Cyclodiathermy: Results in Various Types of Glaucoma*

650

S H E R M A N Β. F O R B E S

REFERENCES 1. Thiel, R.: Cited by Kimura, S. J., Hogan, M J . , and Thygeson, P.: Uveitis in childhood. Arch. Ophth., 51:80, 1954. 2. Amsler, M . : L'uveite chronique. Bull. Soc. ophtal., France, 4:407, 1952. 3. Fritz, M. H . : Cited by Kimura, S. J., Hogan, Μ. J., and Thygeson, P.: Uveitis in childhood. Arch. Ophth., 51:80, 1954

CYCLODIATHERMY:

RESULTS

IN VARIOUS

TYPES

O F

GLAUCOMA*

SHERMAN B . FORBES, M . D . Tampa, Florida

In the treatment o f glaucoma, a new era

the high incidence o f corneal opacity, prob­

had its beginning in the 1930s with the use

ably due to damage to the cornea by the

of diathermy by the ciliary-body approach.

diathermy current."^

A s early as 1932, Weve^ employed surface

THE NEW TECHNIQUE

diathermy o f the ciliary region in the treat­ ment

o f infantile

was

later

glaucoma. This

emphasized

by

method

Albaugh

and

Dunphy,^ and Weckers" used much the same

A t midcentury the literature stressed probability

that

the

intraocular

the

pressure

might be lowered through changes produced

technique. In 1936, V o g f first described the

in the ciliary nerves or by diminution o f the

use o f perforating

cyclodiathermy in glau­

blood supply o f the ciliary body with subse­

coma. His original technique consisted o f as

quent atrophy. Reiser,^ therefore, advocated

many as 100 punctures in three rows, the

placing the

closest row placed 2.5 mm. from the limbus,

limbus and was most careful to cauterize the

punctures

8.0

mm.

from

the

over a band extending one third to one half

insertion of the muscles in order to close off

o f the circumference o f the globe. H e em­

the

ployed a needle 0.5-mm. long in phakic eyes

emphasized

and 1.0-mm. long in aphakic eyes, applying

Arruga* also believed the operation to be

it to the bare sclera. T h e procedure was in

effective through its action upon the ciliary

his opinion the operation o f choice in cases

nerves and accordingly directed his cautery

of glaucoma in which all other surgical and

to the region o f the tendons o f the

medical measures had failed, and in glaucoma

muscles overlying the

secondary to uveitis.

and arteries. H e applied a 1.0-mm. electrode

T h e literature on the subject of cyclodi­ athermy is copious, for the subject has re­ mained controversial. T o o , techniques have varied. In the early days the operation con­ sisted of perforation, partial perforation, or surface from

coagulation up to 2.5 to 4.0 mm.

the

limbus.

papers

appeared

praise

and

in

In

due time,

in the

numerous

literature, both in

condemnation

of the

Vogt

ciliary arteries. Other placing

authors''* soon

punctures

well

long ciliary

back.

rectus nerves

for five to 15 seconds and used 15 to 20 appHcations through the conjunctiva about 9.0 mm.

from the limbus. Later, in the

1952

edition o f his textbook,'" he gave an excel­ lent description o f the operation. In nique

1951, Castroviejo^' described a tech­ differing

from that o f A r r u g a , '

in

which he made eight to 10 punctures over half the globe, 6.0 mm. back from the limbus,

method. B y the late 1940s, the use o f cyclo­

using

a

1.0-mm. needle and

applying

the

diathermy was on the wane "because o f its

electrode for 10 seconds at each application.

unpredictable effect upon ocular tension and

Occasionally, he encircled the entire globe.

* Presented in part before the Florida Society of Ophthalmology and Otolaryngology, 15th annual meeting, Hollywood, Florida, April 25, 1954.

he employed it for all types o f glaucoma.

Enthusiastic about the use o f this procedure, A t my last observation o f his surgery, in his

CYCLODIATHERMY IN GLAUCOMA

controlled

diathermy

he

was

employing

Pennsylvania

"the

651

newer

technique

has

air

proved to be quite safe." H e declared also

injection into the anterior chamber, repeat­

that he had encountered no serious complica­

transconjunctival

punctures

and, after

ing the procedures if the tonometric readings

tions, as with the older technique, and none

warranted.

o f those mentioned by the authors w h o had

Largely through the w o r k o f Castroviejo^^

complained that the results o f perforating

in this country and Weckers^ in Europe,

cyclodiathermy by Castroviejo's method are

cyclodiathermy by 1951 was beginning to

unpredictable and the procedure not entirely

enjoy a second wave o f popularity. In his

safe.

