- Email: [email protected]
Sclerotomy with Cautery
VOL. 62, NO. 5
PLASTIC LID PROCEDURES
955
SUMMARY
REFERENCES
U s e of Eastman 910 monomer for adher ing eyelashes to the skin of the eyelids a p pears to be safe and of great advantage in certain plastic procedures on the eyelids. Adherence of the lashes of the upper lid to the skin of the lower lid has been used to create temporary "tarsorrhaphy" for protec tion of the cornea in facial nerve paralysis. Eastman 910 monomer can also be helpful in correction of cicatricial entropion by using adherence of the eyelashes to the skin of the lid as a substitute for sutures with transverse tarsotomy.
1. Methyl 2-cyanocrylate monomer, Physiolog ical Tissue Adhesive Review, Medical Research Dept., Ethicon, Inc., November, 1964. 2. Ellis, R. A., and Levine, A. M.: Experimen tal sutureless ocular surgery. Am. J. Ophth. 55-.733,1963. 3. Bloomfield, S., Barnert, A. H., and Kanter, P. D.: The use of Eastman 910 monomer as an adhesive in ocular surgery: I. Biologic effects on ocular tissues. Am. J. Ophth. 55:742, 1963. 4. Bloomfield, S., Barnert, A. H., and Kanter, P. D.: The use of Eastman 910 monomer as an adhesive in ocular surgery: II. Effectiveness in closure of limbal wounds in rabbits. Am. J. Ophth. 55:946, 1963. 5. Straatsma, B. R., Allen, R. A., Hale, P. N., and Gomez, R.: Experimental studies employing adhesive compounds in ophthalmic surgery. Tr. Am. Acad. Ophth. Otolaryng. 67 :320, 1963.
1514 Jefferson
Highway
(70121)
SCLEROTOMY WITH
CAUTERY
A REVIEW OF 1 1 0 OPERATIONS AT THE ILLINOIS EYE AND EAR INFIRMARY A L F R E D J. N A D E L , M . D .
Chicago, Illinois This is an analysis of the results of sclerotomy with cautery (periperhal iridectomy with scleral cautery [Scheie]) performed at the Illinois E y e and E a r Infirmary be tween 1958 and 1964. It is based on a r e view of the out-patient and hospital records of 92 patients, supplemented by personal examination of approximately one third of the group. Despite the lack of uniformity of the recorded observations, a fact that must be stressed, and despite the lack of regular ity of postoperative visits, related to the somewhat dulled sense of medical responsi bility among patients with numerous socioeconomic problems, sufficient data were ac cumulated to allow evaluation of the opera tion as a treatment for glaucoma. M A T E R I A L A N D PROCEDURES
T h e series includes all sclerotomies with cautery performed as primary antiglauFrom the Department of Ophthalmology, The University of Illinois, College of Medicine.
comatous operations. In the chronic openangle glaucomas, the indication for surgery was progressive field loss despite intensive (nearly maximal) medical therapy. In the angle-closure glaucomas the decision to per form sclerotomy with cautery was based on evidence of severe trabecular damage. W i t h few exceptions, the operations were performed by the resident staff according to the descriptions given by Scheie. 10 ' 11 Topical steroids and mydriatics were administered routinely during the postoperative period until the inflammatory reaction subsided. RESULTS INTRAOCULAR PRESSURE
T h e effect of the operation was evaluated primarily in terms of intraocular pressure. Routine tensions during the period of this study were taken with Schiprz tonometers and the results interpreted according to the calibration scale of 1955. I t was deemed justified to apply this procedure to the fol-
956
AMERICAN JOURNAL OF OPHTHALMOLOGY
Sclerotomy with Cautery at IEEI 120 110-
no
100Pw/thfi
mm.
