 1. E., TO WHOM THE AUTHOR OWES SO MUCH To PRIESTLEY SMITH, M.Sc, M.B., B.Ch., F.R.C.S., Etc. KINDLY CRITIC, AND GENEROUS HELPER, WHOSE LIFE-LONG WORK IN CONNECTION WITH GLAUCOMA PROBLEMS HAS MADE THE WORLD HIS DEBTOR, THIS BOOK IS DEDICATED BY HIS VERY SINCERE ADMIRER PREFACE, The present time may be spoken of in ophthalmological history as The Glaucoma Age. The magnificent work of past decades, associated with the honoured names of Priestley Smith, Lagrange, de VVecker and many other workers, has suddenly reached fruition. The underlying principle is to be expressed in the one word " Sclerectomy." The methods proposed to carry out the common object are very various, and time alone will show which of them is the best. To me trephining seems the ideal procedure, and though I clearly recognise that my judgment may not be, I should almost say cannot be, unprejudiced, I desire to lay my case fully and freely before the Medical Profession. At that bar we must all be tried, and I for one have no doubt that the ultimate verdict, even though delayed, will be the just and right one, be it what it may. Medical men have written to me from many parts of the British Isles, from our Colonies, from America and from Europe to ask questions about the procedure I have recom- mended for the operative treatment of glaucoma. Most of their questions have been fully answered in past articles I have written or read during the last four years. I felt that it was necessary therefore to collect all that could be said on the subject of trephining within the covers of a single volume, so that all who would could read it. I have endeavoured to acknowledge much of the kind aid I have received, but I should be remiss if I failed to specially remember a few of my helpers. To Mr. Sydney Stephenson I owe more than I can easily express, but in that respect I am on equal terms with a large body of ophtlialmologists throughout the English-speaking world, to whom the arrival of the monthly Ophthahuoscope is a looked-for event. To my staff, whose untiring and devoted work has made possible any work I may have done, I am deeply indebted. Lieutenant Craggs has been invaluable in the after-treatment of the patients ; Assistant Surgeon Taylor has assisted me in many ways, and not least by the aid of his excellent photo- graphs. Sub-Assistant Surgeon Ranganatha Row has made the writing of the book possible by the untiring and excellent work he has put into it in his capacity of Surgical Registrar of the Government Ophthalmic Hospital, Madras. To Majors Kirkpatrick and Hime I am under much obliga- tion for their assistance in the revision of the proofs, and for many valuable suggestions. I have to acknowledge the courtesy of the Editor of The Ophthalmoscope, of Messrs. Arnold & Sons, and of Messrs. Jno. Weiss & Sons in lending me the blocks of illustrations which were in their possession. I have left till last, though far from least, my acknowledg- ments to Mr. Sydney Stephenson, to Dr. A. J. Ballantyne, and to Dr. Temple Smith for so kindly allowing me to include their very able articles in chapters ii and xii of the book, ROBERT HENRY ELLIOT. Shawfield, Egmore, Madras, India, 19]3. PREFACE TO THE SECOND EDITION. Before " Sclero-Corneal Trephining " had been eight months in print, the publishers were asking for a second edition. My visit to the United States, at the very kind invitation of the American Academy of Ophthalmology and Oto- Laryngology, made it impossible for me to commence the task for some months. Nor was this the only cause of delay, for the year (1913) of the book's first publication proved an exception- ally full one for its writer. In it, I had the honour of taking part in a number of very interesting discussions on the subject of glaucoma. These included (l) The Glaucoma Discussion in London at the International Congress of Medicine (August, 1913), of which I was one of the openers, my distinguished colleagues being Professors Priestley Smith and Lagrange ; (2) The Congress of the American Academy of Ophthalmology and Oto- Laryngology (October, 1913), before which, by their kind invitation, I delivered the Anniversary Oration on Trephining ; (3) The Symposium on Glaucoma, held by the Chicago Ophthalmological Society (November, 1913), in which Professors Weeks, de Schweinitz, and Jackson also took part as my fellow guests of the Society, and (4) The Oxford Congress of Ophthalmology (1913). Besides these, there have been a number of other occasions on which it has been my privilege to meet the members of various ophthalmological societies, and to take part in their deliberations on the subject of the treatment of glaucoma. In the short space of two months I had the pleasant but arduous task of performing the operation of sclero-corneal trephining on 135 eyes, in 28 hospitals, in 14 of the large towns of the United States of America ; and I have also had the opportunity of demonstrating my technique in a number of hospitals in England. In addition to tiiis, I have carefully studied the very numerous recent additions to the literature of glaucoma. Some idea of the task involved may be gatliered from the fact that trephining alone has claimed about five hundred references during the past three years. The consequence of all this has been that the issue of a second edition has practically involved the re-writing of the book, and no pains have been spared to bring the treatment of the subject up to date. The work of others has been drawn on very freely, and to the many who have written to me from Europe, America, Canada, Australia, New Zealand, Egypt, and the East, I tender my grateful acknowledgments, and I regret that it is not in my power to here express to each one individually my deep sense of indebtedness. I can only hope that they and others will still further help me in the future. I very greatly appreciate their assistance. By special request of many of my American friends, I have greatly expanded Chapter V, giving very minute details of the technique of the procedure which I have advocated. Chapter VI has been brought well abreast of the times, the opinions and practice of others being given freely, and it is hoped impartially. Chapter XI has, thanks to Captain Gray's kindness, and to Mr. Ranganatha Row's work, been completely revised ; enabling the reader to judge of the results of over four years of trephining in Madras. Chapter XII is new, and puts forward the experience and statistics of a number ot well-known ophthalmologists. Chapter XV is the ' lumber- room ' of the book, but it is hoped that many will consider that the 'lumber' it contains is not without value. Chapters III, IV, VII, VIII and IX have also been largely added to, or recast. A number of new illustrations have been added. Captain W. C. Gray, I. M.S., who, since I left India, has been acting as Superintendent of the Government Ophthalmic Hospital, Madras, has been most kind in helping me in many ways, and not least in furnishing me with statistical and other information. To his head assistant, Lieut. Craggs, to Mr. Taylor, and to his whole staff, I am indebted very deeply, but XI. I must not omit to specially mention the excellent work done for me by the surgical registrar, Mr. Ranganatha Row, whose painstaking study of case-sheets has added so much to the value of the rewritten chapter on our Madras results. I am indebted to the Editors of The British Medical Journal, The Lancet, and The Ophthalmoscope, for permission to reproduce articles which have appeared in their columns, and to the last-named gentleman for much other assistance. In conclusion, I wish to take yet another opportunity of adding my meed of homage to that which Professor Lagrange has already so justly earned from the profession throughout the world, by the great work he has done. He it is who gave us "sclerectomy " ; this conception has been the foundation stone of all our progress in the treatment of glaucoma ; it has materialised the dream of von Graefe, and has converted the longing foresight of that great German into the practical triumphs of the surgery of to-day. In mmor matters of technique I may have to disagree with Professor Lagrange, but he has no more sincere admirer, and no one who more fully recognises the greatness of his achievement than ROBERT HENRY ELLIOT. 54, Welbeck Street, Cavendish Square, London, W. CONTENTS. Chapter I. Chapter II. Chapter III. Chapter IV. Chapter V. Chapter VI. Chapter VII. Chapter VIII Chapter IX. Chapter X. Chapter XI. Introductory Historical Indications for Sclero-Corneal Trephining ... Preparations for the Operation Tlie Technique of the Operation Modifications of Operative Technique suggested b}' other surgeons Complications met with during the Operation After-management of the Patient The Diagnosis of Glaucoma in Southern India Method of Compiling Statistics The Results of Trephining as Judged of by the Statistics of Returned Cases ... Chapter XII. The Experiences of other Surgeons in Trephining.. Chapter XIII. On the Site of Trephming for Glaucoma ; It Importance Chapter XIV. A Comparative Study of tlie Modern Operations for Glaucoma Chapter XV. Anatomical and Pathological PAGE 1 4 33 46 54 80 99 108 120 128 134 145 152 159 167 LIST OF ILLUSTRATIONS. FIGURE ] 1. Secti(M: of the Sclera and Conjuncti\a, in Lagrange's operation 2. Kesection of tlie Sclerotic, in Lagrange's operation ... 3. Making of the Iridectomy, in Lagrange's operation ... 4. Result of Lagrange's operation ... 5. Position of the knife blade in making the first Incision, in Herbert's operation ... 6. Position of the knife blade m making the second Incision, in Herbert's operation ... 7. The Histology of Sclerectomy ... 8. Holth's Punch Forceps ... 9. Section of a Sclerectomy Cicatrix (Holth) 10. McKeown's Irrigator 11. Do. do. 12 ] and [ Photographs of Operation Groups 12.A j 13. 14. 15. 16. 17 to 20. 21. The Madras Cataract Bandage ... The Incision etc., in the earlier trephine operation ... The Incision etc., in the present trephine operation ... Diagram of area laid bare by conjunctivo-corneal flap Diagrams showing the possible Interferences of Iris Tissue with the Trephine Hole Sydney Stephenson's Trephine ... 22a I and -George Young's Trephine 22b. ) 23. Lang's Trephine ... 24. Lang's Knife for Splitting the Cornea .. 25. Elliot's Instruments for Trephming 25.\. Elliot's Chuck Trephine 26. Pusey's Trephine ... 27. von Hippel's Trephine ... 28. Vogt's Motor Trephine 13 14 14 15 17 17 23 24 25 48 49 50 52 58 58 59 76-77 80 81-82 84 84 85 89 90 FIGURE I'AGE 29. Taylor's Motor Trephine 90 and - Verlioefl's Sclerectome ... ... ... ... ... ... 92 31. 32 ] to VVerhoeft's Operation 34. ) 35. McReynold's Corneal Wedge .. 36. McReynold's Conjunctival Forceps 37. Fixation of an Eye by means of a Suture during Operation 38. Filtration area 3^ years after Operation 39. Do. do. 3 years do. 40. Do. do. 5 months do. 41. Do. do. 4 months do. 42 A section of the Eye in the neighbourhood of the trephine area 154 43. von Mende's Flap ... ... ... ... ... ... 167 44. Dupuys-Dutemps' Flap ... ... ... ... ... 168 45. Hill-Griffith's earlier Flap 168 94 95 95 100 139 140 141 142 CHAPTER I. INTRODUCTORY. The idea of substituting trephining for sclerectomy as performed by the older methods, had been present in the writer's mind for a long time before he ventured to put it into execution. An enormous amount of glaucoma is met with in Southern India, mostly in a chronic or sub-acute form, and the results yielded by iridectomy were such as to leave much to be desired. When Lagrange and Herbert brought their new operations before the profession, the Madras Hospital was one of the first to give these a full and free trial. To the writer the soundness of the new operations appealed so strongly that he ventured to bring the matter before the local branch of the British Medical Association in the year 1906, and he then expressed the opinion that the day of von Graefe's operation was over, and that its sun had set after nearly fifty years of undisputed supremacy. The members present were greatly taken aback, and it was suggested that too hopeful, if not too premature, a view had been taken of the case. Time, however, declared its verdict in favour of the new methods, and, little by little, iridectomy was abandoned in favour of one form or another of sclerectomy. The after-results in the cases that returned to the Madras Hospital gSLve us great encouragement. During this transition period another interesting observation was frequently made. All cases which had undergone iridec- tomy for glaucoma were carefully examined on their return to hospital, and in a large number of these, in which good vision had been retained, a filtering scar was found to be present, whilst in the failures no such evidence of filtration existed. We had therefore reached the conclusion that Herbert and Lagrange had established their two contentions, viz., (1) that it is possible to form a permanent filtering cicatrix between the anterior chamber and the sub-conjunctival space, and (2) that the establishment of such a condition permanently reduces a raised intra-ocular tension. To Lagrange's operation and to Herbert's earlier method, there were however very distinct objections. It is not easy to graduate the amount of sclera to be removed by the former method, especially as the scleral section has to be made on an opened, and, often, on a congested eye, nor is the operation free from tlie dangers of serious vitreous accident, and of intra-ocular hajmorrhage. Every moment of this procedure is fraught with anxiety, and at the late stage at which operation is so frequently called for in Madras, disaster is at times unavoidable. Herbert's original operation was tricky and difficult, although wiien correctly performed it yielded excellent results. The essential feature of the new operations w as the removal of a portion of the outer tunic of the eye, and the establishment thereby of drainage from the interior of the eye into the sub- conjunctival space. So far, we were obviously on firm ground, but our methods of accomplishing our object left all too much to be desired. Whilst mentally balancing this position, it occurred to the writer, at the close of 1907, that the key to the difficulty might be found in the use of the trephine. At once there surged up a number of difficulties : would a trephine hole be permanent ? would there be room to apply a trephine ? would it be an easy or a difficult operation ? would unexpected complications attend it ? what size of blade should be used ? These and many other questions presented themselves to the author's mind, whilst those surgeons whose opinions were asked, looked askance at the suggested procedure, which did not recommend itself in the least to them. To break ground on a new method, with a patient's eye at stake, is always a serious matter for any surgeon; and yet in spite of discourage- ments, the idea returned insistently, that trephining was sound in principle and should be given a trial. This was the position at the beginning of 1908, and a determination to put the matter to a crucial test had been all but reached, when unexpected circumstances compelled the writer to leave India on very short notice. Whilst at home on leave, he had the opportunity, rarely given to an ophthalmologist in the East, of discussing this question with confreres, and he returned to India deter- mined to try trephining as soon as opportunity offered. The first chance was on August 2nd, 1909. The operation proved to be an extremely easy one, and two more were performed the same mornmg. From that time on, several eyes have been trephined weekly in Madras, the number rising to double figures on many occasions, so that when the writer left India, he had the carefully recorded notes of about 900 cases to draw on : since then he has had the opportunity in America and in Europe of adding more than another 150 cases. Experience has only served to strengthen the opinion that the method is as easy of execution as it is sound in principle. It is no part of the present purpose to contrast the writer's ■operation with that of others. This has been ably done by Dr. Temple Smith, whose paper is reproduced in Chapter XIII of this book and it is also dealt with in Chapter XIV. But he desires at this point to state clearly the objects which he has kept consistently before him from the very first. The light of experience, and the valuable advice which he has ungrudgingly received from all parts of the world, have enabled him, in important details, to modify the technique of his operation ; the essential feature of the procedure has, however, never altered. His object has been to tap the anterior chamber and to drain it permanently into the sub-conjunctival space. In doing so, he has endeavoured consistently to reduce to a minimum the amount of trauma inflicted upon the eye. Iridectomy enters into the procedure exactly as it does into that of the combined operation for cataract. In other words it is a necessary evil. Fortunately however, as we shall see later, the evil can, in this operation, be reduced to a practically negligible quantity. Every effort has been made to avoid any interference with the ciliary body. Cyclodialysis, so far from having been courted, has been sedulously shunned. It is for these reasons that the site of the trephining has crept forward till the operation is now a sclero- corneal, or almost a corneo-scleral procedure. In searching for a title to describe the operation, none seems more suitable than that of " Sclero-Corneal Trephining for the relief of Glaucoma." Chapter II. HISTORICAL. The History of Trephining in the Surgical Treatment of Glaucoma is of sufficient interest to justify a chapter being devoted to it. Fortunately this side of the question has recently been very fully and ably