review o f the literature on glaucoma f o r

Since the reversal in technique which has

1952-1953, Haas'^ observed a decided tend­

limited the perforating procedure to a dis­

ency to move the site o f diathermy poste­

tance o f 6.0 mm. from the limbus, ranging

riorly so that the electrocoagulations are made

out to 11 mm., the average distance in m y

7.0 to 9.0 mm. from the limbus. Neubauer'^

w o r k has been 6.0 to 9.0 m m . from

modified the operation by placing surface

limbus. Although m y 10 years' experience

the

diathermy just in front o f the external rectus

with

muscle, thereby creating a partial oblitera­

period in which it was the practice to make

tion o f the branches o f the

diathermic

long ciliary

the

procedure

includes

applications

too

the

close

earlier to

the

arteries. H e reported success in 63 percent

limbus, in m y hands this newer therapy has

of

been safe. Certainly, an eye subjected to an

cases. Arató'* employed a similar p r o ­

cedure, using 1.5-mm. perforating electrodes,

operation o f this type does not pose the later

and encountered no complications. It was

difficulties o f extracting the lens through a

his belief that the operation is indicated in

filtering wound, nor does it present the diffi­

chronic glaucoma and as a

culty sometimes experienced even with a

procedure

supplementary

in congenital glaucoma and

in

preliminary iridectomy.

aphakic glaucoma.

T h e technique I have worked out is as

Scheie,^" w h o in mid-1949 had

discon­

follows:

tinued use o f the V o g t technique because o f its "erratic effect" on intraocular

pressure

In adults, local anesthesia is usually em­ ployed, and in children general

anesthesia.

and "frequent corneal damage," resumed the

N o t much topical anesthesia is used because

performance o f cyclodiathermy early in 1951

of

after being influenced by Castroviejo's en­

A f t e r adequate anesthetization,

thusiasm for the newer technique employed

in the muscle cone, an incision is made in the

in Europe. In July, 1952, he reported his

conjunctiva from the lower border o f one

experience with the V o g t technique in an

o f the horizontal muscles to that o f the other

eairly group o f cases and with the newer

6.0 m m . from the limbus. T h e inferior rectus

the danger

o f devitalizing the cornea. particularly

method in a later group, and concluded that

is exposed, and the tendon is picked up on

the newer technique appeared to be useful

a hook. T h e sclera is bared both in the

in situations in which other operative p r o ­

temporal and nasal quadrants, and the globe

cedures had failed and in advanced glau­

is kept constantly elevated with the hook.

coma. O n e year later, in discussing a paper

Accurate marking is made o n the sclera 8.0

by Lachman and Rockwell,^® he observed

mm. from the limbus in each quadrant, and

that the present-day techniques, as suggested

the coagulation begins from there.

by

and

Usually the punctures number about 30

W e c k e r s ' and Reiser® in Europe, all recom­

Castroviejo"

in

this

country

on a 6.0- and o n an 8.0-mm. arc, with at

mend application o f the current 6.0 mm. o r

least 15 in each lower quadrant o f the bare

more from the limbus and that in his experi­

sclera. In some cases, the number o f coagula­

ence at the Hospital o f the University o f

tions is increased, and they are placed out

S H E R M A N Β. F O R B E S

652

as far as 9.0 to 11 mm. and in as close as 6.0 mm., with as many as 25 in each quad­ rant. It is my practice to make certain that there is vitreous presentation in a few punctures when the intraocular pressure is especially high and also to reduce the pressure when cyclodiathermy is combined with an intra­ ocular procedure such as a cataract extrac­ tion or an iridectomy. In case a second operation is desirable, it is performed above. The same method is utilized as in the lower quadrants, with a hook placed under the superior rectus, pull­ ing the globe down. If a third operation is attempted,

it is performed immediately in

front o f and behind the insertion o f the in­ ternal and external recti to affect the region of the long ciliary vessels. O f late I have given more attention to the area about the insertion o f these muscles, aiming for the effect on the long ciliary vessels and nerves. A 1.0-mm. electrode is used, and the cur­ rent is determined

which will produce a

browning of the sclera. T h e applicator is not kept in contact more than four seconds at any time and usually two to three seconds. A t all times an effort is made to keep a dry field, and

the greatest

surgical respect is

paid to the cornea. In adults, the conjunctiva usually is closed with a running 6-0 silk suture, and in chil­ dren an absorbable plain catgut suture is used. Eserine ointment and antibiotic oint­ ments are used in the operated eye or eyes. Both eyes are padded even though the pro­ cedure is only monocular. T h e technique o f cyclodiathermy is rela­ tively simple and is being improved. A sur­ geon with limited experience can perform it with safety. T h e speed o f the punctures, in my opinion, does not have to be controlled. In personal

observation, however, o f

the

surgery for retinal separation performed by Dr. Dohrmann Κ. Pischel, I noted that if the cornea showed any tendency to cloud be­ cause o f elevated intraocular pressure in the course