90
>25
P with % <25 P without f} < 20
8070-
59
605040-
=81; 33
30-
:49: 20-
wm
24
m :20;
10-1
:I2; 0
J
1
=5=
2 3 4 5 Length of Follow-up in Years
Fig. 1 (Nadel). This graph illustrates the over-all results of surgery during the entire period of clinical follow-up. low-up of sclerotomies with cautery since there is no evidence of a systematic change in ocular rigidity resulting from this opera tion. Consistent readings indicating pressures below 20 mm Hg without hypotensive medi cation of any kind were adopted as the cri terion of success. Actually, in 94% of the "successful" cases, the tensions registered below 18 mm Hg. Patients, in whom consis tent postoperative tensions below 25 mm Hg were maintained only with the aid of miotics or epinephrine derivatives, were designated as qualified successes. Eyes with consistent pressures above 25 mm Hg de spite medication were classified as failures. The first graph (fig. 1) illustrates the re
NOVEMBER, 1966
sults. At the end of the first year, 81 eyes, or 74% of the entire series, fell into the cat egory of successes. These eyes were charac terized by the presence of filtering blebs, either thick-walled or cystic, and by the gonioscopic appearance of a cleft in the an terior angle wall, visible best by indirect il lumination. None of these eyes changed its status during the period of observa tion. In succeeding years, because of a greater failure-to-return rate among patients whose medical management was difficult, the suc cesses became relatively more prevalent. A net increase in the number of successes oc curred through a change in status of two eyes whose medication was withdrawn after the first year without pressure elevation above 20 mm Hg. A third case, uncontrolled during the first 12 months, subsequently was controlled with miotics. An answer to the question of the most ap propriate time for evaluation of the result was sought by comparing the mean pressure of 50 eyes during the first six months with the mean pressure during the second six months following surgery. Figure 2 illus trates the results. Tensions during the post operative period from six to 12 months were significantly lower. In four eyes with tensions above 20 mm Hg during the first six months, the tension dropped below 20 mm Hg between the sixth and the 12th month. Similarly, of 10 eyes with tensions above 18 mm Hg for the first six months, only three remained at that level after 12 months. The end of the first postoperative year appears, therefore, to be the time when the establishment of fistulization can be judged most accurately and the prognosis for the individual can be determined. The status of the 110 eyes at the end of the first year, broken down according to race and sex, is shown in Table 1. Neither characteristic had a statistically significant effect on the percentage of success. The bet ter results apparently achieved among fe males in this series was unrelated to the pre-
VOL. 62, NO. 5
22-i
SCLEROTOMY WITH CAUTERY
957
Sclerotomy with Cautery-Effect upon Pressure
20-
o
8-
o
6-
Q_
d 14-1
•
•
•
c\J 12-
9> 103
8-
n = 48 b=.60 r=.67
6o CD
4-
••
2T
2
6
8
10 12 14 16 18 20 22 24 26 28
Mean Pressure-6 Mo. Post-op. Fig. 2 (Nadel). This graph compares the mean pressures in SO patients recorded in the clinic during the first six postoperative months with those recorded during the second six postoperative months.
dominance of a particular type of glaucoma among the female population. Wide-open angles and narrow angles occurred with equal frequency among males and females. The relationship between the surgical re sult and the type of glaucoma treated is in dicated in Table 2. Of the 62 patients with open-angle glaucoma, 79% gained control of the intraocular pressure. In the patients with evidence of angle-closure mechanisms, the clinical course was of acute attacks in 15 eyes and of gradual, progressive angle-clo sure with minimal symptoms in the remain ing 24 eyes. Only 47% success was achieved in cases of acute angle closure, while 7 1 % success was achieved in cases of chronic angle closure. The eyes with secondary and juvenile glaucoma were too few to deter mine significant percentages of success.