dealt with by Mr. Sydney Stephenson and by Dr. Arthur J. Ballantyne in the pages of The Ophthalmoscope . No apology is needed for reproducing these articles at length, but the author desires to acknowledge his indebtedness to both these writers for the permission to thus, make use of their work. THE TREPHINE IN THE TREATMENT OF GLAUCOMA. BY Sydney Stephenson,' LONDON, ENGLAND. The use of the trephine in the surgical treatment of glaucoma has recently been advocated by Dr. Freeland Fergus' and Major R. H. Elliot- respectively. The method, however, is by no means new, although the precise application of the method may perhaps be so. Writing thirty-four years ago, the late Dr. D. Argyll Robertson^ described what he called " A New Operation for Glaucoma." He drilled a hole, about l/12th of an inch in diameter, through the upper part of the sclera at or about the junction of the ciliary processes with the choroid. In his last two cases Robertson turned up a flap of conjunctiva with a * The Ophthalmoscope, Feb. 1910. cataract knife before applying the trephine, and afterwards replaced it over the aperture. Finding that Bowman's trephine was not in all respects well adapted for perforating the sclera, he introduced certain modifications in the instrument. For example, he added to the original trephine a collar of German silver roughened on its outer surface, so as to afford a good hold for the surgeon's fingers ; and, furthermore, he modified the cutting end of the trephine, so as to enable perforation of the sclera to be more readily effected, and also to prevent tlie instrument from passing too deeply into the interior of the eye. By these means Robertson had operated on four patients, and he believed that in the operation he described we possessed " an effectual means of reducing increased intra-ocular tension." '" At the International Medical Congress at Madrid (section of ophthalmology) Dr. Blanco,* of Madrid, advocated the removal from all blind and painful eyes of a circle, 4 mm. to 5 mm. in diameter, of sclera, choroid, and retina. A proposal to revive the operation of trephining the sclera in glaucoma, meanwhile condemned by certain writers and looked on askance by others, was brought up by Dr. Konrad Frohlich^ twenty-eight years after Argyll Robertson had described the operation. A triangular flap of conjunctiva, 10 mm. to 12 mm. long, having been reflected from the lower- outer part of the eyeball, a disc of sclera w^as removed with von Hippel's trephine, provided with a 5 mm. crown. The choroid and the retina were not touched. On completion of the operation, the conjunctival flap was replaced, and kept in position by means of several sutures. Frohlich treated by these means five painful eyes blinded by glaucoma, and all made an uncomplicated recovery (with a single exception) in from ten to fourteen days. The failure appears to have been due to the fact that the trephine was inadvertently pushed through all the membranes, whereby profuse extra- and intra-ocular haemorrhage was brought about. In case of failure, Frohlich advocated evisceration of the eyeball. As to the more recent suggestions, those of Fergus^ and of Elliot,' they differ from one another somewhat as regards details, and collectivelv, again, they also differ from the methods advocated by Robertson, Blanco, and Frohlich. Whereas Robertson, Blanco, and Frohlich removed a disc from the sclera immediately posterior to the ciliary body, both *It should be noted that Argyll Robertson advocated his operation only under special circumstances — as, for example, when iridectomy could not be performed or when it had failed. Fergus and Elliot advocate a more anterior position. All the writers named reflect a flap of conjuncti\a prior to trephinin^^ the sclera. When we come to examine a little more closely the proposals of Fergus and Elliot, we find a considerable difterence in the operations they advocate. Fergus,' after dissecting a large conjunctix al flap up to the sclero-corneal margin, removes with the trephine a piece of sclera as near to the cornea as possible. The point of an iris repositor is then passed from the scleral opening into the anterior chamber. The last step is to replace the conjunctival flap, and to stitch it into position. Although Fergus regards his operation as a mere modification of the sclerectomy devised by Lagrange,'' yet it obviously bears an even closer resemblance to Heine's cyclodialysis, in which the ligamentum pectinatum is broken through by means of a spatula, an incision having first been made through the denuded sclera at a distance of about 5 mm. from the limbus. By this operation, as every- body knows, Heine endea\oured to establish a permanent communication between the anterior chamber and the supra- choroidal space. Elliot,- after reflecting a flap of conjunctiva, applied the crown of a small trephine (2 mm.) as close to the limbus as possible, and aims at allowing the instrument to cut its way into the anterior chamber. The surgeon may then leave the disc of sclera in place, or remove it altogether. Iridectomy may or may not be combined with the trephining. Elliot aims at establishing a permanent filtering cicatrix between the anterior chamber and the subconjunctival space. Of fifty patients treated in this way in none did the operation fail to- relieve tension. Elliot claims that by his operation even a tyro can accomplish all that Herbert and Lagrange aim at in their operations, the technique of which is more difficult. Both Frohlich and Fergus lay some stress upon the fact that the sclera can be trephined without general narcosis, as by chloroform. REFERENCES. (i) Fergus, Freeland. — Brit. Med. Jour., Octol)er 2nd, 1909. (2) Elliot, R. H. — llie Ophthalmoscope, December, 1909. (3) Robertson, D. Argyll. — Royal London Ophthalmic Hospital Reports, Vol. VIII, Part 3, May, 1876. (4) Blanco. — A7««. Monatsbl. fiir Augenheillainde, Bd. XLI, Heft ii, S. 150, IQ03, (5) Frohlich. — A7/;/. Monatsbl. fur Augenluilkiinde, Mai, 1904. Ab- stracted in 'I'he Ophthalmoscope, 1905, p. 462. (6) Lagrange.^ 77/(? Ophthalmoscope, September, ?907. THE NEWER OPERATIONS FOR GLAUCOMA BV Arthur J. Ballantyne, M.D/'' SURGEON TO THE GLASGOW EYE INFIRMARY. There are few more interesting chapters in the recent literature of ophthalmologv than those which record the efforts of surgeons to devise an operation that will be both easy of performance and devoid of serious risk, and will at the same time offer reasonable prospects of improvement or cure in chronic glaucoma. Since its introduction by von Graefe, half a century ago, iridectomy has held the field practically undisputed, and any attempt to displace it from its position of security was at first looked at askance. It is admitted on all hands that the results of iridectomy in acute glaucoma leave little to be desired. In chronic congestive or inflammatory glaucoma its beneficial effects have been scarcely less notable, but it is almost universally recognised that in chronic simple glaucoma iridectomy has not been by any means so successful as in the other forms of the disease. A growing dissatisfaction with the relative futility of iridectomy in this condition has led to the introduction, from time to time, of alternative operations, but although each has had its body of supporters, none has yet been received as the last word in the surgical treatment of chronic glaucoma. \\'hatever may be the true pathogenesis of the condition, the working hypothesis on which all efforts at treatment are based is that there exists some abnormal relationship between the intra-ocular pressure, on the one hand, and the resistance of the ocular tunics, on the other. We are compelled therefore to seek means whereby the tension of the eye may be permanently reduced by facilitating the outflow of the intra- ocular fluids. The authors of the newer glaucoma operations claim that they do establish this permanent reduction of the ocular tension, and if their claim is found to be justified, these operations will mark a distinct and valuable advance in ophthalmic surgery. Readers of The Ophthalmoscope have been kept in touch with the literature of this subject, through its abstracts, reviews and original articles, which, however, are now distributed over a period of four years. The present Review, undertaken in view of the expected discussion at the forthcoming Oxford Ophthalmological Congress, is presented in the hope that it may give the reader some idea of the chief points round which ** The Ophthalmoscope, July, 1910. discussion may be expected to centre. It will be convenient in the first place, at the risk of repeating what has already been published here and elsewhere, to classify and briefly to describe the operations which we are to consider. Thereafter we may ask and attempt to find an answer to some questions bearing upon their utility and safety. Sclerotomies. The writings of Lagrange, Herbert and their followers, have made us familiar with the conception of the " filtering cicatrix," but lest we should imagine that the idea originated with these writers, it is well to recall the fact that von Graefe, de W'ecker and others were quite familiar with the idea of the filtering cicatrix. It was, indeed, de W'ecker who coined the phrase. In the discussions which centred round the modus operandi of iridectomy in glaucoma, de Wecker held that to explain the apparent success of iridectomy where the iris was atrophic one w-as forced to conclude that the effect depended on the scleral incision, which was followed by a " cicatrice a filtration." When it came to be suspected that in chronic simple glaucoma iridectomy was useless or even harmful, de Wecker felt that an alternative operation was desirable, and in 1867 proposed sclerotomy, the cicatrix of which facilitated the filtration of aqueous, and consequently secured a permanent reduction of intra-ocular pressure. Not only did de Wecker aim at the production of a filtering scar, but he also insisted that the sclerotomy wound must be free from incarceration of iris.^ Since its introduction, sclerotomy, in some form, has, next to iridectomy itself, been the operation most largely practised in simple chronic glaucoma. It has been accepted as a safe procedure, although repetition of the operation on the same eye is frequently required owing to the want of permanence of the results. Dianoux" has recently reaffirmed its value, but recom- mends that it be followed up by massage of the eye, to prevent first intention healing, and to cause the formation of a permeable cicatrix. He is supported by Wicherkiewicz,' who recom- mends the same measure after iridectomy. The operation of sclerotomy has assumed many forms in the hands of different operators. The two classical methods are those of de Wecker and Quaglino, the former being probably the more popular. If one may judge by the absence of any expression of dis- approval of the newer operations from the supporters of sclerotomy, one is led to the conclusion that in chronic glaucoma sclerotomy, after forty years, has, like iridectomy, failed to give the satisfaction that it seemed to promise. But the belief that it ought to be possible to produce deliberately a corneo-scleral wound which will lead to a permanently filtering cicatrix, has never been altogether lost, and was the motive which inspired the newer operations, which will be considered under the heading of sclerectomies. In addition to the classical sclerotomies of de Wecker and others, one or two more recent forms may be alluded to. Querenghi's operation of sclero-choriotomy^" consists in paracentesis of the posterior chamber with a perfectly linear Graefe knife, making puncture and counter-puncture immediately behind the insertion of the iris. The author believes that glaucoma is due to a hydropsia of the peri- choroidal space, and that his operation overcomes this by establishing a communication between the perichoroidal space and the aqueous chambers. Bjerrum's operation'' is recommended for simple glau- coma if myotics fail. With a narrow Graefe knife he makes an incision, the puncture and counter-puncture .being placed at the limbus and the knife being made to cut out obliquely, so that it emerges through the sclera from 3 mm. to 6 mm. from the upper or lower edge of the cornea. The incision is rendered subconjunctival by making the conjunctival puncture and counter-puncture some distance from the limbus. Among the sclerotomies should also be included the pro- cedure tried by more than one operator in the past, and recently revived by Herbert,' namely, the infolding of a slip of conjunctiva between the lips of a corneo-scleral wound, with a view to the establishment of a filtering cicatrix. Still another form of sclerotomy is the subconjunctival paracentesis operation introduced by Herbert two years ago.^ Having subconjunctival! y passed a narrow Graefe knife into the anterior chamber, in such a way that it makes a short incision parallel to the corneal margin, and 1 mm. from it, he carries the knife, from each end of this incision a short distance inwards towards the cornea. In this way he isolates a rectangular tongue of sclero-corneal tissue, the partial shrinkage and displacement of which are said to lead to the formation of a filtering cicatrix. More recently^ he has been making a broader tongue, placing it at the upper limbus, and combining it, in some cases, with an iridectomy. Abadie's Operation. — In an article which appeared in the Archives d'OpJitalniologie for May, 1910, and a trans- lation of which will be found in the present number* of •July. 1909. 10 Tlic Ophfluihiioscopc (p. 501), Abadie describes the new operation of " Ciliarotoniy." Abadie b.as always disputed the claims of Lagrange, chiefly on theoretical grounds. He holds that filtration through the cicatrix is not the cause of the reduction of tension after iridectomy or sclerectomy, that a very small iridectomy is as efficacious as a large one, and that the effect is really attributable to division of the nervous circle of the iris. Believing that in certain cases glaucoma is due to irritation of the nerve plexus in the ciliary zone, he hopes to produce an " anti -glaucomatous " action in such cases by division of the nervous circle. This he does by first dissecting up the con- junctiva and then with a Richter's triangular knife making a 7 mm. to 8 mm. incision through the ocular tunics in a meridional direction immediately behind the root of the iris. The conjunctiva is sutured in place over the wound. The operation has given Abadie excellent results in relief of pain, reduction of tension, and improvement of vision, in cases of absolute glaucoma and glaucomatous degeneration. Cyclodialysis. Heine, of Breslau, introduced this operation to the Ophthal- mological Congress at Heidelberg in 1905.^" With a straight lance knife he makes an incision in the sclera parallel to the corneal margin and 5 mm. or 6 mm. outside of it. A small spatula is then passed through the wound and between the sclera and uveal tract into the anterior chamber, breaking through the ligamentum pectinatum. The operation is based largely on the suggestion of Axenfeld, that the choroidal detachment which Fuchs had observed after operation for. cataract, occurred also in glaucoma iridectomies, and was responsible for the good results of these operations. Heine believed it possible to set up, by means of his operation, a communication between the anterior chamber and the supra- choroidal space. The abundance of references to this operation in the literature of the last few years ^^ '"" ^" ^"^ '" "^ shows that it has excited a good deal of attention. Operations vary considerably as to the safety and trustworthiness of the operation as a means of relieving pain and tension, and as to the permanence of its results. The interest manifested in Heine's operation has no doubt been somewhat lessened by the advent of the " filtering cicatrix " operation, but cyclodialysis has again appeared as an integral part of Fergus's sclerectomy with the trephine, to be referred to at a later stage. 