o f diathermic

applications, he

re­

tarded the speed o f the punctures and also cooled the eye by means o f saline irrigation. In three cases I have observed a rather rapid rise o f intraocular pressure during surgery as shown by indenting the globe and corneal clouding. Following the immediate use o f eserine ointment postoperatively, no signifi­ cant complications developed. T h e results o f cyclodiathermy in congeni­ tal glaucoma in my h a n d s " have been highly gratifying, both when it was used alone and in combination with goniotomy. A detailed report o f this group of my cases is n o w in process o f preparation. In a g r o u p o f cases with associated retro­ lental fibroplasia, vitreous dysplasia, and often microphthalmos, cyclodiathermy is in m y opinion the operation o f choice. I have had one case of aniridia in which treatment with cyclodiathermy was successful. In three cases o f glaucoma associated with rubeosis iridis diabetica this operation has proved successful in my hands. In one of these cases there was an associated throm­ bosis o f the central vein. In reporting a case, deRoetth'^ concluded that cyclodiathermy is the only procedure thus far found to lower the intraocular pressure in cases o f glaucoma associated with rubeosis iridis diabetica. I have been impressed with the efficacy o f this procedure in glaucoma occurring in Negroes. A m o n g them the disease has fre­ quently presented a problem difficult to solve, f o r treatment by any method has proved much less satisfactory in this race. F o r the control o f intraocular pressure in N e g r o cases in m y experience, prior to cyclodiathermy it had been necessary to c o m ­ bine an iris inclusion operation with a corneosclerectomy. Cyclodiathermy was employed successfully in 27 o f the 33 cases occurring in Negroes in the series o f cases reported here, the results comparing favorably with those in white patients. M y results with cyclodiathermy in aphakic glaucoma have been g o o d . I n o w can concur in the opinion o f A r a t ó " that this therapy is indicated f o r glaucoma in aphakia. In the

CYCLODIATHERMY IN GLAUCOMA present series it was successful in 11 of 14 eyes. A N A L Y S I S OF CASES

A

series

of

80 cases in which cyclodi-

athermy was performed one or more times is reported and the individual cases are summarized in Table 1. There were 47 white and 33 Negro patients in the series. The age of the youngest patient was 15 months and of

the oldest patient 83 years, the average

being

55 years.

Cyclodiathermy was per-

formed 141 times in 120 eyes; it was repeated once in 17 eyes and twice in two eyes. The

cember, 1952, there were 36 cases, in almost all of which the punctures were made 6.0 mm. or less from the limbus. In the 4 4 cases since that time, the newer technique has been employed consistently with the distance from the limbus increased to 6.0 to 10 mm. The which

have

improved appreciably

with the newer technique, are tabulated in Tables 2 to 6. After

by Dr. Arthur R. Beyer of Tampa in June, 1951. He reported failing vision for several years. Late chronic noncongestive open-angle glaucoma was present in both eyes with vision in the right eye 5/200, imimproved, and in the left eye 20/30 with a greatly constricted visual field in the latter. After miotics failed to control the intraocular pressure, which was 64 mm. H g (Schiøtz), cyclodiathermy was performed in July. The complication of slight vitreous bleeding cleared readily. Three years later, in April, 1954, the intraocular pressure was 34 mm. H g in the right eye and 30 mm. H g in the left eye without medication. The vision was about the same in the right eye, but in the left eye it was 20/20 plus, and the visual field was slightly larger than at the time cyclodiathermy was performed.

series covers a period of five years

from mid-1949 to mid-1954. Prior to De-

results,

653

discussing

the matter with many

ophthalmic surgeons, I have concluded that the upper limit of normal in glaucomatous eyes should be 30 mm. Hg. Apparently, the majority of these eyes with

long-standing

disease will respond well if the basic pressure is maintained around this level without progressive deterioration of the visual acuity

C A S E 52

Chronic noncongestive open-angle glaucoma in a white person. K. C , a stenographer, aged 42 years, the sister of a physician, had experienced failing vision over a period of years and had been told that she had glaucoma. On ocular examination in May, 1953, the pupillary reaction was sluggish, and the pupils were partially dilated. There was an open angle with no anterior peripheral synechias visible. Funduscopic examination revealed a typical glaucomatous disc of the advanced type. A Rönne nasal step and a Bjerrum scotoma were present in both eyes. The facility of outflow was 0.05 in each eye. Corrected vision in both eyes was 20/20. Ten days after the examination cyclodiathermy was performed on the lower half of both globes. Eight months postoperatively the vision was 20/20 and the intraocular pressure 25.6 mm. H g (Schiøtz) without medication in both eyes. Two months later, the pressure in both eyes was 16.7 mm. Hg. C A S E 22

Chronic noncongestive narrow-angle (iris-block) glaucoma. J. Α., a white man, aged 71 years, had a history of glaucoma over a period of several have classified results in this series on this years with gradually failing vision. On ocular ex­ basis. It is to be remembered in evaluating amination in July, 1950, the anterior chambers were shallow with many peripheral anterior results in cases of this type that successful synechias. Corrected vision was 20/30 in both eyes. therapy varies with the individual case. In The intraocular pressure varied between 38 and one instance control of intraocular pressure 54 mm. H g (Schiøtz) in both eyes with conservative treatment until February, 1952, when it may mark success whereas in another avoidwas definitely determined that the visual fields ing enucleation may be its measure. were contracting and the blindspots getting larger. Eight cases are described to illustrate the Cyclodiathermy was performed below in the lower nasal and temporal quadrants of both eyes. use of cyclodiathermy in various types of The intraocular pressure has been controlled to glaucoma. In six of these cases this therapy date in the right eye in spite of slightly progressive was successful and in two unsuccessful. lenticular pathologic changes. In the left eye the pressure ranged as high as SO mm. H g until cycloREPORT OF CASES diathermy was performed in the upper nasal and C A S E 19 temporal quadrants in March, 1953. A t the last recording in February, 1954, the pressure in this eye Chronic noncongestive open-angle glaucoma in a was 29.2 nun. H g without medication. In the right Negro. R. J., a Negro, aged 30 years, was referred and restriction of the fields. Accordingly, I