VISUAL ACUITY
Eighty eyes with a preoperative visual acuity of 20/400 (Snellen) or better were evaluated for changes in vision related to surgery. Figure 3 shows the initial visual acuity plotted against the visual acuity after TABLE 1 CORRELATION OF SURGICAL RESULTS AFTER THE FIRST POSTOPERATIVE YEAR WITH DIFFERENCES IN RACE AND SEX
Success
+ Success
Failure
Male
26 (65%)
8 (20%)
6 (15%)
Female
55 (80%)
11 (15%)
4 (5%)
White
33 (72%)
10 (22%)
3 (6%)
Negro
48 (75%)
9 (14%)
Total
81 (74%)
19 (17%)
7 (11%) 10 (9%)
958
AMERICAN JOURNAL OF OPHTHALMOLOGY TABLE 2
fication of the lens, following the pattern of senile cataract. In eight eyes with a preoperative acuity better than 20/70, lens extractions became necessary within two years after the fistulizing procedure. In the others with significant alteration in visual acuity, the lens changes were less pro nounced. These findings give an over-all impression of a nonspecific variable—an ad verse effect of the surgery upon lens metab olism. In no case did the loss of vision ap pear to be the consequence of central field loss. Not included in Figure 3 were 30 eyes with an initial acuity less than 20/400 due to advanced glaucoma. Very little could be learned from a review of the records re garding the effect of surgery upon these remnants of vision.
CORRELATION OF TYPES OF GLAUCOMA TREATED SURGICALLY WITH RESULTS ONE YEAR LATER Results
+
+
Wide
29
3
4
Narrow
20
S
1
7
6
2
17
4
3
Secondary
4
1
0
Juvenile
4
0
0
81
19
10
Open-Angle
Acute
Angle-Closure
Chronic
TOTAL
NOVEMBER, 1966
-
one year. Twenty-seven eyes lost more than two lines on the Snellen chart, while 53 showed little or no change. A loss greater than two lines was considered significant, that is, beyond the probable error of mea surement inherent in hasty clinic refrac tions. The major cause of the postoperative loss of vision, as far as could be gleaned from the records, was progressive opaci-
T O N O G R A P H I C EVALUATION
Tonographic tracings 26 of the 110 eyes one Figure 4 shows a good pressures and outflow one eye with consistent
were recorded on year after surgery. correlation between facilities. All but pressures below 20
Sclerotomy with Cautery- Visual A c u i t y %oo"
1c
5*
7zoo-
•
\
••
\
•
•
m
\
2
z
2
%0" 20
s. o
2
/70-
%o-
2
2
2
•b X •
%-
X
X 5r • • 20/ /20
20/ /30
&
* * / S
••
/
% • "'*
*/
** s •
/
Fig. 3 (Nadel). This graph com pares the best preoperative visual acuity in 80 eyes with the visual acuity one year after surgery, x in dicates lens extraction one year after and xx indicates lens extrac tion two years after glaucoma sur gery.
^r
AC
•
%
%o%o-
\
AC
*. •
AC = Angle Closure Glc. x = Lens Extraction
1 r——i 1 1— 2 20/ 20/ 2 % 0 ^/ZOQ % /40 /50 Before Operation
2
1 %Q
VOL. 62, NO. 5
SCLEROTOMY WITH CAUTERY
mm Hg had outflow facilities of 0.20 or greater. The mean of the successes was 0.29, and the range from 0.18 to 0.45. Only 20 of these eyes were studied prior to sur gery while in a relatively steady-state on medication. Sixteen had a facility of outflow less than 0.12; four had a facility greater than 0.12, including one case of possible hypersecretion glaucoma. Thus, this study, as several earlier ones, shows the principal mode of action of the operation to be an im provement in outflow two to three times greater than the preoperative facility. In five eyes requiring miotic therapy to maintain tensions between 17 and 20 mm Hg, the outflow facilities ranged from 0.08 22
959
to 0.16. Probably, this indicates a small con tribution made by the surgical procedure. These patients belong to the group of qualified successes. In one eye with a pressure of 19 mm Hg, the outflow facility was 0.18. This patient never was placed on miotics because pres sures remained below 20 mm Hg. Tonography performed one year later, two years after surgery, indicated a pressure of 18 mm Hg and an outflow facility of 0.23, sup porting the classification of this patient as a success. COMPLICATIONS
Serious complications specifically related
Results of Sclerotomy with Cautery-C vs. Pc
20
o o
I8i
•
ook
16 I4H
\r
• tr**.
12
i t IO 86420 '
n - 26 eyes, Iyear post-op r=7 • P<20 o P>20 i
1
.04
.08
1
1
1
.12
.16
.20
I
l
I
l
1
1
I
.24
.28
.32
.36
.40
44
.48
Outflow Facility Fig. 4 (Nadel). This graph summarizes the tonographic results obtained in 26 eyes one year after surgery.