11 Operations involving incarceration of the iris in the wound. The operations comprised in this group resemble the most recent procedures of Lagrange and his followers in their aim of ultimately establishing a permanently permeable cicatrix, but the former differ from the latter in that thev seek to attain their object by means which are deliberately avoided by the advocates of the iris-free filtering scar. The authors of the incarceration operations base their pro- posals on the following three facts : — (1) that in such an operation as extraction of cataract the entanglement of iris in the wound frequently leads to the formation of a cj'stoid, or, at least, a fistulous, scar, and that the eye in consequence remains permanently soft, with evidence of leakage of aqueous fluid inco the subconjunctival tissue ; (2) that in iridectomies done for acute glaucoma the best and most permanent results are found in cases where the iris has become entangled between the lips of the wound ; and (3) that the risk of infection of a prolapsed or incarcerated iris is greatly less in the cases where the latter is covered with conjunctiva. If the beneficial effect of iridectomy in many cases is due, not to the iridectomy but to an accidental inclusion of iris, why not, they ask, set out to produce such an inclusion in a regulated and deliberate manner^ adding the conjunctival covering to avoid risk of infection ? In June, 1903, ]\Iajor H. Herbert' communicated the results of no fewer than 130 operations for the production of a subconjunctival prolapse of the iris in primary glaucoma. In thirteen the iris was left uncut, in five an iridotomy was added, and in all the others iridectomy was performed. He found that the relief of tension was certain and permanent, although in some cases the reduction was not immediate but was estab- lished only after the use of massage and myotics for periods up to two or three months. The effect on vision was found to be more favourable than could be looked for in the same class of cases from iridectomy, and this was most notable in cases with advanced failure of vision, for in early simple glaucoma the post-operative astigmatism was apt to disturb the good central vision. He also held that the risk of late infection was very small, and that early serious complications were less frequent than in similar cases operated on by large iridec- tomies. In 1908, Herbert'' was still convinced of the value and safety of the operation. In the Anuales d'Oculisfique for 1907, Holth'^ advocated a somewhat similar procedure. He varies his operation some- what in regard to the form and position of the incision, and 12 the method of producing the incarceration ; but in most cases he makes either a flap incision at the Jimbus, with a linear knife, covering it with a conjunctival flap, or a 6 mm. incision 1 mm. outside the corneal border with a keratome, which is first made to pierce the conjunctiva 8 mm. to 10 mm. from the limbus, so as to render the corneo-scleral wound subcon- junctival. An iridectomy or iridotomy is done before the iris is drawn into the wound. Holth reported that he had done the operation 41 times, in 85 per cent, of which he had obtained persistent conjunctival oedema with normal tension. In a later paper'' he published the results of a further series of 87 operations with 86 per cent, of filtering cicatrices. He had had no bad results and had not lost an eye. Some of the cases were found still satisfactory on subsequent examinations six months to two years later ; but the author seems to have felt that the results were a little uncertain, and he turned his attention later to the production of a filtering cicatrix by means of sclerectomy. Borthen"-*^ has done fifty operations for establishing a subconjunctival prolapse without previous iridectomy. In no case of simple or absolute glaucoma did he fail to obtain the desired results. INIaher, in the discussion following a contribution by Lawson,'-^ stated that he had performed a similar operation combined with iridectomy, and in ten or twelve years had lost only one eye from iridocyclitis. He thought the benefits outweighed the risks of inflammation or of sympathetic disease. The fear of disaster from infection of the eye, or from sympathetic ophthalmitis of the fellow eye in these operations which we have -just been considering, and the difficulty of regulating the effect produced, supply two good reasons why we should carefully weigh the claim made on behalf of the next group of operations, some of which are stated to be free from both of these drawbacks. Sclerectomies. Quite a number of these operations are now on trial, but first in point of time come those of Lagrange and Herbert. Lagrange's Operation. — In May, 1906, Lagrange brought forward his operation, the details of which have been made familiar through a now fairly large number of papers from the pen of Lagrange and others (biblio- graphy 22 to 38). He is of the opinion that in iridectomy the removal of iris per se is not answerable for the success of the operation. He says that in operations for glaucoma, hypertension interferes with the co-aptation of the 13 wound. The cicatrix allows a certain amount of filtration, and this phenomenon explains the success of the iridectomy. In chronic glaucoma with low tension operation is valueless because the wound does not give place to a filtering cicatrix. The conditions are strictly comparable to those in the normal eye, in which no form of scleral incision is able to produce a permeable scar (Schoeler^''). Again, he recognises that a filtering cicatrix can be produced by sclerotomy and in iridectomy, if the iris is involved in the wound, but he sets out to produce an " iris- free filtering cicatrix " and this he claims to have succeeded in accomplishing. His operation he now calls that of " Sclerecto-iridectomy," the sclerectomy being the essential part of the operation, the iridectomy only conditional. .- ..^.. Fig. I. — Section of the Sclera and Conjunctiva. The accompanying diagrams (Figures 1 to 4) will help to explain the steps of the operation. Using a narrow Graefe knife, a small corneo-scleral flap is made at the upper part. Puncture and counter puncture are made 1 mm. outside the corneal margin, and the blade is carried upwards,, parallel to the iris and as close to it as possible, the first object being to sever the scleral insertion of the ciliary muscle. The plane of the knife blade is then changed, so that it emerges from the sclera 2 mm. or 3 mm. from the limbus and thus bevels the posterior lip of the incision. The incision is completed with a large conjunctival flap (Fig. l). This flap having been turned down, the corneal lip of the wound is- 14 Fk;. 2. - Resection of tlie Sclerotic. remoxed by the scissors (I'^ig. 2). If iridectomy is considered desirable, it is done at this stage (Fig. 3), and the replacement of the conjunctival flap completes the operation. Iridectomy, Fig. 3. — The Making of the Iridectomy. 15 although done in all the earlier operations, is not considered essential. It should always be done where for any reason, such as hypertension, prolapse is feared. No iris must be left between the lips of the wound. The result of the operation is shown in Fig. 4. From his extensive experience of the operation, Lagrange has reached the following conclusions. — 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 : (l) 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 Fig. 4. — The Result of the Operation. 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 w"hole thickness of the sclera in an eye the seat of high tension. In cases of high tension, even a simple sclerotomy will allow ample filtration, owing to the gaping of the wound, while in cases without elevation of the tension, sclerotomy will be quite ineffectual. He therefore proposes the following rules ot procedure: — (a) If tension is normal to + 1 do sclerectomy without iridectomy, the amount of sclera excised being inversely proportional to the degree of hypertension, (b) If tension is +1 to +3 do sclerecto-iridectomy, the iridectomy 16 being added to avoid entanglement of the iris. He does not recominend his operation for acute glaucoma. It is especially adapted for cases of chronic simple glaucoma. Herbert's Operation. — Next in point of time comes Major H. Herbert's^" operation of " wedge-isolation." In the argument which precedes his description of the operation he speaks of permeable cicatrices as belonging to three groups, the cysloid, the fistulous, and the filtering. By the filtering as opposed to the fistulous cicatrix he appears to mean a cicatrix in which only microscopic channels exist to allow the percolation of fluid. While Lagrange started from the observations that in an eye the seat of high tension, sclerotomy is succeeded by a gaping wound which allows of permanent filtration, and that no kind of scleral incision can permit permanent filtration in an eye with normal tension, Herbert takes as his starting-point the clinical fact that cataract extractions with a large conjunctival flap return after long periods, with a more or less gaping wound, and cede ma of the overlying subconjunctival tissue from filtration of aqueous. This he takes as his type of filtering cicatrix, and he describes it as " the condition which has been long desired, but never attained with any approach to regularity' in the treatment of glaucoma." From such observ'ations he argues that the iris- free filtering cicatrix is a practical entity, and he aims at its production in glaucoma. Herbert's first device to secure delayed union and con- sequent filtration was his "jagged incision" operation — a form of sclerotomy — dating from April, 1906. In this operation he made one or both lips of a small comeo-scleral incision as jagged and uneven as possible by means of sawing mo\'ements of the narrow Graefe knife. With experience of sixty cases, he obtained results which were excellent, on the whole, but somewhat uncertain. He also used the operation of Lagrange, both in its original form and combined with the jagged incision, but he soon abandoned these procedures in favour of his "wedge-isolation" operation, first carried out in December, 1906. In this operation the intention is to cut out a wedge, or rather a prism-shaped piece of corneo-sclera, the long axis of which shall be tangential to the corneal margin, its base attached to the under surface of the conjunctiva and its edge towards the posterior surface of the cornea. The isolated wedge is raised a little from its bed by the escaping fluid, and as it has now to depend for its nutrition on the conjunctiva to which it is attached, it shrinks sufficiently to provide tor filtration from the anterior chamber to the subconjunctival tissue, but not enough to cause an actual 17 fistula. The operation is claimed to permit of the establishment of different degrees of filtration ; it is safe ; and if it fail to produce the desired result, it does not prejudice the subsequent performance of the usual operations. It is difficult to follow this operation from verbal descrip- tion alone, but perhaps the following summary of the steps, with the assistance of the accompanying diagrams, may make it more or less clear. — A very narrow Graefe knife is used. (1) Proceeding as if the intention were to make a shallow corneo- scleral flap, puncture and counter-puncture are made close to a:^--/' Fig. 5. — Position of the knife blade in makin^r the first incision. Fig. 6. — Position of the knife blade in making the second incision. The thin line shows the position of the first incision which has been partly made. the margin of the cornea, the knife point having previously passed through the conjunctiva a little distance above the point of entrance. The upward cut is made with the knife blade bevelled a little backwards, and at this stage the bridge of sclera is left undivided (Fig 5). (2) The knife is brought down again and its edge turned forward. A forward cut is made perpendicular to the scleral surface, care being taken not to cut through the conjunctiva (Fig. 6). This incision makes the lower boundary of the wedge of tissue. (3) The knife is drawn backwards, and rotated upwards to lie in the original incision, which is continued upwards until the knife edge emerges through the sclera, a millimetre or so from the corneal margin. This completes the isolation of the wedge. The blade of the knife is now turned upwards and backwards to form a long conjunctival flap, which, however, is left attached at its upper extremity. A small basal iridectomy is advisable in order to prevent prolapse. 18 The widespread interest which tiiese operations have excited has led other operators to introduce nioditications, which, while carrying out the ideas or Lagrange, might be simpler of performance and freer from risk than his operation. The first of these modifications was proposed by Holth.'" Sclerectomy with punch-forceps. — This operation dates from May, 1909, and it will be found fully abstracted and illustrated in The Ophthalmoscope of November, 1909 (p. 774). The first step of the operation, the formation of a corneo-scleral flap, may be carried out either by a Graefe knife or with the keratome. In the former case the conjuncti^•al flap is cut in completing the section, in the latter the keratome is made to enter the conjunctiva some distance above the scleral puncture. Iridectomy follows, and then the anterior lip of the wound is partly cut away by means of punch-forceps, which are a modification of Vacher's (Fig. S) or de Lapersonne's irido-capsulectomy punch-forceps. Brooksbank James's Operation. — In the discussion on Lawson's contribution"' Brooksbank James referred to a modification of the Lagrange operation practised bv him in six cases. A description of his method has more recently appeared in the Transactions of the Ophthalinological Society (Vol. XXX, Fasc. I, 1910). He dissects down a flap of conjunctiva and then with a Beer's knife makes an incision into the anterior chamber from without inwards, 1 mm. from the limbus. After an iridectom^s a portion of sclera from the lip of the wound is removed by scissors or punch forceps, preferably the latter. Sclerectomy with the Trephine. — The latest additions to the list are the two operations in which the trephine is used to remove a segment of the corneo-sclera. These are the operations respectively of Fergus and of Elliot. Both of these operations are based on that of Lagrange, and as the reader may gather from the Review on the Use of the Trephine, published by Sydney Stephenson in The Ophthalmoscope for February, 1910, they have a much closer affinity to Lagrange's operation than to the older operations of Argyll Robertson, Frohlich, etc., in which the trephine was formerly employed. Fergus's Operation. — Fergus has employed this operation since January, 1909, and he demonstrated it before the Ophthalmological Congress at Oxford and the Ophthalniological Section of the British Medical Association at Belfast in July of the same year. The only published account of it was contained in an abstract of the latter contribution in the British Medical Journal'^^ until the author took occasion to describe the genesis and the nature of the operation in The Ophthalmoscope of February, 1910.'' 19 The technique of the operation is simple. — A conjunctival flap is dissected up towards the cornea and laid over the corneal surface, while with the trephine (Bowman's), a small disc of sclera is removed, a millimetre or two from the apparent corneal margin. At first the operation was completed -at this stage by replacing the conjunctival flap, but Fergus soon introduced a modification which now forms an essential part of his operation, namely, the passage of an iris repositor from the trephine hole into the anterior chamber, keeping it in close contact with the sclera and cornea. The conjunctiva is then replaced, and stitched in position. Elliot's Operation. — About the time that the above •operation was on trial. Major Elliot, in Madras, had independently conceived the idea of utilizing the trephine in a similar way. He first used the trephine in August, 1909, and by the time of his first communication,*' he had operated on 50 eyes. Elliot also raises by dissection a flap of conjunctiva with its base at the corneal margin. His trephine opening is made as far forward as possible, so as to enter the angle of the anterior chamber. The disc of sclero-cornea is removed, iridectomy is done, if necessary to prevent incarceration in the wound, and the conjunctiva replaced. It is unnecessary to describe the operation in any greater detail, as it \\'\\\ be found fully discussed in the article by Elliot himself, which appears in the present''' issue of The Ophthahiioscope (p. 482). Elliot found that in his first 50 cases tension was relieved in every one. While these two operations have features in common, it is obvious, as stated by Sydney Stephenson {loc. cit.), that they have marked points of difterence. Elliot's operation is as nearly as possible the operation of Lagrange, making allowance for the use of the trephine instead of the scissors, since the opening forms a communication between the angle of the anterior chamber and the subconjunctival tissue, this object being attained by keeping the trephine as far forward as pos- sible. The iridectomy is added, not as an integral part of the operation, but merely to avoid the risks of prolapse. Fergus's operation, on the other hand, involves an opening up of the suprachoroidal space, to which is added a cyclo- dialysis. It is true that Lagrange, in stating the aims of his operation, speaks of cutting through the scleral attachment of the ciliary muscle and opening up a communication between the anterior chamber and the suprachoroidal space, but the successful accomplishment of this incision must be difficult, and it may be shown in the future that in most cases the *Jaly. 1910. 20 incision is purely into the anterior chamber. In any case Lagrange in his later papers seems to lay most of the emphasis on the formation of a fistulous track between the anterior chamber and the subconjunctival tissue-spaces. Fergus's operation, therefore, would seem to have a nearer relation to the cyclodialysis of Heine, substituting a trephine opening for a scleral incision with the keratome. Verhoeff's Operation — \'erhoeff's contribution to the subject^' is the substitution of a special instrument — the *' sclerectome " for the trephine. As its inventor says : " it combines the actions of a punch and a trephine." An incision 2-3 mm. long having been made parallel with, about half a millimetre from the corneal margin, the instrument is passed through the wound, and having been carried to one end of the incision it is made to cut out a small clean round hole, the diameter of which is one millimetre. A small buttonhole is made in the iris. The operation, like the others, is carried out under a conjunctival flap. Bettremieux's Operation. — This operation appeared in 1907'*'' under the title of " simple anterior sclerectomy." The author sets out from a different standpoint from that of the other operators. He states*" that he has been impressed by the following facts : (l) that glaucom.a has been caused experimentally by the cautery applied round the cornea, or by tying the anterior vessels, or, accidentally, by burns at the corneo-scleral junction, i.e., by conditions which block the intra-ocular blood circulation ; (2) that Exner explains the action of iridectomy in glaucoma on the ground that the arteries and veins in the iris are made to communicate directly with each other ; and that this restores the normal circulatory conditions. Taking this as his basis, he operates as follows : The sclerotic having been exposed, with a needle slightly curved at its end, he traverses tangentially to the corneal margin, the outer layers of the sclera, which he then excises with a thin and narrow Graefe knife. This produces what he calls a " filtering zone,'' but later he lays all the emphasis on the setting up of an anastomosis between the deep scleral and more superficial subconjunctival vessels, which restores the normal blood circulation of the eye. If Bettremieux's own conception of the operation be the correct one, it probably ought not to be included in the group of operations aiming at the production of a filtering cicatrix. Lagrange, in speaking of his own operation, warns the reader against confusing it with the simple anterior sclerectomy of Bettremieux, by which, he declares, a filtering scar cannot be produced. 