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CYCLODIATHERMY IN GLAUCOMA

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TABLE 2

TABLE 3

RESULTS OF CYCLODIATHERMY IN VARIOUS TYPES OF GLAUCOMA (120 EYES)

VISUAL RESULTS OF CYCLODIATHERMY IN VARIOUS TYPES OF GLAUCOMA (120 EYES)

Number Tension (30 mm. Hg Schifjtz or less) Controlled without miotics Controlled with miotics Hypotonic Tension reduced 20 to 40 mm. Hg Uncontrolled Enucleated Eviscerated

64 19 1 22 13 1 0

Percent Vision Vision Vision Vision

53.3 15.8 0.8 18.3 10.8 0.8

Number

Percent

40 54 22 4

33.3 45.0 18.3 3.3

improved unchanged decreas«! lost

120

TOTAL

half of both globes, and at the same time a combined intracapsular cataract extraction was performed in the right eye. The postoperative course was uneventful. Five months after the operation vision in both eyes with refraction corrected was eye, with the use of Carcholin alone twice a day 20/100; the intraocular pressure was 25.6 and the pressure was 33.1 mm. Hg. The corrected vision 29.2 mm. H g in the right and left eyes, respecwas 20/30 in both eyes. tively. Cataract extraction is planned for the left C A S E 61* eye in the immediate future. This case was demonstrated at the 1954 meeting of the Florida Society Cyclodiathermy combined with cataract extracof Ophthalmology and Otolaryngology. tion. B. S., a Negress, aged 69 years, had experiTOTAL

120

enced loss of vision over a period of 10 years, with a diagnosis of glaucoma. Ocular examination in September, 1952, disclosed glaucoma of the openangle type, pronounced nuclear opacities of the lens, and restricted visual fields. In both eyes considerable excavation of the disc and displacement of the vessel funnels were present. Vision in the right eye was 5/200, unimproved, and in the left eye 20/200, unimproved. The intraocular pressure with profound miosis was 42.5 mm. H g (Schijitz). At operation one week following the examination, cyclodiathermy was performed on the lower

C A S E 67

Late chronic noncongestive narrow-angle (irisblock) glaucoma associated with lenticular pathologic changes. J. P., a physician's wife, aged 73 years, gave a history in December, 1953, of gradual loss of vision, particularly in the left eye. She was using a two-percent solution of pilocarpine three times daily in both eyes and a four-percent solution four times a day in the left eye. The corrected vision in the right eye was 20/30, minus, and in the left eye 10/200, unimproved. Under profound miosis the intraocular pressure was 25.6 mm. H g (Schiøtz) in the right eye and 62.9 mm. H g in the left eye. In both eyes the glaucomatous changes in the disc and the nuclear anterior and posterior subcapsular changes in the lens were pronounced. In January, 1954, cyclodiathermy was performed on the lower half of the globe in both eyes, and in February combined intracapsular extraction of the lens was performed in the left eye under local

• The patient in Case 61 was seen in the fall of 1955. The cataract extraction had been done on the left eye in December, 1954. A t the time of the last examination the corrected distance vision was 20/40— in the right eye and 20/100 in the left eye. The intraocular pressure was 23.4 mm. H g (Schijitz) in the right eye and 27.1 mm. H g in the left eye.

TABLE 4 COMPARISON OF RESULTS IN WHITE AND N E G R O PATIENTS

White 65 Eyes (47 Cases)

Tension 30 mm. Hg (Schifitz) or less Controlled without miotics Controlled with miotics Tension reduced 20 to 40 mm. Hg Uncontrolled Vision improved Vision unchanged Vision decreased Vision lost

Negro 55 Eyes (33 Cases)

Number

Percent

Number

Percent

35 11 12 6 17 27 IS 3

53.8 16.9 18.4 9.2 26.1 41.5 23.0 4.6

29 8 10 7 23 27 7 1

52.7 14.5 18.1 12.7 41.8 49.0 12.7 1.8

S H E R M A N Β. F O R B E S

662

TABLE S POSTOPERATIVE COMPLICATIONS FOLLOWING CYCLODIATHERMY ( 1 2 0 EYES)

Complications

Number

Immediate Hyphema Uveitis

Percent

2.5 1.6

Delayed Pseudomonas keratopathy Partial thrombosis of central vein Glaucoma (absolute)

1

0.8

1 1

0.8 0.8

anesthesia, as the intraocular pressure was normal­ ized in both eyes following the cyclodiathermy. The pressure remains stabilized, being 16.7 mm. H g in the right eye and 2 9 . 2 mm. H g in the left eye early in April, 1954. The vision was 2 0 / 4 0 in the right eye and finger perception in the left eye.

sistent hyphema, which gradually cleared within two weeks. The diabetes was not well controlled during the postoperative period, but six weeks after these surgical measures the intraocular pres­ sure was down to 4 0 mm. H g with the use of eserine ointment in the eye twice a day and Rutorbin and C V P by mouth. Surprisingly, con­ siderable visual function remained in this eye.