960
AMERICAN JOURNAL OF OPHTHALMOLOGY
to surgery occurred in four eyes of this se ries. One case of endophthalmitis began as an infection of a thin, cystic (at one time, leaking) filtering bleb four years after suc cessful surgery. Unfortunately, the patient delayed reporting to the clinic for two weeks. Judging from the history, the infec tion started as a catarrhal conjunctivitis ac companied by pain behind the eye and in the forehead. Though the infection was brought under control, the eye became phthisic. The second patient began to show clinical signs of infection on the second day after surgery and was treated successfully with antibiotics. The end-result was a well-func tioning sclerostomy. The third serious complication occurred in a patient with chronic glaucoma in both eyes, probably related to a bilateral granulomatous uveitis which followed an extracapsular lens extraction in one eye eight years earlier. Several months after the sclerotomy with cautery in one eye, the uveitis recurred in both eyes. Despite vigorous treatment with steroids, both eyes went into atrophy. A similar complication in a fourth case may not have been related to the scleral cau tery. The patient, aged 56 years, underwent a scleral cautery in one eye one week after a posterior lip sclerectomy had been per formed on the other eye. The sclerectomy was unsuccessful and five months later, a combined anterior lip sclerectomy and iridencleisis was performed on the same eye. Shortly thereafter, the patient developed a severe bilateral uveitis suggestive of sympa thetic ophthalmia. After a long downhill course, useful vision in both eyes was lost. No specimens were obtained for pathologic study. Complications of lesser magnitude were encountered in several other eyes. There were two cases of vitreous loss at the time of surgery. One patient maintained postop erative pressures below 20 mm Hg, while the other remained uncontrolled despite
NOVEMBER, 1966
miotic therapy. A posterior lip sclerectomy on the latter patient's other eye also was complicated by loss of vitreous and high postoperative tensions. In two eyes of the series, inadvertent per forations of the conjunctival flaps occurred during surgery. Both eyes were reoperated within the week and turned out successes in terms of pressure control. In 28 of the 110 eyes, the restoration of the anterior chamber was delayed for peri ods of five to 22 days. This did not affect the final result as measured in terms of pressure. Similarly, of the 15 cases of hyphema of more than three days' duration, 14 later were characterized as successes. Thirteen eyes had consistent postopera tive tensions below 9.0 mm Hg, without the eyeground or acuity changes characteristic of hypotony. This number of cases was too small for a study of the relationship between hypotony and lens changes. FAILURES
Of the 10 failures in this series, six were recognized shortly after surgery when pres sures remained at their preoperative levels. The other four showed a progressive rise in tensions during the first three months after surgery, indicating gradual closure of the fistulizing tract. The specific mechanism of failure could not be identified from a review of the records or from re-examination of the patients. Most eyes in this category showed obliteration of the bleb and closure of the sclerostomy by fibrosis, with or without incarceration of the ciliary processes. The response of the 10 failures to further therapy is shown in Table 3. Only one pa tient turned out an unqualified success after a second operative procedure; in this case, a posterior lip sclerectomy. The others re mained difficult to control despite intensive medical therapy. DISCUSSION
The results of sclerotomy with cautery,
SCLEROTOMY WITH CAUTERY
VOL. 62, NO. S TABLE 3
OUTCOME OF PATIENTS WHOSE INITIAL SCLEROTOMY WITH CAUTERY WAS A FAILURE
Pressure (mm Hg) <20
<25
25-30
>30
Reoperation
1
2*
0
1*
Medical R*
0
0
3
3
* With medical Rx The status of each patient is indicated according to his condition at the time of his last clinic visit.