21 Remarks. Having thus briefly considered each of the newer operations, we are now in a position to ask, and, if possible, to answer some questions which must, sooner or later, be satisfactorily disposed of if these operations are to attain to a permanent place in ophthalmic surgery. We have first to put to ourselves the question, " Is there such a thing as a filtering cicatrix ? '' It is usually admitted that the cystoid scar which occurs after a certain number of cataract extractions and glaucoma iridectomies, is evidence of a permanent fistulisation of the eye, and it has been repeatedly acknowledged by experienced surgeons that the most successful glaucoma iridectomies are often those in which iris has become entangled in the wound. No one proposes to attempt to form a cystoid cicatrix in its extreme form, but Holth's iridencleisis and Herbert's subcon- junctival prolapse aim at the inclusion of iris in the wound, and we may take it that the claim of these operators to set up permanent drainage of the anterior chamber is fairly well established, the opposition to their operations being based on their alleged dangers and the difficulty of regulating the amount of the effect produced. That filtration of fluid occurs through a simple, iris-free, corneo-scleral wound before cicatrisation is complete is hardly questioned, and it is not denied that for a limited period after healing is apparently complete, the cicatrix may be in some degree permeable. Moreover, one would have thought from a perusal of the papers of de Wecker and Lagrange, and their followers, that it might be accepted as an axiom, that the possibility of a permanently filtering cicatrix was an established fact. All of them have agreed in assuming that the filtering cicatrix occurred accidentally, and that it was but natural to aim at the deliberate production of a condition which was believed to be beneficial in certain cases. At this very point, however, the filtering cicatrix operations are met by the opposition of Thomas Henderson,^*^ who denies the j>ossibility of a permanent filtering cicatrix. It cannot be said, however, that he has substantiated the truth of his opinion. It is proverbially difficult to prove a negative, and we now have to set against such statements of what can happen, the statements of others as to what has happened. We have already seen that Herbert devised his operation in the belief that the filtering scar is a " practical entity," basing his belief on the observation of filtering cicatrices accidentally produced in the extraction of cataract (compare Elliot's third case quoted below). This belief he continues to uphold, and as clinical evidence of the existence of filtration, he submits these two points: (1) that there is true cedenia over the scar,, evidenced by pitting on pressure with a probe, and an unusually translucent appearance of the conjunctiva ; and (2) that this tt'denia is increased by pressure on the globe, or if not already in evidence, is produced by the same method. He is equally convmced'' of the possibility of producing a permanent filtering cicatrix by his operation of modified subconjunctival paracentesis. Five out of six cases which he was able to observe at periods up to two years after the operation, ga\ e reduced tension and filtering cicatrices. Elliot^'* expresses himself as quite convinced of the reality of the permanently filtering iris-free cicatrix. The cases on which he bases his opinion include one seen twelve weeks after the Lagrange operation, one three-and-a-half years after iridectomy, another seven-and-a-half years after iridectoni)-,. and, lastly, one ten years after a combined extraction of cataract. In all of them the existence of filtration through the cicatrix was proved by the presence of oedema as described by Herbert {vide supra). Verhoeff"'*^ says it is certain that it is possible to establish permanent drainage by this means. All the doubts cast on the reality of the filtering cicatrix as a result of the sclerectomies of Lagrange, Herbert, and others,, will apply with double force to the simpler operation of sclerotomy, as practised by de Wecker and his successors with the same end in view. In this case the opponents would have the support of Schoeler,^' who satisfied himself by animal experiments that no kind of scleral section can produce per- manent filtration, and what applies to the normal eye will apply equally to the case of chronic simple glaucoma with normal tension, de Wecker himself recognised the fact that in chronic simple glaucoma the cicatrix consolidates and the effect diminishes, hence the repetition of sclerotomy, so often advised to prolong its effect, and the employment of massage of the eyeball, as an adjuvant to delay the unavoidable closure of the filtration channels. Lagrange, while holding that the good results of iridectomy in glaucoma with elevated tension Avere due to the sclerectomy rather than to the iridectomy, saw that the case of chronic simple glaucoma without tension was simply that of the normal eye, and it was this very fact that led him to devise his sclerectomy operation in the hope of producing a gap which could be permanently occupied, not by an increasingly dense tissue, but by a more or less fistulous, cicatrix. 23 So much for the clinical evidence for the existence as a recognisable entity of the filtering cicatrix. We may take it that from the clinical point of view this evidence is almost, if not quite, conclusive, and meanwhile we may accept as a sign of the presence of filtration, the conjunctival oedema as. described by Herbert and Elliot. - ; S'^'*v- .0»fv,^ Let us now turn to the histological aspect of the question. The clinical results are the ultimate standard by which these operations will be judged ; but having claimed to produce a filtering cicatrix, it lies with the authors to prove that such a thing exists. One imagines that it will be confessed, even by the advocates of the filtering cicatrix operations, that the histo- logical evidence in their favour is still somewhat scanty and unsatisfactory, nor is this surprising, considering the short period during which the operations have been on trial. Lagrange, in one of his earlier papers,"''^ speaks of his hope of examining microscopically eyes operated on by his method and the eyes of dogs submitted to his operation, but so far very little of this material is available for our purpose. 24 Demicheri^'' had occasion to examine an eye enucleated fourteen days after the Lagrange operation on a subject with ha^morrhagic glaucoma. He found between the lips of the wound, from within outwards, a small knot of atrophied iris, a mass of cellular tissue, and a quantity of loose vascular cedematous tissue containing cystic cavities and numerous pigmented cells apparently washed into it from the iris by a stream of fluid. From his examination of the wound he felt sure that there had been a true filtration of fluid through it from the anterior chamber to the subconjunctival connective tissue. He found no trace of communication between the anterior chamber and the supra-choroidal space. At the extremities of the incision there was incarcerationof the iris. He inclines to think that a true scleral fistula, as conceived by Lagrange, does not persist for long, and that the tissue may ultimately become so dense as to put a stop to all filtration. Lagrange"'' disowns Demicheri's case on two grounds ; that it is not an example of his operation if iris is entangled in the >«yL Fig. 8. — Punch-forceps. wound, and that he does not perform his operation in acute glaucoma. Early in last year Lagrange made an important contribution to the histological aspect of sclerectomy by publishing illustrations of sections from the eye of a dog submitted to his operation eleven months earlier (Fig. 7). During the eleven months the eye had remained quiet and with normal tension. Microscopic examination showed beneath the conjunctiva larger and smaller cavities communicating with each other and with the anterior chamber. Further, the anterior chamber could be seen to communicate also with the supra-choroidal space. The walls of the spaces were neither thickened nor covered with epithelium. Weekers and Heuvelmans''" claim to have established the truth of Lagrange's statement, that such a fistula can be pro- duced, by their microscopic examination of the eyes of a rabbit operated on five months before according to the method of Lagrange. Holth^^ accompanied his description of his operation of sclerectomy with punch-forceps, with a photomicrograph of 25 the Iwound six weeks after the operation (Fig. 9). It shows fistulisation. This case had presented normal tension, and marked improvement in visual acuity and field. I am not aware of any references in the literature to the microscopic examination of eyes after the operations of Herbert, Elliot, Fergus, Verhoeff, or Bettremieux. The material at our disposal being so scanty, the question that naturally arises as to the nature of the filtering cicatrix Fig. 9. — Sagittal section through the cicatrix of a sclerectomy of the anterior lip with the punch-forceps six weeks after the operation. The patient died from pulmonary embolism following a fracture of the femur. and how it acts, cannot yet receive a satisfactory answer. In the communications describing the aims of the various opera- tions and the methods employed to attain them, it will be found that each author has set out with a conception of some kind concerning the conditions that will obtain in the cicatrix after complete consolidation has been reached. Thus, Lagrange said his aim was to make his incision cut through the scleral attachment of the ciliary muscle, and he believed that it brought the perichoroidal lymph spaces and the chambers of the eye into communication with the subconjunctival cellular 26 tissue. To fulfil this ideal, he aims at making his incision as far back as possible so long as it lies in front of the iris. Morax, in the discussion which followed Lagrange's communi- cation,-' while acknowledging the good results obtained by the operation, doubted the possibility of producing the exact incision spoken of, namely the dixision of the scleral attach- ment of the ciliary muscle. Given an open angle in the anterior chamber the possibility of making the incision described is undeniable, and figure 7 seems to be an example of a successful attempt ; but we are probably safe in saying that the great majority of so-called Lagrange operations will comprise a section which gives the root of the iris a fairly wide berth. Lagrange himself has recently seemed to lay more stress on the communication between the anterior chamber and the subconjunctival spaces. An attempt was also made by Herbert to classify the possible forms of permeable cicatrices into filtering, fistulous, and cystoid. The distinction between the first two was that in the first the channels of communication were many and of micro- scopic size, while in the second we had a single fistula recognisable as a dark point lying under a '' filtration area " of the conjunctiva. Lagrange speaks in one place of the orifice becoming transformed into a tiny fistula, and in another of the attempt to produce a cicatrix with microscopical apertures. In all his communications he makes " fistulisation " the keynote of his operation, but he seems to indicate a cicatrix permeated with microscopic channels. It will be remembered that Demicheri, on the strength of the microscopic examination of an eye after sclerectomy, doubted the persistence of a true scleral fistula. Weekers and Heuvelmans'"" in speaking of the conditions of success in this operation, say the whole thickness of the sclera must be excised if a permanent fistula is to be obtained ; but against this we may put the section from Holth's case, in which only a part of the scleral fiap was excised, while filtration was reported to have been present. Herbert, from the outset, has looked for the formation of a filtering scar. He conceives of a shrinkage and displace- ment of the isolated corneo-scleral wedge sufficient to provide for filtration, but not sufficient to cause a fistula. In the photomicrograph of Holth's case already referred to (Fig. 9), the gap between the lips of the Avound was filled bv a loose connective tissue derived from the subconjunctiva, but this perhaps should not be taken as an indication of the ultimate state of the cicatrix, as only six weeks had elapsed since the operation. Fergus and Elliot put forward no theory as to the nature of the cicatrix produced by their respective operations, and no 27 results of histological examination of eyes submitted to scleral trephining are yet available. \'erhoeff apparently looks for the formation of a single fistulous opening as the result of the clean-cut circular wound produced by his instrument. He says it is impossible to produce a filtering cicatrix, but that we can establish a subconjunctival fistula. Such evidence as we possess, then, regarding the histological characters of the cicatrix points to its persistence as a loosely- built tissue derived from the subconjunctival or other neigh- bouring tissues, and permeated with fine channels which form a possible path for the aqueous fiuid, and, on the whole, we may take it that there is both clinical and histological proof that the filtering cicatrix is a reality. To come now to the question of permanence, we must wait longer before we can feel assured of the permanence of the filtration. Lagrange's sclerecto-iridectomy" is only four years old, Herbert's wedge-isolation operation three and a half years, Bettremieux's about three years, Holth's sclerectomy with the punch-forceps two years, Fergus's eighteen months, Elliot's ten months, and VerhoefT's seven months. It is not possible to separate clearly the results obtained by most writers into those relating to filtration, to tension, and to vision. We meet too often with vague references to '" good results," and similar phrases. We give, without comment, the following figures : Lagrange, in July, 1907,"" said he had already recorded the results of 27 cases watched for more than six months. Three had no benefit, and four had been lost sight of. Of the twenty good results twelve had improved vision, and in eight vision was maintained. He adds six other cases, in all of which the results were good. In 1908' he reported six cases in which sclerectomy had been done without iridectomy. In one the operation was too recent for comment. Four of the others, seen from three to six months after the operation, had main- tained improvement in \'isual acuity and visual field with per- sistence of filtration. The case operated on by Lagrange at the Ophthalmological Congress at Oxford, in July, 1907, was reported by Doyne'*' six months later with distinct improvement in vision and extent of visual field. Weeks, in the discussion on Lawson's communication,^' said he had done Lagrange's operation thirty or forty times, but the anticipation of permanent lowering of tension had not been entirely realised, Rochon-Duvigneaud*' reports a case in which he obtained a good result. Tension remained iiiiiitis, and the cupping of the disc disappeared. * July, 1910. 28 In July, 1908, Herbert had operated on sixty-three cases, about one-third of which had then been under observation for more than six months. He showed a few cases illustrating the i:fOod results following both of his operations. At a recent meeting of the Ophthalmological Society'' he said he had now the results of six out of eight eyes on w'hich he had done his sub-conjunctival paracentesis in two years. One of the six was a failure from attachment of the iris to the wound. The others all had reduction of tension to normal by filtering cicatrices, but sometimes it took several months for tension to reach the normal level. For the other operations the following particulars are avail- able : — Bettremieux^^ reports a case of simple chronic glaucoma with poor sight and retention of the outer part of the field only. The patient recovered central vision and still retained it five months later. Holth,'" between June, 1908, and May, 1909, had done his sclerectomy with punch-forceps 30 times. In the first 10 he punched the posterior lip of the w'ound and the results were not permanent. In che last 20 he removed sclera from the anterior lip and always produced a fistulous cicatrix. There are no specific dates given for subsequent examinations. No figures are available as to the number of times Fergus's operation has been performed, or with regard to the results. Elliot's paper,"*^ printed in this issue* of The Ophthalmo- scope, deals with 128 operations. The communication is of interest, not only on account of the large amount of material •dealt with, but also because of the detailed manner in which the results are recorded. A special interest attaches to the table giving the most important facts regarding fifteen cases which have been seen again at intervals ranging from one to nine months after the operation. In Elliot's opinion filtration has been maintained in all except one which was doubtful. It will be seen that the tension in practically all the cases was, at the latest examination, lower than before the operation, and slightly higher than immediately after it. It should also be borne in mind that these are tonometer records. Time alone Avill show whether this position of the tension represents the ultimate condition of the eye, or whether it indicates a tendency to return to the state prior to the operation. Nine months is perhaps too soon to give a definite answer. It is also of interest to note that vision was in many improved, in others stationary, while it was diminished in one case only. There must be a large amount of material now available on * July, 1910. 