Certainly, I would not leave the impres­ that all cyclodiathermy leads to the Elysian fields in the treatment o f glaucoina. It is by no means a panacea, as the t w o cases which will n o w be described will show. T h e y afford examples o f the unsuccessful em­ ployment o f this therapy in chronic non­ congestive narrow-angle (iris-block) glau­ coma and in the aphakic eye. sion

CASE 3 8 CASE 6 6

Cyclodiathermy in the treatment of glaucoma secondary to rubeosis iridis diabetica. C. G., a white man, aged 5 2 years, was referred by Dr. M. A. O'Toole of Clinton, Massachusetts, in January, 1954. There was a history of diabetes with many severe acute episodes of rubeosis iridis diabetica glaucoma in the left eye. He had been using a four-percent solution of pilocarpine in both eyes eight times daily. On ocular examination, with maximum miosis signs of chronic noncongestive narrow-angle (iris-block) glaucoma were observed in the right eye. In the left eye a pronounced con­ gestive phase was present. The intraocular pres­ sure was 77.3 mm. Hg (Schijatz). Corneal edema was also pronounced, as was vasculogenesis of the iris with tremendous vessels. The pupil was dilated and fixed. The intraocular pressure was not con­ trolled with the most energetic conservative treat­ ment. Under local anesthesia cyclodiathermy was per­ formed in this eye on the lower half of the globe in the nasal and temporal quadrants, several vitreous presentations through the punctures soften­ ing the eye. After closure of the conjunctiva, a classical Graefe iridectomy was performed from above with no complications. The postoperative course was uneventful except for a rather perTABLE 6 CyCLODIATHERMY COMBINED W I T H OTHER PROCEDURES ( 1 2 0 EYES)

Procedure Total iridectomy Peripheral iridectomy Paracentesis and air injection Retinal detachment surgery Combined cataract extraction Discission

Number

Percent

7 2 5 1 5 1

8.7 1.6 4.1 0.8 4.1 0.8

Chronic noncongestive narrow-angle (iris-block) glaucoma. B. P., a white woman, aged 5 8 years, was referred by Dr. Albert C. Esposito of Hunting­ ton, West Virginia. There was a history of failing vision over a period of several years with treat­ ment by Dr. Esposito for the preceding three months. His report, in which I concurred, was: Shallow anterior chambers, pronounced cupping of the discs, vision in the right eye 2 0 / 2 5 — 2 and in the left eye 2 0 / 5 0 — 1, and intraocular pressure varying between 4 0 and 6 0 mm. H g (Schifltz) in both eyes. With the administration of a four-per­ cent solution of pilocarpine in each eye every three hours during the day and once during the night the pressure was normalized most of the time. There was in both eyes constriction of the visual fields with loss of the nasal field in the left eye. After a considerable period of observation, the patient was subjected to cyclodiathermy in both eyes in December, 1952. The pressure then was controlled fairly well until April, 1 9 5 3 . Thereafter, despite the use of miotics it was elevated at times, particularly in the left eye. Although vision was holding up well, the visual fields were becoming constricted in the right eye. On March 2, 1 9 5 4 , iridencleisis was performed in both eyes with in­ clusion of both iris pillars under local anesthesia. To date, the pressure has been completely normalized, the range being 1 8 to 2 0 mm. H g without medica­ tion. CASE 5 8

Cyclodiathermy in aphakia. K. M., a white woman, aged 5 3 years, underwent combined intra­ capsular cataract extraction in the left eye in June, 1953, with no complications. Corrected vision two months later was 2 0 / 3 0 , but four months after the operation the intraocular pressure was ele­ vated to as high as 6 2 . 9 mm. H g (Schijzftz). Cyclodiathermy was performed on the lower half of the globe with control of the pressure for an-

663

C Y C L O D I A T H E R M Y IN GLAUCOMA other three months. It then became elevated again and this time conventional cyclodialysis was per­ formed with an air injection into the anterior chamber. The pressure has remained under con­ trol, and the corrected vision in this eye is 20/30 plus. The eye in this case was one of 14 eyes in this series in which glaucoma was associated with aphakia. In only three of the 14 eyes was cyclo­ diathermy unsuccessful.

DISCUSSION

surgery, such as cataract extraction, may be performed satisfactorily and with no more danger than in the common procedures in the eye with normal pressure. T i m e alone will determine whether or not this therapy, which reduces the facility of aqueous inflow, will have great bearing o n the indications f o r glaucoma surgery. T h e modus operandi o f lowering intra­

Obviously, this study is limited in scope

ocular pressure by cyclodiathermy has not

by numerous factors. It is offered to sug­

yet been adequately explained. Some authors

gest that:

adhere to the belief that the procedure di­

1. Cyclodiathermy is a safe and also fre­

minishes the production o f aqueous humor

quently an effectual procedure which is not

either by atrophy o f the uveal tract at the

with many unusual complications,

site of application o f the electrode and also

perhaps n o more than the older procedures.

anteriorly and posteriorly, or b y changes in

2. It may be performed as a preliminary

the nerve pathways leading to the ciliary

procedure or simultaneously with a cataract

body which cause a change in the neuro-

fraught

regulatory mechanism. Personal discussion

extraction in indicated cases. 3. It is an operation which does not muti­

with a number o f ophthalmic surgeons has

late or distort the ordinary pathways o f an

seemed to indicate the consensus among them

extraction, thus posing no difficuhies should

that cyclodialysis likewise may act o n the

cataract surgery later become necessary.

neuroregulatory

system

in a similar

way

4 . T h e procedure may be repeated with

rather than by forming a communication

safety at proper intervals twice or even three

between the anterior chamber and the supra-

times in different areas.

choroidal space.