74% success after one year, in this series of 110 eyes, surgically treated by the resident staff, compares favorably with those ob tained in other large series reported by Scheie,12'13 Leopold,5 Tyner and associ ates15'16 and Bounds and co-workers1 in the United States, and by Miller, 7 Malbran and Malbran,6 and Guinan2 in other coun tries. The Infirmary series, with its pre ponderance of cases with relatively short follow-up periods, probably presents an ac curate picture of the major events of the first year after surgery. The similar percentage of success in Negro and in white patients seems to refute the widely held opinion that the results of fistulizing operations generally are poorer in the Negro. Other factors, such as the high percentage of females, may obscure the race factor. The possibility of a different response to surgery between males of the two races will have to be investigated in a larger series before definite conclusions can be stated. The poor response of the 15 eyes of this series with acute angle-closure glaucoma probably is related to the far-advanced, ne glected state of the glaucoma in 13. The pa tients had had symptoms of acute angleclosure for periods ranging from six weeks to six months prior to their initial clinic visit. Visual acuity, as well as the general condition of their eyes, was poor at the time of surgery. Only seven responded favorably and few recovered useful vision. This does
961
not refute the opinion of other authors that scleral cautery is indicated when permanent damage to the angle results from an acute episode of closure. Among the patients treated at the In firmary, 27 of 80 eyes showed a sig nificant visual loss one year after surgery. Analysis of the 52 eyes followed for two or more years reveals that the progres sion of cataractous changes became slower after the first year in most patients with ini tial visual loss. Those with no change in vi sion during the first year maintained their acuity. Though the decrease in visual acuity may be exaggerated in this series because manifest refractions were performed under difficult clinic conditions, it appears that sclerotomy with cautery, like other fistuliz ing procedures, affects the vision of a large number of patients. The occurrence of late infections has been reported by other observers. Scheie,13 for example, noted four instances of late post operative endophthalmitis among 215 cases. These complications emphasize the impor tance of making the patient aware of the dangers inherent in a thin-walled bleb. Careful attention to the simple rules of ocu lar hygiene and the prompt use of antibiotics may prevent the intraocular spread of infec tion in a bleb. In general, the iritis or iridocyclitis which occurs immediately after surgery is of mod erate degree and subsides after topical ad ministration of steroids for three or four weeks. This reaction is sufficient, however, to cause posterior synechiae (noted in 75% of cases reported by MpTler7) so that the use of mydriatics following surgery seems indicated. The operative complications of hyphema and delayed reformation of the anterior chamber had no demonstrable effect on the control of tensions or on visual acuity in these 110 eyes. Only one case, with a flat chamber for 22 days, required a posterior sclerotomy and air injection to reform the
962
AMERICAN JOURNAL OF OPHTHALMOLOGY
anterior chamber. Scheie 12 reported three cases among 162 in which this procedure was deemed necessary. I n general, he re served it for patients in whom the chamber remained flat for longer than two weeks after surgery. One feature brought out by this series is the information obtained from tonography. According to tracings made one year after surgery in 26 eyes, an outflow facility less than 0.20 probably indicates partial or in complete function of the fistulizing tract. Eyes with outflow facilities greater than 0.20 tend to maintain such facilities during succeeding postoperative years. Nine of 10 patients followed with tonography for two and three years after surgery showed the same pressure and outflow relationships. Only one demonstrated a decrease in the fa cility of outflow, though tensions remained below 20 mm H g without miotics. Thus, tonography not only confirms clinical suc cess but indicates more accurately the func tion of the sclerostomy. CONCLUSIONS