29 which conclusions might be founded as to the permanence of the resuhs of these operations. Many of the reports are rendered somewhat valueless for our present purpose througli absence of necessary particulars. It is mucti to be desired that operators who have the opportunity to examine cases some time after operation would publish details as to the state of the tension, visual acuity under correction, and field of vision, both before and after operation, as well as particulars as to the appearance of the cicatrix at intervals. Only by the accumulation of such details can the question of the value of these operations be settled. To refer briefly to the related operations, it may be taken as accepted that filtration of fluid does not occur through the scars in which iris is included, and it will be equally freely admitted that a similar scar results from the subconjunctival prolapse of Herbert, and the iridencleisis of Holth. We have seen that Bettremieux does not insist on the filtering nature of the scar in his operation. I am not aware of any histological proof of the existence of the mechanism by which he tries to reduce ocular tension. There is no microscopical evidence of the justice of Querenghi's claim to set up a communication between the aqueous chambers and the suprachoroidal space. This idea supplies also the raison d'etre of Heine's operation of cyclodialysis. Doubts have been cast on the permanent existence of the communication between the anterior chamber and the suprachoroidal space by Weekers,^^ Krauss,"'and Joudin,'*^ who have found in microscopic exami- nation of eyes after cyclodialysis, no such communication, but the ciliary body tightly bound down by cicatricial tissue or impacted in the wound. In the next place we have to ask ourselves whether the amount of the eff"ect produced by the various operations can be regulated. Lagrange and Herbert are the only authors who attempt to answer this question. Lagrange, as we have seen, shortly after introducing his operation, laid down certain rules to guide the operator in the choice of a procedure for eyes under diff'erent degrees of tension. Herbert claimed, as one of the advantages of his wedge-isolation operation, that it could be manipulated to allow of more or less filtration. Elliot is still in doubt as to the size of trephine opening which will meet the mean between too large an aperture, with softening of the globe, and too small an opening, with early blockage of the wound. Lastly, though first in importance, we are faced by the question, do these operations lead to benefit or to cure, especially in chronic simple glaucoma in which iridectomy has failed to give full satisfaction ? 30 A consideration of the results already quoted leaves the impression that the claims of the various authors ha\-e all been more or less substantiated, and that a sphere of usefulness, still to be more accurately defined, exists for each of them. There have, indeed, been surprisingly few attempts to deny their beneficial results. Henderson, in disputing tlie contentions of Lagrange, did not deny the good results obtained by his opera- tion, but held that they were attributable to the accompanying iridectomy. Lagrange did not consider the iridectomy an essential part of his operation, and he took up Henderson's challenge by performing his sclerectomy without iridectomy. The good results of four such operations have already been alluded to. (Juite as convincing as this demonstration of Lagrange's was that of \''alude,"* who on one patient performed iridectomy in the better eye and sclerecto-iridectomy on the other. The latter improved as regards tension and vision, while the other retained high tension and failing vision. Sclerectomy was then done on this eye and resulted in improved vision. But while Valude has given his support to the operation of Lagrange, he states that the problem of glaucoma is not sohed by establishing a filtering cicatrix. In one case, where an ideal filtering scar had been obtained, vision continued to deteriorate, and he thinks the operation should not be done until the vision begins to fail in spite of myotics. We have not yet the knowledge which would enable us to gauge the respective merits of these operations. An operation which lends itself to lucid description will naturally be more widely adopted than one the explanation of which is difficult. Herbert's wedge isolation operation has no doubt suffered some neglect on this account. Elliot, who has had the advantage of learning it from Herbert himself, says it is " a tricky and difficult operation." Simplicity and absence of difficult technique will also be factors of great importance in the choice of an operation, other things being equal. The operation of Lagrange presents no difficulty that cannot be overcome with practice, but sclerec- tomy by the punch-forceps or the trephine is held by many to be a simpler operation. Of the risks of accidents, such as vitreous prolapse, iritis, cyclitis, and sympathetic ophthalmitis, Ave can only hope to learn by our individual mistakes and misfortunes, or by the experience of others who have the courage to publish all their results, good and bad. As several of the operations involve interference with the ciliary body, a considerable amount of material must now be accumulating to show whether the traditional fear of wounds in that region is justified. 31 It cannot be too often insisted on, and we may be allowed to repeat it in conclusion, that the great desideratum now is that ■every case of glaucoma operated on by one of these newer methods and reobserved on a subsequent date, should be carefully reported with reference to the details already enumera- ted, and, needless to say, considerable value will attach to any investigations that will throw light on the histological character of the resulting cicatrices. BIBLIOGRAPHY.* (') de 'Weck.eT.~.'l/a/nte/tfO/>/i/a////o/o,^'e,iS8g. (-) Dianoux. — Ainiales cfOculiifiqiie, fevrier, 1905, T. CXXXIII. (■') Wicherkiewicz. — Aiuiales d'Oculislique, aout, 1905, T. CXXXIV. (') Querenghi. — Zeifsc/iriff. f. Augeiikeilk., Jamiar, 1908. (') Querenghi.— AiiU'i// if 0//a/Nio/og/a, Vol. XXXVI, 1907. (") Bjerrum. — L'' Ophtalmologie Provinciale. mars, 1909. (") Herbert. — Transactions of the Ophthalmological Socie'y of the United Kingdom, Vol. XXIII, 1903. C) Herbert. — The Ophthalmoscope, January, 1908. (') Herbert. — British Medical Journal, 14th May, 1910. {'") Heine. — Deut. medizin. If'ochenschr., No. 21, 1905. (") Wernicke. — A7/;/. Monalsbl. f. Atigenheilh.,l>io\'timher-T>ezemhex, 1908. (1-) Meller.— Graefe's Anhiv. f. Ophthal., Bd. LXVII, Heft iii, 190S. (I'j Joudin. — W'eUnik. CphtalmoL, mars, 1908. ('^) Boldt. — Beitriioe zni Augeuheilk., Juni, 1907. (^'') Weekers.— yV////. Monatsbl. f. Augenheilk., Bd. Xl-V, Heft ii, S. 230, September, 1907. {"■) Krauss. — Zeitschrift. f. Augenheilk.,'?>(\.yj^\,]\.\\\, 1908. ('') Herbert. — The. Ophthalmoscope, July, 1908. (i«) \\.o\'Ca..—Aunales d' Octilistiqne, t. CXXXVII, mai, 1907. (1") Holth. — /i^/^.. T. CXLII, juillet, 1909. (■^f) Borthen, — Archiv. f. Augenheilk., Bd. LXV, 1909. (-') Lawson. — Trans. Oph. Soc. of the U.K., Vol, XXIX, 1909. (■-■-) Lagrange. — Rev. General d'Ophtalmol., 1906. (-^) Lagrange. — Archives d' Ophtalmol., z.o\\\., 1906. (-') Lagrange. — Archives d'OphfalmoL, T. XXVII, 1907. (-') Lagrange. — .Innales aOcitlistiqne, i^vnex, 1907, T. CXXXVII. (^'*) Lagrange. — 77^^ Ophthalmoscope, Vol. V. 1907. (-'') Lagrange.— ^;r/;m,'s d Ophlalmol., T. XXVIII, 1908. i'^") Lagrange — The Ophthalmoscope, Vol. VI, 1908. ('■^") l^agTcLUge. - Annales d'Oc/ilisli(//ie, novembre, 1908, T. CXL. (■'") l^agTcLnge. — A'ecneil d Ophtalmol., 1908. (") Lagrange. — .Archives d Ophtalmologie, 1909. ('-) Rochon-Duvigneaud. — Archives d' Ophlalmol., T. XXVIII, 1908. ('■') Rochon-Duvigneaud. — Recueil d' Ophtalmol., 1907. (■'') Valude. — Annales d' Ocnlistique, T. CXL, 1908. (■'') Doyne. — 77;« Ophthalmoscope, Vol. VI, 1908. (^'') Demicheri. — .Annales d' Octilistique, T. CXL, I9(jS. ('") Abadie. — Archives d' Ophtalmologie, 1909. (■'") Meller. — Klin. Monatsbl. f. Augenheilk., Dezember, 1909. (■'■') Schoeler. — Berlin klin. Wochensclirift, No. 36, 1881. *Some of the volumes referred to contain more than one contribution by the same author. 32 Herbert. — The Ophthalmoscope, Vol. V, 1907. Fergus. — British Medical Journal, and October, 1909. Fergus. — The Ophthalmoscope, February, 1910. Elliot. — The Ophthalmoscope, December, 1909. Verhoeff. — 7"//^ Ophthalmoscope, March, 1910. Elliot. — The Ophthalmoscope, July, 1910. Bettremieux. — La Clinique Ophtalmologiqiie, 1907. Bettremieux. — La Clinique Ophtalmologiqiie, 1908. Henderson, Thomson. — The Ophthalmoscope, December. 1907. Henderson, Thomson. — The Ophthalmic Revieiv, September, 1907. Henderson, Thomson. — The Ophthalmic Review, July, 1907. Herbert. — Ophthalmological Society. Abstract in British Aledical Poitrnal, I4tli May, 1910. Weekers and Heuvelmans. — Archives d'Ophlalm., novembre, 1909. Bettremieux. — Bull, de la Societt Beige d'Ophtalm., No. 23, 190S. Chapter III. INDICATIONS FOR SCLERO-CORNEAL TREPHINING. It would be possible to consider the subject dealt with in this chapter from the point of \iew of the exceptions, rather than from that of the rule. In other words, one might take up the position that, with very few exceptions, Sclero-corneal Trephining is the operation of choice in dealing with all forms of glaucoma. It is, however, admitted that in the present state of ophthalmological opinion, it is advisable to look at the question from the 0]:>posite point of view. This will therefore now be done. (1) Chronic glaucoma. Sclerectomy has admittedly supplanted the older operations for the relief of this form of glaucoma. In choosing a method of performing sclerectomy, we shall go far before we find a simpler and easier tediiiique than that of trephining, or one which permits of more subtle gradation of the effects produced. Sufficient time has elapsed to enable us to say, with certainty, that the filtration obtained in these cases is permanent. Some of our earliest cases, done in 1909, are still under observation, and continue to filter freely, whilst we have now a number of eyes, trephined over 2 and 3 years ago, which continue to preser\e a normal or sub-normal tension, and to enable the patients to do useful and even strenuous work. It has been said of our Indian statistics that, inasmuch as it is only possible to follow up a percentage of the cases, the results are of little value : the obvious reply is that whilst we have admittedly not been able to follow up more than about 22 per cent, of our cases, the total bulk of operations performed has been so great that even this percentage comes to a total numerically larger than the whole out-turn of most operators. This mass of figures has shown most conclusively the value of sclero-corneal trephining. In order to convince medical opinion, however, one must look not to the statistics of the author of a method, or to those of any one surgeon, be he who he may, but to the results obtained by many workers in many lands, workmg under many conditions. For this reason the evidence given at the epoch-making discussion on glaucoma D 34 operations before the International Congress of Medicine in London last year (1913) is one of the greatest importance. Men from Europe, Canada, America, Egypt and the East bore testimony to the results they had obtained with the trephine in chronic glaucoma. Nor must we omit to mention the Congress of Ophthalmology at Heidelberg in 1912, the discussion at the American Academy of Ophthalmology in Chattanooga in 1913, and the Symposium on glaucoma at Chicago in November, 1913. These have been only a few of the many occasions on which this subject has been discussed in many parts of the world, and the testimony has been so extraordinarily favourable that little more need be said. In addition to this evidence and to the many individual papers which have appeared so profusely in ophthalmological journals during the last two years, the author has received private and other communications of a like purport from practically e\'ery part of the civilised world. The fact that the new procedure has obtained a world-wide trial within four years of its first publication, provides a sufficient justification for leaving it confidently to the judgment of the medical profession. Some statistics will be found quoted in chapters XI. and XII. (2) Congestive glaucoma. — It must be admitted that there still exists in many quarters a feeling against trephining in cases of acute glaucoma. Many, even of those who have found trephining " a safe and easy method " in simple cases, hesitate still to apply it for the relief of congestive glaucoma. No surgeon approaches an operation for glaucoma with a light heart. It is, and always must be, a hazardous procedure, be the technique what it may. The operating surgeon requires for it manipulative skill, courage and re- source. The procedure that will recommend itself in the long run to ophthalmologists, will be that which combines, to the greatest possible extent, the elements of safety, certainty, and precision. It is first necessary to clear away a possible source of mis- understanding as to what is meant by the term " acute glaucoma." Some would reserve the name for " the form of the disease which begins with acute symptoms," believing, as they do, that the onset of these symptoms marks, in some cases at least, the very beginning of the disease. Hence there appears from the operative point of view to be a tendency to place " acute primary attacks of glaucoma" in a category apart, and to draw a sharp distinction between them and the acute or sub- acute exacerbations of cases of chronic glaucoma. But despite its apparent suddenness, the first attack of high tension may be merely an exacerbation of an extremely mild glaucomatous 35 state. The histories given prove that this is so in many instances. One hears from surgeons who are confident that they have met with cases, in which the eyes were not glaucomatous before the acute attack began, but it is quite obvious that in every such eye the physical factors, which predispose the organ to an attack of high tension, must at least have been present, whilst to prove that the eye was normal beforehand would be difficult, if not impossible. It may be urged that in the exacerbations of chronic cases, iris adhesions introduce an element of complication. The same cannot be said of the class of case we shall deal with under the next heading, in which violently acute attacks of secondary glaucoma complicate the course of intumescent cataract. The only discernible difference between these cases and those of acute primary glaucoma, lies in the rapidity of the onset of those physical conditions which invite the glaucomatous ■explosion. It is quite certain that in the violence of their symptoms, these attacks sometimes yield pride of place to nothing less acute than a glaucoma fulminans. In India cases of acute primary glaucoma are rarely met with ; this is accounted for by the reluctance of the people to resort very early to medical relief, and by the fact that diagnosis is often not made at this stage, owing to the paucity of trained medical men ; but Ave have trephined a number of cases of acute and sub-acute exacerbations of chronic glaucoma, and of acute glaucoma secondary to cataract, with the most satisfactory results. In fact, very soon after we first began to use the trephine in Madras (1909), we adopted it in the operative treatment of all forms of glaucoma, and there was no question in the minds of any of those who tried it there, that sclero-corneal trephining is at once the safest and the easiest method of dealing with acute and subacute, as well as with chronic, cases. A subconjunctival injection of adrenalin and cocaine renders the operation practically painless, and does away with the risks of vomiting and straining after the operation. The opening into the eyeball is minimal, and the relief of pressure is more gradual than that obtained by any other method ; indeed, in the last respect the effect of trephining is almost comparable to that obtained by scleral puncture. The two cases, published by the writer in The Ophthalmoscope, of November, 1910, will serve as examples of the value of trephining in patients suffering from acute congestive glaucoma. More could easily be added from our note books if necessary ; but we have felt that the ophthalmic world would hesitate until a. confirmation of our views was afforded by other surgeons. The cases published by Sydney Stephenson {The Lancet, 36 October 21, 1911) and hy Hradburne, of Southport {Ibid.y. December 9, 1911) were the earliest contributions to the subject. Since tliat time the volume of evidence has been growings Wallis, reporting the practice of the staff of the Royal London Ophthalmic Hospital {.The Opiitliahiioscope, \'o\. XI, p. 588), writes : " In not a few cases Elliot's trephining has been resorted to in acute glaucoma with satisfactory results. This operation has usually been done, xchen the ptipil has become dilated, and itiactive to a myotic, or when a general anccstJietic has been contra-indicated (the italics are the author's). During a recent visit of the writer to the ^lan- chester Royal Eye Hospital, he was informed that in that institution sclero-corneal trephining had practically supplanted iridectomy and all other operative procedures, in the treatment of all forms of glaucoma. This statement is amply proved by a perusal of the annual report of the hospital. Grey Clegg, one of the first surgeons to take up trephining, and who has operated on over 100 eyes " according to the Elliot technique,'' writes:'' " I have employed it not onlj' in chronic and subacute glaucoma, but also in quite acute conditions, with most satisfactory results." IMaddox, " another pioneer of the method, " regards the operation as admirable in most cases of both chronic and acute glaucoma." He adds, " In one case of double acute glaucoma, iridectomy was done on one eye and trephining on the other, and the trephining answered best." In America, Webster Fo.x, Wendell Reber, Nils Remmen, Luther Peter, and many others are trephining for acute glaucoma and are well satisfied with their results. Not a few of the German surgeons have had the same experience, and notablj' Stock, of Jena, who when speaking at the International Congress in London (1913), was able to quote from statistics of 118 operations with the trephine. Last, but far from least, ^leller has recently given some very \aluable figures in con- nection with 178 trephine operations performed in the \'ienna clinique ; he holds that in difficult and dangerous cases, trephining may be substituted for the classical iridectomy of von Graefe. The facts we have quoted make a strong case for a full trial of sclero-corneal trephining in the operative treatment of acute and subacute glaucoma, and we therefore feel that it is neither necessary nor advantageous to take up more space by an enumeration of the names and experiences of the very many surgeons whom the author has had the pleasure of hearing from on the subject. Suffice it to say that they have been many, and that emboldened by success they are * Private communications. 