5. It requires the minimal period o f hos­

Whatever the mechanism o f action, cyclo­

pitalization. T h e newer technique o f placing

diathermy appears to be winning its place

dis­

in ophthalmic surgery. T h e different authors

refractory

have made various uses o f it. W h i l e Vogt*

cases approaching the long ciliary vessels

used it in a number o f cases in preparation

the diathermic applications a greater tance from and

nerves

brought

the limbus and along the

recti

improved results.

in

muscles

Also,

advent o f vitreous presentation

with

has

for cataract surgery. Sugar,''" on the other

the

hand, found use f o r the procedure only "in

one feels

much safer in avoiding any acute episode o f glaucoma.

blind

painful

enucleation

glaucomatous

is psychologically

eyes

where

premature."

Blake,^^ however, recently employed it in the

In my opinion, this operation is not an

treatment o f glaucoma complicating congeni­

office procedure, as described by Hurwitz,^*

tal aniridia, a most difficult problem, and

despite current advertisements that leading

after wide inquiry among ophthalmologists

ophthalmologists are employing it that way.

he concluded that this operation is becom­

O n the other hand, there is the consideration

ing increasingly popular and modifications

that Diamox, or some similar future product,

in techniques are making f o r better results.

may make this and other operative proce­

It is m y belief, contrary to that o f many

dures for glaucoma unnecessary. This new

ophthalmologists, that the danger o f post­

agent, described as in effect a medical cyclodi­

operative complications, particularly phthisis

athermy both controllable and reversible, ap­

bulbi, has been greatly magnified. M y o b ­

pears to give promise o f reducing intra­

servation o f the small series presented leads

ocular pressure to a level where ordinary

me to conclude that there are probably no

S H E R M A N Β. F O R B E S

664

more complications with cyclodiathermy than

from.

with standard glaucoma procedures, particu­

achieved to suggest that a surgical principle

larly since the new technique has been em­

of great value has been discovered. Especially

H o w e v e r , enough success has

been

ployed. The main complication o f the opera­

significant are the favorable results in some

tion has been a serous nongranulomatous type

of

of iritis easily controllable with therapy. It is

been considered intractable, especially rube­

my impression that in my cases the opera­

osis iridis and absolute glaucoma."

those conditions which had

heretofore

tion has not precipitated nor caused unusual

M y experience leads me, three years later,

progression o f lenticular pathologic changes,

to concur in the conclusion o f Cowan^^ that

as occasionally happens in iris inclusion and

a valuable surgical principle not to be un­

trephining procedures.

derestimated has become available. W i t h him

Berens,

Sheppard,

and DueF^ found cyclodiathermy a

useful

I also agree that the ultimate in technique

procedure and observed in 1950: " T h e most

may not yet have been evolved, but, in his

dread postoperative complication is sympa­

words, "whatever

thetic ophthalmia. S o far, in the total o f 766

the success o f the cyclodiathermy should,

cyclodiathermy operations and 108 cycloelec­

and will, be exploited through many other

trolysis operations

techniques until its full measure o f benefits

reported

in the

United

States o f America, no unquestioned case o f sympathetic ophthalmitis has followed either

factor is responsible for

can be applied." It is noteworthy that the enthusiasm o f

procedure." This complication did not occur

Castroviejo^^

in my series.

waned. In a personal communication to me

A t the time cyclodiathermy was beginning

for

this procedure

has

not

on A p r i l 12, 1954, he stated: " M y views on

to regain favor. A r r u g a " stated that per­

this operation have not changed. I continue

forming the punctures t o o near the limbus

to use it in all kinds o f glaucoma and feel

had made corneal opacities the complication

that it is superior

most frequently encountered. H e mentioned

glaucoma surgery."

opacity o f the lens, iridocyclitis, and hemor­ rhage

into the anterior chamber as

other

complications and pointed out that loss o f vitreous, which is not a complication, must even be provoked to a certain extent. A d d i n g that recurrence

o f the

hypertension

con­

stitutes failure o f the operation, he observed that "this does not occur as frequently

as

the p o o r quality o f the eyes operated

by

cyclodiathermy would lead one to expect, since the results are rather promising." Cowan,^^ in 1951, summarized the status of perforating

cyclodiathermy at that time

in these w o r d s : " I f its long-term effects live up to its early promise, glaucoma surgery may very well be revolutionized in the di­ rection o f further simplicity. W e have not reached this desired goal yet. T h e operation has been done in too few cases, by too few operators, and the patients have been fol­ lowed for too short a time. T h e skeptics, as well as the enthusiasts, will have to be heard