1. Sclerotomy with cautery or iridectomy with scleral cautery (Scheie) is a filtering procedure with a high incidence of success in the hands of surgeons of varying experi ence. Of the 110 eyes reported in this series, 7 4 % were maintained at consistent Schijzftz tensions below 20 m m H g one year after surgery. Those patients with successful re sults continued to have low tensions for as long as six years after surgery. 2. T h e surgical procedure is suitable for patients with both open-angle and angle-clo sure (acute and chronic) glaucoma, with equal chance of success in Negroes and Cau casians. 3. Tonography is valuable in corroborat ing clinical success and in identifying patients
NOVEMBER, 1966
with barely adequate fistulizing tracts. 1855 West Taylor Street (60612) ACKNOWLEDGMENT
I am grateful to Dr. Peter C. Kronfeld for his advice and recommendations during this study. REFERENCES
1. Bounds, G. W., Jr., et al.: Peripheral iridecto my with scleral cautery. Am. J. Ophth. 58:84, 1964. 2. Guinan, P. M.: Peripheral iridectomy with scleral cautery: Scheie's operation for glaucoma. Tr. Ophth. Soc. U. Kingdom, 81: 713, 1961. 3. Kronfeld, P. C : The effects of topical ste roid administration on intraocular pressure and aqueous outflow after fistulizing operations. Tr. Am. Ophth. Soc. 62:375, 1964. 4. Laval, J.: Results of surgery in patients with tubular fields due to glaucoma. Arch. Ophth. 63:850, 1960. 5. Leopold, I. H.: Fistulizing operations for glaucoma: Their complications. J. Internat. Coll. Surg. 33:171, 1960. 6. Malbran, J., and Malbran, E.: Surgical man agement of primary glaucoma. Am. J. Ophth. 47 :34, 1959. 7. Miller, P. M.: Sclerotomy with cautery and iridectomy for glaucoma. Acta Ophth. 41:151, 1963. 8. Preziosi, C. L.: The electro-cautery in the treatment of glaucoma. Brit. J. Ophth. 8:414, 1924. 9. Riise, P.: Long-term prognosis in glaucoma surgery. Am. J. Ophth. 45:807, 1958. 10. Scheie, H. G.: Retraction of scleral wound edges: As a fistulizing procedure for glaucoma. Am. J. Ophth. 45:220 (Apr. Pt. II), 1958. 11. : Peripheral iridectomy with scleral cautery for glaucoma. Arch. Ophth. 61:291, 1959. 12. : Filtering operations for glaucoma. Am. J. Ophth. 53 :571, 1962. 13. : Iridectomy with scleral cautery. Tr. Ophth. Soc. U. Kingdom, 84:127, 1964. 14. Shaffer, R. N.: Open-angle glaucoma. Symposium: Indications for surgery in glaucoma. Tr. Am. Acad. Ophth. Otolaryngol. 67:457-493, 1963. 15. Tyner, G. S., et al.: Peripheral iridectomy with scleral cautery: A report on the operative treatment of 42 eyes with glaucoma. Arch. Ophth. 64:268, 1960. 16. Tyner, G. S., and Arnold, C. O.: Periph eral iridectomy with scleral cautery: A report on the operative treatment of 72 eyes with glaucoma. Arch. Ophth. 68 :581, 1962.
PLASTIC LID PROCEDURES
955
SUMMARY
REFERENCES
U s e of Eastman 910 monomer for adher ing eyelashes to the skin of the eyelids a p pears to be safe and of great advantage in certain plastic procedures on the eyelids. Adherence of the lashes of the upper lid to the skin of the lower lid has been used to create temporary "tarsorrhaphy" for protec tion of the cornea in facial nerve paralysis. Eastman 910 monomer can also be helpful in correction of cicatricial entropion by using adherence of the eyelashes to the skin of the lid as a substitute for sutures with transverse tarsotomy.
1. Methyl 2-cyanocrylate monomer, Physiolog ical Tissue Adhesive Review, Medical Research Dept., Ethicon, Inc., November, 1964. 2. Ellis, R. A., and Levine, A. M.: Experimen tal sutureless ocular surgery. Am. J. Ophth. 55-.733,1963. 3. Bloomfield, S., Barnert, A. H., and Kanter, P. D.: The use of Eastman 910 monomer as an adhesive in ocular surgery: I. Biologic effects on ocular tissues. Am. J. Ophth. 55:742, 1963. 4. Bloomfield, S., Barnert, A. H., and Kanter, P. D.: The use of Eastman 910 monomer as an adhesive in ocular surgery: II. Effectiveness in closure of limbal wounds in rabbits. Am. J. Ophth. 55:946, 1963. 5. Straatsma, B. R., Allen, R. A., Hale, P. N., and Gomez, R.: Experimental studies employing adhesive compounds in ophthalmic surgery. Tr. Am. Acad. Ophth. Otolaryng. 67 :320, 1963.
1514 Jefferson
Highway
(70121)
SCLEROTOMY WITH
CAUTERY
A REVIEW OF 1 1 0 OPERATIONS AT THE ILLINOIS EYE AND EAR INFIRMARY A L F R E D J. N A D E L , M . D .