37 now employing the trephine operation for all cases of glaucoma alike. It is significant that not a few ophthalmologists, and amongst them men as distinguished as Professor Meller, though reluctant to give up iridectomy in their acute cases, nevertheless employ the trephine in those where exceptional difficidty presents itself. The author hopes that surgeons will publish their results in acute and subacute cases. At the same time he would remind his readers that any and all of the operations for the acuter forms of glaucoma will be attended by a per- centage of complications and of failures. The contention that iridectomy, when employed in acute cases, gave results which were ' all that could be desired,' will not, we believe, bear statistical investigation. Von Graefe's operation gave a good percentage of excellent results ; time and the publication of careful statistics can alone show whether trephining will not give us still better results. The author believes it will. One will sometimes hear a surgeon speak of the performance of an iridectomy as if it were an easy procedure, but this is never the language of a man of large operative experience. In Madras the author had the opportunity, given to very few, to teach the operative surgery of the eye, on the living, to a large number of surgeon visitors, and his experience w^as that it is more difficult to teach anyone to perform a clean neat iridectomy than to teach him to extract a cataract or to do almost any other operation on the eye. The man who has learnt this lesson is a past-master in operative technique, and will find other manipulations comparatively easy. (3) Glaucoma secondary to cataract.^ — Judging from the literature of the subject, one gathers that this form of glaucoma is comparatively rare in European countries. It is, however, all too common in India for the simple reason that the patients do not resort to surgical aid so freely as they do in countries where the general standard of education is higher. The writer has himself followed quite a number of such cases from an early stage of the cataract, and witnessed in them the onset of well marked secondary glaucoma. Of these cases, two stand out pre-eminent in his mind, as in both of them all vision was lost after an acute glaucomatous attack, although he had repeatedly and over a period of years advised both patients to submit to cataract extraction, and had pointed out to them the ever-present danger of an access of high tension. Both were presumably well-educated men, and one was exceptionally intelligent. We have, on a number of occasions, seen the onset of acute glaucoma in patients waiting at the Government Ophthalmic Hospital, Madras, for cataract extraction, although they had come in with apparently normal 38 tension. In one period of nineteen months, no less than three patients wlio had been admitted for primary cataract developed secondary glaucoma whilst under observation in hospital. In one of these high tension came on within twenty -four hours,, and in a second within tweKe days c-f admission. In both of them tlie onset was presumably brought on by mental worry and anxiety. The third developed glaucoma twenty-six day& after admission whilst under silver nitrate treatment for lid conditions. To judge from the papers which have appeared in ophthalmic journals, many European surgeons have failed to make up their minds as to the existence even of this complication of cataract; on the other hand, the Madras out-patient room records show its occurrence in nearly 50 cases yearly. The appearance of the lens in these cases is characteristic of primary cataract, the history is unmistakable, and the existence of a primary,, and hitherto uncomplicated, cataract in the opposite eye often clinches the diagnosis. At the best the prognosis is a bad one, especially when one takes into consideration the fact that the patients too often lose valuable time, after the onset of glaucoma, before they make up their minds to resort t& European treatment. To extract the cataract at once is far too hazardous. Our practice formerly was to perform an iridectomy, and to await the settling down of the eye. When the globe had become quite quiet, extraction was undertaken. This line of treatment is by no means unsatisfactory when the class of case is taken into account. But the necessarily large wound, both of cornea and iris, presents very distinct disadvantages as compared with that made in trephining. In Madras, glaucoma secondary to cataract is not only of common occurrence, but it is also, not infrequently, of a very acute type. In this connection it is interesting to note several points, viz. : (l) Glaucoma secondary to cataract is more than half as common again in females, as in males, in spite of the fact that many more males than females seek relief for cataract. (2) The period the cataract has lasted before glaucoma super- venes is always a protracted one, the complication resulting from continued neglect on the part of the patient to appeal to surgical interference until long after the cataract is fit for extraction. (3) It is a point which it would not be advisable to labour, but statistics taken over 50 cases showed that the age of onset of glaucoma secondary to cataract is not above that at which cataract extraction is ordinarily performed in Madras. The inference would appear to be that two factors are at work,. viz., an early onset and a long duration of the cataract. An important point of clinical interest is thus raised, for it is the 39 intumescent type of cataract which in our experience is most commonly comphcated by secondary glaucoma. This would bear out Priestley Smith's contention as to the influence of lens-swelling on the production of glaucoma. In a number of cases trephined in Madras for relief of this form of glaucoma, the results were excellent ; but in a few, the intumescent lens forced its way into the trephine hole, its semi-fluid contents following the line of least resistance. We were, therefore, led to go back to our old method of a preliminary iridectomy in these cases, the lens being extracted as soon as the eye had quieted down. Trephining Avas reserved for the class of case in which the lens was not semi-fluid, and in which no great forward movement of the lens and iris had occurred. It is more than doubtful whether it is sound practice to trephine when the lens is of the pearly-sectored, the intumescent, or the milky Morgagnian types. The value of any method employed to combat this form of glaucoma will best be estimated by the visual results yielded after the patient has returned and had the cataract extracted. So far, we have only been able to perform extraction in a meagre percentage of those patients whom we have trephined for this condition. Every one of them was particularly re- quested to return, and all those who had a reasonable prospect of vision after removal of the lens, were carefully instructed as to the prospects awaiting them. Unfortunately, a large number of these patients placed no faith whatever in our explanation. The idea of the trephining operation was a new one to them, and they lost all confidence in us when they found their sight unrestored after an operation had been performed It is likely that some of them resorted to other practitioners, and not a few to Mahommedan couchers, whilst many probably settled down in their villages to what they believed to be inevitable blindness. Dealing with those who did return, and remembering how long they had delayed to present themselves for the first operation, one can look with gratification on the visual results, quite a large percentage of which varied from 5/20 to 5, 50. Captain W. C. Gray, of iSIadras, has written to suggest, that when a cataract extraction is made on an eye which has been previously trephined, the incision should be brought out well within the cornea, so as to avoid all interference with the trephine aperture. It has been his experience that if the latter is interfered with, the resulting cicatrisation may, and often does, lead to obliteration of the filtration channel. The author is entirely in agreement with this proposition, and with the grounds on which it is made. He learnt very early, in his 40 woik with the trephine, that it is most important to give the corneo-scleral aperture a wide berth in subsecjuent operations on the eye, and he therefore always made a point of cutting out into the cornea, just as Captain Gray suggests. (4) Staphyloma. — In Madras we have trephined more than twenty-five eyes for staphyloma of the cornea, or of the ciliary region, with a view in most cases of arresting the progress of the bulging, and thus of a\oiding the necessity for enucleation. In endeavouring to estimate the ^'alue of the operation in tliese cases, there are certain factors which must be borne in mind. In every such case it is safe to assume that there has been chronic peri-corneal inflammation and that this has been associated with adhesion of the iris to the cornea : both these conditions are extremely unfavourable to the maintenance of a permanent and satisfactory result in trephined eyes, and the prognosis must therefore obviously be a very guarded one. Moreover, secondary cataract is very likely to supervene, whether we operate or not. It does not necessarily follow that the tonometer reading in a case of staphyloma will be a high one, but it is clear that the tension is too high for the coats of the eye in their diseased state. With these preliminary remarks, we may proceed to deal with the results we have attained. In several cases, in which high tension existed, vision distinctly improved with the subsidence of the staphyloma. This improvement was not always maintained, owing to degenerative changes in the eye, which continued to progress despite the fact that the tension remained reduced. We have been able to follow these cases for periods \'arying from five to twenty-three months after operation, and to satisfy ourselves that the reduction in tension of the eye, and the corresponding flattening of the staphyloma, promised to be permanent in quite a number of them. We can at least say that the results have been sufficiently encouraging to make us persevere with the method in selected cases. Coppez, of Brussels, trephined a staphylomatous eye which presented a rise in tension, consequent on an attack of blennorrhagic ophthalmia ; the staphyloma disappeared, and the tissue remained normal. The author's technique was adopted. In a personal communication kindly made by Gray Clegg, it is stated that " trephining has also been employed in anterior staphyloma, with moderately satisfactory results." Others have written and spoken still more favourably of the procedure. In view of the ordinary behaviour of staphylomatous eyes, any prospect of improvement in the condition is to be welcomed. (5) Conical Cornea. — The conditions of an eye suffering from conical cornea, both resemble and differ from those met 41 with in staphyloma of the cornea. In both the intra-ocular tension, though possibly not above the average for the human eye, is yet too high for the weakened tunic. On tlie other hand, the iris is not adherent to the sclero-corneal coat and the chamber is deep. Trephining should therefore be a compara- tively easy operation. It will probably be admitted that no operative procedure, which has hitherto been recommended for the relief of conical cornea, can be regarded as wholly satis- factory. Trephining merits a trial in these cases, and even if it fails, it will leave the eye no worse than it found it. In Madras conical cornea is so rare a condition that we had few opportunities of trephining cases of the kind. The operation seemed to be of value in paving the way for the final procedure on the cornea. Our practice was to perform a preliminary free sclero-corneal trephining in order to permanently reduce the tension of the eye well below the normal, and then a few weeks later to trephine again over the apex of the corneal cone. Very recently, Adams, of Oxford, has published the notes of eight cases, in which he treated conical cornea successfully by cauterising the apex of the cone, " and then at once proceeding to trephine the eye at the corneo-scleral margin, according to Elliot's method, with the performance of a subsequent small iridectomy." (6j Glaucoma following Cataract Extraction. — We have trephined nine eyes for the relief of glaucoma supervening after the removal of a cataract. The condition is of such unusual interest as to justify some details of the cases being given. In the first the patient had had an extraction eight years previously ; for five years his vision remained good ; then chronic glaucoma set in, and when he presented himself his vision was reduced to hand movements. A successful tre- phining was performed and he was seen a year and three days later ; the failure of vision had been arrested completely by the operation and the tension still remained normal {25 mm. Hg., by Schiotz tonometer). In the second case congestive glaucoma came on suddenly three months after a successful •extraction in which, however, a tag of iris had been left impacted in the wound. Vision on re-admission was 5/50 ; he was trephined one week after the onset of congestive symptoms and his vision rapidly rose to 5/30. He was under observation one month after operation, and was doing well when last seen. The third case was followed for eleven months after opera- tion, with a tension of 12 mm. Hg. and with his visual power improved to 6/18 as contrasted with 6/36 before operation. In a fourth case in which sclerotomy had failed to reduce the tension. Dr. Temple Smith, of Sydney, Australia, who 42 was working in Madras, trephined the eye. Eleven montns later the tension was 17 mm. Hg. and the vision had gone up from 5 '50 to 5/20. In a fifth case, followed for three months, trephining had been performed one and a half years after cataract extraction ; the tension before operation was 51 mm. Hg. and the vision 6 18. When last seen three months later the tension was 21 mm. Hg. and the \ision 6 12. In one case the operation utterly failed to reduce the tension and the eye was lost. In the remainder the results were not unsatisfactory, but the cases were under observation for too short a period to justify any stress being laid on deductions from them. It may be unhesitatingly said that the prognosis, in cases of glaucoma following cataract extraction, is always bad and often desperate. Under these circumstances the above review of the results attained by trephining must be considered as encouraging in the extreme. If the operation is to be successful, it is presumably a primary condition that the aqueous and vitreous chambers should be shut off from each other. If there is reason to think that there is a free com- munication between the two, it is probably inadvisable to trephine. On the other hand, a case of post - operative glaucoma m which the anterior chamber is filled with semi- fluid vitreous substance is probably a desperate one in any case. (7) Glaucoma secondary to Leukoma Adherens or to Occlusion of Pupil. — On several occasions in Madras we have operated for these conditions, and so far as we have been able to follow these cases, the results have been satisfactory. Gray Clegg writes :"' " In sympathetic disease trephining has caused long continued lowering of tension, without exciting anything beyond the most transient irritation, and the same may be said with regard to persistent plus tension in other forms of irido-cyclitis." He, of course, does not claim uniformly good results in such cases as these. (8) Glaucoma following Injury. — We have trephined thirteen eyes in Aladras for glaucoma following injury. As might be expected the conditions, which immediately gave rise to the increase of tension, were varied and the prognosis was never otherwise than bad. Nevertheless a careful review of the notes indicates that relief was almost invariably given, and that trephining proved of distinct service under conditions in which little could be hoped from any form of treatment. (9) Blind Painful Eyeballs. — In India it is a common thing for a patient to first present himself for treatment after every vestige of vision has been lost as the result of * Personal communication. 