to any

other

type o f

CONCLUSION Basically, it is m y conclusion that cyclo­ diathermy has great potential value in con­ genital glaucoma, open-angle glaucoma, nar­ row-angle (iris-block) glaucoma to a les­ ser degree, glaucoma associated with con­ genital defects o f the globe, and secondary glaucoma o f all types. A l s o , it has special value in combination with operative proce­ dures such as cataract extraction, much as a posterior sclerotomy o r an iridectomy h a s ; as a preliminary operation prior to a cataract extraction, it is likewise valuable, and in combination with iridectomy in the treat­ ment o f congestive glaucoma it gives one the advantage o f performing the iridectomy o n a soft globe. In 11 o f 14 aphakic eyes the procedure has been successful in m y hands, the intraocular pressure in the remaining three being normalized later by cyclodialysis. It is noteworthy that in the past, opera-

CYCLODIATHERMY IN GLAUCOMA

tions f o r glaucoma were designed to elimi­ nate the aqueous. N o w , the newer methods in cyclodiathermy and cycloelectrolysis aim to decrease the production o f aqueous. T h e newer technique in cyclodiathermy has brought improved results, and the simplicity o f the operation is in its favor. T h e ideal surgical approach, as pointed out recently by Weckers,''* would be an operative proce­ dure or combined procedures which would affect favorably the rate o f aqueous p r o ­ duction and also the facility o f aqueous out­ flow. This paper is presented in the hope o f stimulating the development o f such a solu­ tion to the problem o f glaucoma surgery. A series o f 80 cases is reported and ana­ lyzed in which cyclodiathermy was employed in the treatment o f various types o f glau­ coma with gratifying results. T h e cases are summarized in Table 1, and the results in Tables 2 to 6. S i x cases in which this therapy was successfully employed and t w o in which it was a failure are described. T h e old and the new techniques are discussed, and the role o f the procedure in glaucoma surgery is evaluated. In evaluating the results o f any surgical treatment o f glaucoma, one must keep in mind the broad range o f results which may

665

be termed successful. In many instances pa­ tients seek treatment only after the glaucoma is far advanced and some are blind in one eye. Recently, Lloyd^" aptly o b s e r v e d : " I f the tension can be controlled or an enuclea­ tion avoided, that is surely as satisfactory a result as reducing the tension, enlarging the field, and improving the vision in eyes with vision such as 2 0 / 3 0 . T h e important consid­ eration is that the standard f o r success in glaucoma is control o f tension and retention o f vision in some cases, but in others con­ trol o f tension is just as much a triumph, and in still other cases avoiding an enuclea­ tion, even with higher than normal tension, if the eye is not troublesome, is a greater accomplishment." Each individual case has its o w n yardstick o f success. 409 Citizens Building (2). ADDENDUM

Since this paper was submitted for publication, cyclodiathermy has been performed on 38 eyes with even more favorable results than indicated in the series reported herein. I have been particularly im­ pressed with the efficacy of cyclodiathermy in wideangle glaucoma in the Negro. From the results in these additional cases and a further evaluation of the restJts in the cases reported, it is my impres­ sion that this type of procedure fulfils the need in one of the most difficult types of glaucoma, the open-angle type in the Negro.

REFERENCES 1. Weve, H . J. M . : Clinische Lessen, Nederl. tijdschr. v. geneesk., 76 :S335, 1932. 2. Albaugh, C. H., and Dunphy, E. B.: Cyclodiathermy: An operation for the treatment of glaucoma. Arch. Ophth., 27:543-557 (Mar.) 1942. 3. Weekers, L . : Mode d'action des operations antiglaucomateuses. Ophthalmologica, 118:564-574 (Oct.Nov.) 1949. 4. Vogt, A . : Versuche zur intraocularen Druckherabsetzung mittelst Diathermieschädigung des Corpus ciliare (Zyklodiathermiestichelung). Schweiz, med. Wchnschr., 66:593 (June) 1936; Ergebnisse der Diathermiestichelung des Corpus ciliare (Zyklodiathermiestichelung) gegen Glaukom. Klin. Monatsbl. f. Augenh., 99:9-15 (July) 1937; Die Zyklodiathermiepunktur (Z.D.P.) gegen Glaukom. Ibid., 103:591599 (Dec.) 1939; and Cyclodiathermy puncture in cases of glaucoma. Brit. J. Ophth., 24:288-297 (June) 1940. 5. Scheie, H . G.: Glaucoma: A review of the literature 1951-1952. Arch. Ophth., 48:752-782 (Dec.) 1952. 6. Reiser, K. Α . : Die "Skleraldiathermiepimktur" (S.D.P.), eine einfache Glaukomoperation. Klin. Monatsbl. f. Augenh., 115:491-500, 1949. Also: Bericht über die Operationsergebnisse mit der Skleraldiathermiepunktur (S.D.P.) Ber. deutsch, ophth. Gesellsch., 56:155-158, 1951. 7. Biozzi, G.: Sulla coagulazione dell'arteria ciliare posteriore lunga (reperto oftalmoscopico). Gior. ital. oftal., 2 :380-383 (Sept.-Oct.) 1949. 8. Arató, I.: La angiodiatermia y su aplicación en el glaucoma, Arch. Soc. oftal. hispano-am., 9:746758 (July) 1949. 9. Arruga, H . : La diatermia ciliar en el tratamiento del glaucoma. Arch. Soc. oftal. hispano-am., 1 0 : 224-229 (Mar.) 1950.