Chicago, Illinois This is an analysis of the results of sclerotomy with cautery (periperhal iridectomy with scleral cautery [Scheie]) performed at the Illinois E y e and E a r Infirmary be tween 1958 and 1964. It is based on a r e view of the out-patient and hospital records of 92 patients, supplemented by personal examination of approximately one third of the group. Despite the lack of uniformity of the recorded observations, a fact that must be stressed, and despite the lack of regular ity of postoperative visits, related to the somewhat dulled sense of medical responsi bility among patients with numerous socioeconomic problems, sufficient data were ac cumulated to allow evaluation of the opera tion as a treatment for glaucoma. M A T E R I A L A N D PROCEDURES
T h e series includes all sclerotomies with cautery performed as primary antiglauFrom the Department of Ophthalmology, The University of Illinois, College of Medicine.
comatous operations. In the chronic openangle glaucomas, the indication for surgery was progressive field loss despite intensive (nearly maximal) medical therapy. In the angle-closure glaucomas the decision to per form sclerotomy with cautery was based on evidence of severe trabecular damage. W i t h few exceptions, the operations were performed by the resident staff according to the descriptions given by Scheie. 10 ' 11 Topical steroids and mydriatics were administered routinely during the postoperative period until the inflammatory reaction subsided. RESULTS INTRAOCULAR PRESSURE
T h e effect of the operation was evaluated primarily in terms of intraocular pressure. Routine tensions during the period of this study were taken with Schiprz tonometers and the results interpreted according to the calibration scale of 1955. I t was deemed justified to apply this procedure to the fol-
956
AMERICAN JOURNAL OF OPHTHALMOLOGY
Sclerotomy with Cautery at IEEI 120 110-
no
100Pw/thfi
mm.
90
>25
P with % <25 P without f} < 20
8070-
59
605040-
=81; 33
30-
:49: 20-
wm
24
m :20;
10-1
:I2; 0
J
1
=5=
2 3 4 5 Length of Follow-up in Years
Fig. 1 (Nadel). This graph illustrates the over-all results of surgery during the entire period of clinical follow-up. low-up of sclerotomies with cautery since there is no evidence of a systematic change in ocular rigidity resulting from this opera tion. Consistent readings indicating pressures below 20 mm Hg without hypotensive medi cation of any kind were adopted as the cri terion of success. Actually, in 94% of the "successful" cases, the tensions registered below 18 mm Hg. Patients, in whom consis tent postoperative tensions below 25 mm Hg were maintained only with the aid of miotics or epinephrine derivatives, were designated as qualified successes. Eyes with consistent pressures above 25 mm Hg de spite medication were classified as failures. The first graph (fig. 1) illustrates the re
NOVEMBER, 1966
sults. At the end of the first year, 81 eyes, or 74% of the entire series, fell into the cat egory of successes. These eyes were charac terized by the presence of filtering blebs, either thick-walled or cystic, and by the gonioscopic appearance of a cleft in the an terior angle wall, visible best by indirect il lumination. None of these eyes changed its status during the period of observa tion. In succeeding years, because of a greater failure-to-return rate among patients whose medical management was difficult, the suc cesses became relatively more prevalent. A net increase in the number of successes oc curred through a change in status of two eyes whose medication was withdrawn after the first year without pressure elevation above 20 mm Hg. A third case, uncontrolled during the first 12 months, subsequently was controlled with miotics. An answer to the question of the most ap propriate time for evaluation of the result was sought by comparing the mean pressure of 50 eyes during the first six months with the mean pressure during the second six months following surgery. Figure 2 illus trates the results. Tensions during the post operative period from six to 12 months were significantly lower. In four eyes with tensions above 20 mm Hg during the first six months, the tension dropped below 20 mm Hg between the sixth and the 12th month. Similarly, of 10 eyes with tensions above 18 mm Hg for the first six months, only three remained at that level after 12 months. The end of the first postoperative year appears, therefore, to be the time when the establishment of fistulization can be judged most accurately and the prognosis for the individual can be determined. The status of the 110 eyes at the end of the first year, broken down according to race and sex, is shown in Table 1. Neither characteristic had a statistically significant effect on the percentage of success. The bet ter results apparently achieved among fe males in this series was unrelated to the pre-
VOL. 62, NO. 5
22-i
SCLEROTOMY WITH CAUTERY
957
Sclerotomy with Cautery-Effect upon Pressure
20-
o
8-
o
6-
Q_
d 14-1
•
•
•
c\J 12-
9> 103
8-
n = 48 b=.60 r=.67
6o CD
4-
••
2T
2
6
8
10 12 14 16 18 20 22 24 26 28
Mean Pressure-6 Mo. Post-op. Fig. 2 (Nadel). This graph compares the mean pressures in SO patients recorded in the clinic during the first six postoperative months with those recorded during the second six postoperative months.