43 long-continued high tension in the eye. It is our practice to trephine in most of the cases of this class. Should trephining fail, or should it in any way be contra-indicated, we perform an optico-ciliary-neurectomy.t Coppez,^ Good," and others^ have successfully trephined eyes blinded by glaucoma, and have thus saved the necessity of enucleating the globes. (10) Prophylaxis. — Whatever may, be the verdict of other countries with regard to glaucoma, one fact stands out prominently in South Indian experience, viz., that the disease is bilateral. One eye is usually attacked first, but once the disease has thus proclaimed itself, the involvement of the opposite side is merely a question of time. The local conditions of an ophthalmic surgeon in the East are different from those of his \\'estern confrere. Many of his patients come hundreds of miles to see him, and not a few of them have begged or borrowed the necessary fares to do so. To such a man a journey to Madras is one of the events of a life- time. It is not the mere distance he has to travel, but the conditions under which he does it. He emerges from a mud village to encounter the bustle of a town of half-a-million people. He has possibly never seen a white man before, and the largest Government institutions of which he has any experience are the dispensary, the police station, or the sub-registrar's office of his village. His mental horizon is bounded to an extent that would astonish the stay-at-home Englishman. The surgeon who deals with him, must in many cases do so once for all, for, if he fails, it is unlikely that his patient will return. The methods that are applicable to the English patient who lives an hour's run from London, or from some large provincial centre, are wholly inapplicable to one of the type we are considering. If he has come with glaucoma in one eye, it is probable that the other is also affected^ but if this be not the case, it will be idle to rely upon any warning being sufficient to bring him back to hospital at an early stage of the disease in the second eye. Nor is it only the ignorant ryot to whom this class of argument applies. Men of higher education, from whom one would expect very different behaviour, often procrastinate with fatal foolishness. It was fThis operation skilfully performed reduces the tension and abolishes pain. It is much more certain in its action than trephining, but it is alsa more difficult to perform. The details of the procedure have been fully- dealt with by the author in the Indian Medical Gazette, Vol. XLI, pp. 433-435 (Nov., 1906). ^Bttll. de la Soc. Beige d'Ophtal., No. 33, p. 29, avril, 1912 ; - Opiith. Record, January, 1913, p. 15; -^Proceedings Ophth. Section Canadian. Medical Association, 12th August, 1912. 44 tlierefore our rule in Madras to trephine both eyes, when one was afl'ected with ghiucoma. We liave, on more than one occasion, /s, and to carry the scissor-points right down into the wound whilst excising the portion of the membrane. The Toilette of the Wound.— It is most important that the iris should be thoroughly replaced, and that no uveal tags should be left in the wound. For this purpose we use the irrigator already described, and placing the nozzle at the entrance of the trephine hole, we direct a bold stream of saline solution into the chamber ; this easily and quickly w^ashes the iris back into place, always provided that it has not been dragged into the wound and impacted there at an earlier stage of the procedure. At the same time the chamber is washed free of any blood which may have been effused, thus giving 72 US a clear view of details. The presence of a round central pupil aftords proof that the iris has been thoroughly replaced. Sometimes when there is a little difficulty, we may attain our object by gentle massage with a spoon over the neighbourhood of the wound, succeeded by another irrigation. If we are still unsuccessful, it is probably due to one of two very different conditions, xuz., (l) Impaction of iris in the wound, as already mentioned, or (2) a return of intra-ocular tension, as the result of the free effusion of fluid into the posterior segment of the eye. The differential diagnosis is easy, for in the former case the eye can still be felt to be soft under the pressure of a spoon applied carefully over the cornea, whilst in the latter the almost stony hardness of the globe is very easily detected. To deal with the former case first : — It is quite safe, and, in skilful hands, certainly not difficult to introduce a spud, with its tip bent forwards, into the trephine hole, and to clear the latter of iris. The use of the irrigator will often complete the replacement still more satisfactorily, once the imprisoned iris has been loosened from its attachment to the sides of the tunnel in the sclero-cornea. On the other hand, when we are dealing with a hard eye, such manipulation as we have been describing, should only be used with the greatest caution. If this rule is dis- obeyed, there will be considerable danger of damage being done to the deeper parts, for these are packed tight against the hole by the pressure of the fluid behind. The pathology of this condition is discussed at length in another chapter, but the clinical aspect of it may profitably find a place here. It is best understood by reference to a phenomenon which may readily be observed by any surgeon who operates on late cases of glaucoma. Up to a certain stage all goes well. The trephine enters the chamber, the aqueous escapes freely, and the iris and lens move forward in the usual way ; at this stage a spoon placed on the cornea shows that the eye is still soft, and yet in a very short space of time the globe is found to harden. We have felt this happen whilst the instrument was actually upon the eye, the tension passing from a condition in which the globe could be easily dimpled into hardness within a minute. At the same time, the outflow channel for the escape of aqueous has become blocked ; fluid may actually be imprisoned in the anterior chamber, and yet it cannot find its way out, although a spud bent as above indicated can be seen to pass right into the chamber in front of the iris, and in doing so to give vent to the imprisoned aqueous. The lesson is perfectly simple ; a rapid effusion of fluid has taken place into the posterior chamber of the eye, either into the vitreous or between the coats of the globe. This has pushed forward 73 the diaphragm of the eye (iris, lens capsule, lens and ciliary body) and by pressure of one or more of these deep structures has blocked the trephine hole. If the patient is got back into bed at once, the eye will, after a variable period, and often even after 24 hours, be found to be sub-normal in tension and to be filtering freely. The author holds most strongly that it is not in the interest of the patient to indulge in any manipula- tion once this hardening condition has manifested itself. He considers the patient should be got back to bed with the least possible delay. It is true that he has at times been able to get a better replacement of the iris by a cautious use of the spud, but he doubts whether even this is justified. To wait, and to use myotics is, he thinks, sounder practice. There remain to be considered two conditions which were not very uncommon in our earlier experience, but which we have not met with since we took to splitting the cornea, and thus placing our trephine hole farther forwards. In visiting a large number of hospitals in different parts of the world, the author has clearly seen that still, from time to time, surgeons, either through a want of appreciation of the importance of trephining far forwards, or through an inability to always carry out the necessary technique, make the mistake of placing the trephine hole too far back, either at or even behind the limbus. It seems, therefore, advisable to deal in this edition also with the two possible complications above referred to, which may result from this mistake. They are (l) the effect- ing of an oblique or valve-like entry into the anterior chamber {vide Fig. 19), owing to the iris base being adherent to the cornea over a large area of the space covered by the trephine, and (2) the direct entry cf the trephine into the posterior division of the aqueous chamber by reason of its cutting through the cornea and the adherent iris as one disc (Fig. 20). We are here dealing with cases in which the adhesions between the corneal and iridic surfaces have progressed so far forwards as to place a line of adherent tissue in front of the spot where the trephine has entered the chamber ; we have tapped the posterior, and not the anterior, division of the aqueous chamber. It is scarcely necessary to insist that the best way of dealing with these difficulties is to avoid them, as may be almost invariably done if the technique advocated in this chapter is carried out. In the last 325 consecutive cases operated on in the latter part of the author's time in Madras, he found that it was always possible to eftect a clean entry into the chamber, and to tap it directly thereby. In the 135 cases operated on in America, and in all those done in England, the same experience has held with one solitary 74 exception. We shall not, therefore, discuss the treatment of a complication which should hardly ever be allowed to occur. Prevention, and not cure, is called for. Having satisfied ourselves that the iris is well returned, we next replace the conjunctival flap in good position, by first laying it back over the raw surface from which it was dissected up, and then stroking it well into place with the aid of a spoon or of some similar rounded and blunt instrument. If after so doing, the surgeon waits a minute or two, he will soon see whether the flap is going to adhere to its bed or not. If it rapidly becomes stuck down, and if the gap made by the incision in the conjunctiva is easily reduced to very narrow proportions, he can confidently close the eye, and dismiss the patient to bed. But if the wound gap is wide, or if the flap shows a tendency to be very easily displaced by slight move- ments of the globe, it is better to insert a suture at once, rather than to risk the inconvenience of having to do so the next day. There are certain other indications for the insertion of a suture ; one should always be used, (l) if the patient is likely to be fidgety or unruly during convalescence ; (2) if a general anaesthetic has been given, since this deprives the patient of self-control during the earlier hours after the operation ; (3) in children ; (4) in those cases in which the area chosen for trephining has been other than the superior quadrant of the eye ; lower flaps often, but not always, require a stitch, whilst lateral flaps should invariably be sutured, or the movements of the lids will certainly displace them; and (5) in those (mostly acute) cases ' in which a subconjunctival injection has been employed before operation to induce local anaesthesia ; for in these cases the edges of the incision tend to curl inward, and it is hard to get them to lie in good apposition with the opposite cut edge of conjunctiva. An operator of large experience cannot fail to be struck with the very difterent coagulability of the blood in different patients. In one, the blood eftused into the chamber clots so rapidly and so firmly that it is difficult subsequently to dislodge it, even with an irrigator, whilst in another case the tendency to coagulation appears to be almost in abeyance, and the chamber can be washed clear of its fluid, though bloodstained, contents without the least difficulty. The interest of the observation lies in the fact that in patients with rapid coagulability the flap seals down quickly and firmly, whilst in those whose blood tends to remain fluid after effusion, the opposite is the case. The latter, therefore, more often require a stitch. A single suture will suffice to keep the flap in place, though two may sometimes secure better apposition. 75 The question naturally asked is : what are the objections to suturing in every case ? They are: — (l)that it is often unnecessary,and that experience shows that if a stitch is required, it can be put in easily, safely and painlessly the next day under instillation of cocaine and adrenalin ; (2) that in this, as in all glaucoma operations, the sooner the patient can be put back to bed with a sound eye, the safer it is for him ; and (3) that to insert a suture even at the margin of a flap, which is, at least for the first few hours, irrigated by fluid which is in continuity with that in the interior of the eye, cannot be an absolutely safe procedure. It is to be borne in mind that after a trephine operation, the condition we aim at setting up is very different from that which should follow a cataract extraction, an iridectomy or anyone of a number of other similar procedures. In those operations, one desires to get the anterior chamber to close at the earliest possible moment, and to shut it off firmly from the space included beneath the conjunctival flap ; whilst after trephining, we deliberately endeavour to keep open a free communication between the chamber and the sub-conjunctival space. In the latter case it is obvious that a fault in the asepsis of our stitch may be a much more important matter than it is in one of the former. It is urged in reply that it is not in the least difficult to put in an aseptic stitch. This is a view with which the author regrets that he cannot concur, and he speaks after having carefully watched the procedure carried out by a large number of very first-rate surgeons. Let anyone who doubts this quietly watch surgeons of undisputed skill putting in a suture high up in the fornix, and let him then say how often the technique would pass the criticism of a bacteriologist. Apart entirely from the surgeon's own hands, he will notice the risks of contamination that befall the suture from contact, if not with the face, then at least with the lid edge, but often with the former as well. Should the watcher be inclined to be censorious, let him next carefully watch, or better still ask someone else to watch, his own sutures as they are inserted, and he will probably cease to criticise others adversely for faults in technique which he himself only too often fails to avoid. It is not suggested that the risks of the insertion of a suture are large ; they are indeed quite small, but they exist, and inasmuch as the best surgeon is, like the greatest general, he who makes the fewest mistakes, we cannot afford to give the smallest point away. Others will weigh the relative risks difterently, and each will decide on the course which it is right for him to pursue in this matter. The author does not venture to criticise them in this ; he merely puts the case as it presents 76 Fig. 17 shows diagrammatically the relation of parts in a trephining in which the iris base has not adhered to the cornea. Fig. 18 shows diagrammatically the iris base adherent to cornea ; the trephine hole lies just in front of the anterior attachment of the iris. The danger of iris prolapse is obvious. 