666

R. W E E K E R S , Y . D E L M A R C E L L E A N D J. G Ü S T I N

10. : Ocular Surgery. New York, McGraw-Hill, Inc., 1952, ed. 3, pp. 718-723. 11. Castroviejo, R . : Lecture, University of Florida Midwinter Seminar in Ophthalmology and Otolarvngology, Miami Beach, Florida, January 18-23, 1952. Letter dated April 12, 1954. 12. Haas, T. S.: Glaucoma: A review of the literature for 1952-1953. Arch. Ophth., 50:764-778 (Dec.) 1953. 13. Neubauer, Η . : Die nichtperforierende Zyklodiathermie dach Grüter. Klin. Monatsbl. f. Augenh., 121:9-15 (Jan.) 1952. 14. Arató, S.: Results of angiodiathermy on the basis of 100 operations. Ophthalmologica, 125:117-124 (Feb.) 1953. 15. Scheie, H. G.: Cyclodiathermy in the treatment of glaucoma. West. T. Surg., 60:322-326 (July) 1952. 16. Lachman, B. E., and Rockwell, P. A . : Follow-up study of 39 patients with glaucoma treated with cyclodiathermy. Arch. Ophth., 50:265-266 ( A u g ) 1953. 17. Forbes, S. B.: Buphthalmos; Results from operative procedures particularly cvclodiathermy: Report of six cases. Am. J. Ophth., 35 :393-398 (Mar.) 1952. 18. deRoetth, A . : Cyclodiathermy in treatment of glaucoma due to rubeosis iridis diabetica. Arch. Ophth., 35:20-22 (Jan.) 1946. 19. Hurwitz, P.; Electrosurgical treatment of glaucoma as an office procedure: Preliminary report. E E N T Month., 32:380-383 (July) 1953. 20. Sugar, H. S.: The Glaucomas. St. Louis, Mosby, 1951, pp. 419-424, 21. Blake, E. M . : The surgical treatment of glaucoma complicating congenital aniridia. Am. J. Ophth., 36 :907-909 (July) 1953. 22. Berens, C , Sheppard, L. B., and Duel, A. B., Jr.: The surgery of glaucoma: Cycloelectrolysis versus cyclodiathermy: A report of 108 cycloelectrolysis and 766 cyclodiathermy operations. Acta X V I Concilium Ophthalmologicum (Britannia) 1950, pp. 959-970. 23. Cowan, T. H . : In discussion of Rubin, I. E., Romig, J. E., and Molloy, J. H . : Early results of per­ forating cyclodiathermy in treatment of glaucoma. Arch. Ophth., 47:544-547 (Apr.) 1952. 24. Personal interview with Dr. R. Weckers of Belgium at the X V I I International Congress of Oph­ thalmology, 1954, New York, September 13-17, 1954. 25. Personal communication from Dr. Ralph I. Lloyd, Brooklyn, New York, dated October 1, 1954.

TREATMENT

OF

OCULAR

DIVERSE

HYPERTENSION

SYMPATHOMIMETIC

BY ADRENALIN

AND

AMINES*

R . WEEKEES, M . D . , Y . DFLMARCELLE, M . D . , AND J. GÜSTIN, M . D . Liege, Belgium Hamburger,^ in

1923, noted that the

in-

stillation o f two-percent adrenalin induced a

suit

would

seem

to

be

occasioned

by

a

lessened formation o f aqueous. A s the miotics

reduction o f tension in glaucoma simplex,

lower ocular tension by augmenting the

Goldmann,^ in 1951, attributed this eflfect to

cility o f flow, adrenalin and

fa-

miotics play a

a prolonged reduction in the rate o f aqueous

complementary role. T h e former reduces the

formation.

formation o f aqueous, the latter facilitates its

In recent publications W e c k e r s , Prijot, and

drainage. T h e

two in association provide a

Güstin^'* have shown by Grant's technique

local

of tonography that adrenalin lowers the ocu-

glaucoma simplex (open-angle

lar tension in open-angle glaucoma without affecting

however

the

pathologically

in-

treatment

particularly

efficacious

for

glaucoma),

T h e theoretic and practical importance o f this tension-reducing action o f adrenalin has

creased resistance to aqueous flow. This re-

stimulated further

——; , ^ r ^ . , , TT · • From the Department of Ophthalmology, University of Liege. This investigation was aided by the support of the Fonds National beige de la Recherche scientifique. The manuscript was submuted to T H E JOURNAL m French. Translation by James E. Lebensohn, M.D., Chicago, Illinois.

nism involved.

The

research on the

mecha-

present study consists

o f t w o parts: ( I ) i h e measurement Ot changes in the delivery o f aqueous under ^j^^ influence o f adrenalin; ( 2 ) a similar , . , ,. . . . Study with diverse sympathomimetic amines.