77 Fig. 19 shows diagrammatically the trephine hole entering the chamber at the anterior part of its circumference, the posterior part being blocked by adherent iris. Fig. 20 shows diagrammatically the trephine hole passing through the cornea and the subjacent layer of adherent iris, in a case in which the iris, is adherent to the cornea far forwards. The diagrams have been modelled on a drawing of Thomson Henderson's. •78 Fif^ures 17 to 20 show diagrammatically tlie interference of iris with the trephine hole. {a) Normal position of conjunctiva. (b) Conjunctiva reflected after dissection off the underlying cornea. (ab) Represents a section of the crescent seen on stripping the conjunctiva from the cornea. (c) Shaded, represents the piece removed liy the trephine. ((/) Iris. (c) Ciliary body. (/) Lens. \g) Cornea. (Ii) Sclera. itself to him, after careful thought and prolonged observation, and after having had the opportunity of discussing the question freely with many able and experienced surgeons. Finally, the upper lid is lifted off the eyeball and brought down to meet the lower one, the patient being at the same time told to look up and to close his eyes. Immediately before doing this, however, we gently stroke the cornea toward the trephine hole with a curette, in order to ascertain whether the eyeball is still soft, and whether the escape of aqueous from the chamber is free. Both eyes are then closed with aseptic pads and a bandage. Instillation of Drops. — Our rule is to avoid all instil- lation immediately after operation, unless the pupil shows a tendency towards upward displacement, in which case eserine drops (grs. 4 ad. oz. 1) are instilled. On the third day, provided that the tension is down, we drop in a solution of atropin (grs. 4 ad. oz. l) unless the pupil is already widely dilated and active. Our reason for this latter instillation is that we find in congestive cases a strong tendency to the formation of posterior synechiae ; the quiet iritis which leads to this exudation gives no other evidence of its occurrence, and must therefore be constantly guarded against. In conclusion it may be permissible to repeat that the operation which the writer has practised and which he has endeavoured to introduce to the notice of the profession, is that of simple sclero-corneal trephining. The motive is to reach, tap, and sub-conjunctivally drain the anterior chamber, with a minimum of injury to the structures of the eyeball. To this end the junction of the cornea and sclera is trephined as far forwards as possible, the ciliary body is avoided, the chamber is entered directly by the trephine, and the iris is only dealt with in order to obviate any tendency it might otherwise have to block the trephine hole, and so to interfere with filtration. The cardinal rules are few and short, viz. : — (l) dissect the 79 conjunctivo-coraeal flap as far forwards as possible, splitting the cornea for the purpose ; (2) utilise every fraction of a millimetre of the space so gained and apply the trephine as far forwards as possible, consistent with the avoidance of injury to the flap, and (3) use a sharp trephine. Chapter VI. MODIFICATIONS OF OPERATIVE TECHNIQUE SUGGESTED BY OTHER SURGEONS. The object of the present chapter is to review the various modifications that have been introduced into the technique of the operation of trephining by other surgeons, leaving the reader to estimate the relative value of each for himself. • ■ Modified Corneal Trephines, and the methods of using^ them. — The original Bowman trephine was an extremely crude instrument. It was difficult to obtain a grip of, and it was consequently very unsatisfactory to work with. In The Ophthalmoscope of June, 1910, Sydney Stephenson presented an instrument, devised by himself and made by Weiss & Son, which he described as a modification of Argyll Robertson's handle-trephine. The instrument is made from Fig. 21. — Sydney Stephenson's trephine. solid steel and drilled. The handle is fixed by a nut which screws on the proximal end and several blades can be obtained with each handle. Each blade is furnished with a cap for protection (Fig. 21). Maddox has abandoned his early trephine with a tubular guide for " one with a dress-coat guard having a rounded knob at the tip." He writes in a personal communication " this seems to me a desirable thing for beginners, since it gives them confidence that they cannot go plump through against the edge of the lens or the suspensory ligament. It is certainly better than any annular stop, since it does not touch the conjunctiva or interfere with the setting of the trephine as far forward on the eye as you teach. Moreover, by noticing the gap between it and the sclera, the beginner 81 knows how deep he is getting, and is more likely to make a " door-shaped disc with the hinge behind, if he bears forward well." Gray Clegg, who has trephined upwards of 110 cases since 1910, has kindly furnished an account of his technique, which closely resembles that described in Chapter V, except that he uses curved blunt-pointed scissors in fashioning the conjunctival flap. He has been using a 1*5 mm. trephine for the last 18 months, " but sees the advantage of the 2 mm. trephine, in that iris can be easily dealt with in a hole of that diameter, " and agrees that when the anterior two-thirds is cut through " by the trephine, the whole of the disc need not be taken " away; there is thus left practically a 1*5 mm. hole in the " antero-posterior direction, and a 2 mm. in the lateral. Thus the advantage of the 2 mm. hole for the iris is combined " with the smaller opening." He adds, " I consider it better " to do a peripheral iridectomy, but it is not essential, as several of my cases prove." Dr. George Young, of New York, writing in the Ophthalmic Record for September, 1910, described his own trephine and his method of using it in the following words : " The trephine I now use can easily be obtained, as it is merely one part of the instrument made for me by Hardy & Co., with the superfluous parts eliminated. It consists, as shown in Fig. 22a, of a tubular knife with a very keen edge that cuts the prescribed hole of 2 mm. in diameter. The bevel which produces the cutting edge is exactly 1 mm. long, and a sliding collar which D Fig. 22a. — George Young's Trephine. hugs the knife closely can be moved with the finger nail and a sliding (not rotary) motion. It is easy to place the collar just at the beginning of the bevel, so the trephine will cut 1 mm. deep, and can cut no deeper. It is safe to start this way, although the sclera is rather less than 1 mm. at the point usually chosen for trephining, at the limbus. It is not possible to wound the ciliary body, which is soft and yields before the cutting edge. A short screw thread at the other end of the knife takes a small perforated nut which acts as an excellent handle. Of course, the instrument can be made any length to suit the operator. I like a short one, and my own measures 35 mm., nut and all (Fig. 22a)." 82 "I now operate in the following manner: — After the conjunctival f^ap is cut and laid back over the cornea, a silk stitch is passed through the episcleral tissue just at the point which is to be the centre of the disc to be removed, i.e., 1 mm. from the limbus. This needs no further comment, Fig, 22b will show what I mean. The step is easy. We are all doing it in advancement operations. The only point to observe is, not to include more tissue in the stitch than can be comfortably surrounded by the calibre of the trephine. The needle is now removed from the thread, the two ends of which are twisted together and threaded through the trephine from the cutting edge toward the nut. The threads are put on the stretch with one hand and the trephine put into Fig. 22b. action with the other. While cutting, the thread not only fixes the eyeball, but pulls the sclera, where it is to be cut, well up against the cutting edge of the trephine, and affords a most excellent way of cutting keenly against a firm base. Furthermore, the eyeball is not indented or squashed ; on the contrary, all pressure is taken off it, and the collar makes it absolutely impossible for the trephine to penetrate the ciliary body. It is quite delightful to see how every fibre of sclera, tissue is severed cleanly and completely, so that as soon as this happens, the disc comes away at the end of the thread, like a cork out of a bottle, right through the trephine." " For keeping the edge of the knife keen I use a horsehide strop, perfectly cylindrical, which fits the trephine rather tightly, bevelled to a rat tail at one end so it can be threaded easily into the trephine from the nut towards the cutting edge. It is pulled right through, and repeating this two or three times, will keep the edge keen as a razor. The strop is impregnated with instrument paste. I had to make my own strop, and hope 83 others will have better luck in getting one made to order than I did ! For cleaning, I use ordinary pipe cleaners. They can be dipped in olive oil to remove any paste adhering to the inside of the tube, or in water, to swab away any debris of tissue or blood after trephining ; to dry the inside, it is quite sufficient to dip a pipe cleaner in ether, and pass it through several times, when the knife will be ready for the next sterilization. It is best to have several knives on hand, as they have to be reset after some use, and that is best left to the instrument maker." The one objection to Dr. Young's otherwise attractive technique, is the difficulty of keeping the cutting edge of the trephine sterile, whilst passing the thread through the lumen of the instrument. Possibly this difficulty is not insuperable. Subsequently to writing as above. Dr. Young has published a modification'' of his method. With the idea of imitating a free sclerotomy he " removes two discs of sclera sufficiently far from the limbus to avoid the anterior chamber." Our views on this subject have been so fully stated throughout the book that it is needless to say more than that we consider it a retrograde step. McReynolds has suggested an allied technique to be sub- stituted for trephining, should a sharp trephine blade be not available. — " Prepare a flap, according to Elliot ; take very fine sharp full curved needle, carrying black silk thread; introduce it through the sclera 2 mm. from the cornea, carrying the point forward to the anterior chamber, from the angle of which the needle should now immediately emerge through the periphery of the cornea ; this enables you to securely grasp 2 mm. of sclera in the loop of your thread, which can now be held gently taut with the left hand ; with gentle strokes of a small knife mark out a semi-circular incision just enclosing on the outer side the small portion of sclera in the grasp of the thread : as the incision passes through the thickness of the sclera the flap thus formed will be drawn towards the cornea by the thread, and the scleral flap may be thus extended by the knife until the anterior chamber is opened at its periphery, when the sclero-corneal flap may be excised as far forward as desired, etc." The author found this suggestion most valuable on one occasion in the thin buphthalmic eye of a child, into which the trephine had entered without cutting out a sufficient portion of the disc. Mr. Basil Lang, who came out to work with the author in Madras, devised a trephine which consists of a handle, a blade, and a corrugated nut. The last named enables the blade to be fixed firmly in the handle, whose expanded upper surface is * The Ophthalmoscope, May, 1912. 84 concave for the reception of the index finger during trephining. This finger suppHes the downward pressure, while the middle finger and thumb seizing the corrugated nut furnish the rotatory motion. The idea is distinctly ingenious, and if the Fig. 23. — Lang's Trephine. The solid part of the upper figure is the instrument ready for use. The blade can be pushed out to suit the operator. The skeleton outline represents the blade drawn into the handle for protection during boiling. The middle figure is the steel tube, and the two lower figures are the handle and its nut, which clamps the blade and holds it firm. Fig. 24. — Desmarres' secondary cataract knife, modified by Lang for splitting the cornea. projecting portion of the blade were shortened to half its present length, the instrument might easily become very popular (Fig. 23). We understand that Lang has adopted this suggestion. Anderson's trephine resembles Lang's. All the various hand-worked trephines before the profession appeared to have the following imperfections : (l) the distance from the handle to the cutting edge, was, excepting in Dr. Young's instrument, too long, making the instrument difficult to hold steady ; (2) the handle did not provide a good grip ; and (3) the blades were expensive and rather difficult to get well sharpened. The author's trephine (Fig. 25) represents an effort to modify Sydney Stephenson's instrument on the lines above indicated. The new^ features presented are as follows : — (1) The Shape of the Handle (a). In order to give the surgeon a good grip and to prevent his fingers from constantly slipping down as he presses, (i) the handle is made conical with the apex of the blunt cone upwards, (ii) the fluting is spiral in arrangement, and (iii) the edges of the fluting are serrated at right angles to its length. 85 (2) The Nature of the Blades (b). These are made so that they can be used and thrown away as soon as they Fig. 25. become blunt. They are manufactured from soHd drawn steel tubing ; one end of each blade is divided into three parts, and opened to form a spring — this when inserted into the handle 86 holds the trephine firmly — the other end forms the cutting blade, and the edge is brought up sharp /ro»/ the inside. This enables the operator to cut a hole the exact size of the trephine. The Method of fitting the Blades. A small pair of pincers (e) is supplied, with which the blade can be easily fitted into or removed from the handle. This should always be done at the time of operating. The blades must never be left in after use. The handle is hollowed throughout so that it can be easily and quickly cleaned and dried after use by means of a pipe cleaner (the best form being the Metropolitan pipe cleaner made in the United States and sold by all tobacconists). The bore of the proximal portion of the hollow is slightly less than that of the distal portion. This, whilst enabling the handle to be cleaned, at the same time prevents the blades from passing up more than the correct distance. (4) A stop (c), which can be fitted to any of the blades, has, by special request of other surgeons been supplied. The author does not recommend its use. (5; A small handle is provided (d) with a loop or hook at the end, through which the blades can be passed. This enables an operator to keep the cutting edge of his blade in one position during the operation, and was intended to be an improvement on the method of holding the blade with forceps. The latter is however much to be preferred. The whole instrument is supplied in a small case by Messrs. Arnold & Sons, of Giltspur Street, E.G., to whom the author is much indebted for the assistance they have given him in working out the details of the instrument. The remaining instruments shown in Figure 25, are supplied in a case complete. This was done at the request of one of the leading English surgeons. More recently, Messrs. Weiss have made a handle, which presents some advantages. It weighs 9'7 grammes, and takes tubular blades of any diameter from 1 mm. to 3 mm. ; it consists of three parts, viz., (l) an outer sleeve or casing of aluminium, tapering toward the proximal end, fluted spirally and grooved laterally, (2) a spring holder cut in four sections from solid steel somewhat on the principle of a lathe chuck, and (3) a screw with a milled head. When this screw is loosened, and the chuck is pushed forward, the sections of the latter open, and the trephine blade can be inserted between them ; when it is worked home, on the other hand, it draws the chuck back into its sleeve, and the blade is then gripped firmly and in the middle line. A pin and groove prevent the chuck from rotating within the sleeve. The use of this handle 87 enables a surgeon to set his trephine blade as long or as short as he wishes to, and also to use any size of blade from the smallest to the largest. Before putting the instrument away after use, it is necessary to take the handle to pieces, to dry each part, and then to vaseline the screw and the outer surface of the chuck. If this be done, the instrument will always be found in working order when needed. Our description would be incomplete without a reference to some of the models of trephines which have been quite recently brought before the profession. The wealth of ingenuity which surgeons have displayed is strong evidence of the popularity enjoyed by the operation of sclero-corneal trephining. Cross's instrument* consists of "a two-inch handle of metal, pivoted at the top of which there is a small, freely revolving finger-rest in the form of a shallow saucer-like disc to permit freedom of rotation and allow perfect control of the pressure and location of the instrument. Immediately below this the handle takes the form of a cone with apex upward. This conical portion can be held with ease, owing to the presence of three knurled rings upon its surface. An expansion chuck at the lower end of the instrument is designed to lock or release the blade or trephine on a half-turn of the handle, the chuck allowing the use of blades of various sizes. This trephine can be revolved from above by means of the thumb and forefinger placed upon the cone, or it can be operated from the side by placing the forefinger upon the loose top and rotating the barrel with the thumb and second finger. By either method the operator has complete control of pressure and position as well as an unobstructed view of the field of operation." Leigh's trephine'" has " the handle both corrugated and cross-hatched to prevent any possible slipping of the grip. The handle is bulbous at each end and contracted in the middle. It can thus be manipulated between the thumb and forefinger, like the Elliot instrument, without the danger of the fingers working off at the top. The trephine blade is attached to the handle by a solid shaft, it has a 2 mm. diameter, is about 5 mm. long, and has an ample perforation to facilitate cleansing. It is a simple little instrument that costs but one dollar, and because of its cheapness can be thrown away when dull." Kuhnt has devised a trephine, whose tubular blade carries s solid style, which can be set at any desired depth from the cutting edge ; he places this guard at a distance corresponding * Both were shown on December 18th, 1913, before the Section on Ophthalmology of the College of Physicians of Philadelphia. with the thickness of the sclera. The rationale of this procedure is not obvious. Brown Pusey " felt the need of a shoulder attachment as a factor of safety," but found it in the way. He writes: — "To avoid these troubles (troubles at least for the beginner in this very promising operation), I have had made a trephine with a barrel of even diameter for 075 mm. from the cutting edge, then a slight flare, as shown in the accompanying picture. This makes a very safe and very efficient instrument." (Fig. 26.) Fig. 25a. — Elliot's Trephine.