dominance of a particular type of glaucoma among the female population. Wide-open angles and narrow angles occurred with equal frequency among males and females. The relationship between the surgical re sult and the type of glaucoma treated is in dicated in Table 2. Of the 62 patients with open-angle glaucoma, 79% gained control of the intraocular pressure. In the patients with evidence of angle-closure mechanisms, the clinical course was of acute attacks in 15 eyes and of gradual, progressive angle-clo sure with minimal symptoms in the remain ing 24 eyes. Only 47% success was achieved in cases of acute angle closure, while 7 1 % success was achieved in cases of chronic angle closure. The eyes with secondary and juvenile glaucoma were too few to deter mine significant percentages of success.
VISUAL ACUITY
Eighty eyes with a preoperative visual acuity of 20/400 (Snellen) or better were evaluated for changes in vision related to surgery. Figure 3 shows the initial visual acuity plotted against the visual acuity after TABLE 1 CORRELATION OF SURGICAL RESULTS AFTER THE FIRST POSTOPERATIVE YEAR WITH DIFFERENCES IN RACE AND SEX
Success
+ Success
Failure
Male
26 (65%)
8 (20%)
6 (15%)
Female
55 (80%)
11 (15%)
4 (5%)
White
33 (72%)
10 (22%)
3 (6%)
Negro
48 (75%)
9 (14%)
Total
81 (74%)
19 (17%)
7 (11%) 10 (9%)
958
AMERICAN JOURNAL OF OPHTHALMOLOGY TABLE 2
fication of the lens, following the pattern of senile cataract. In eight eyes with a preoperative acuity better than 20/70, lens extractions became necessary within two years after the fistulizing procedure. In the others with significant alteration in visual acuity, the lens changes were less pro nounced. These findings give an over-all impression of a nonspecific variable—an ad verse effect of the surgery upon lens metab olism. In no case did the loss of vision ap pear to be the consequence of central field loss. Not included in Figure 3 were 30 eyes with an initial acuity less than 20/400 due to advanced glaucoma. Very little could be learned from a review of the records re garding the effect of surgery upon these remnants of vision.
CORRELATION OF TYPES OF GLAUCOMA TREATED SURGICALLY WITH RESULTS ONE YEAR LATER Results
+
+
Wide
29
3
4
Narrow
20
S
1
7
6
2
17
4
3
Secondary
4
1
0
Juvenile
4
0
0
81
19
10
Open-Angle
Acute
Angle-Closure
Chronic
TOTAL
NOVEMBER, 1966
-
one year. Twenty-seven eyes lost more than two lines on the Snellen chart, while 53 showed little or no change. A loss greater than two lines was considered significant, that is, beyond the probable error of mea surement inherent in hasty clinic refrac tions. The major cause of the postoperative loss of vision, as far as could be gleaned from the records, was progressive opaci-
T O N O G R A P H I C EVALUATION
Tonographic tracings 26 of the 110 eyes one Figure 4 shows a good pressures and outflow one eye with consistent
were recorded on year after surgery. correlation between facilities. All but pressures below 20
Sclerotomy with Cautery- Visual A c u i t y %oo"
1c
5*
7zoo-
•
\
••
\
•
•
m
\
2
z
2
%0" 20
s. o
2
/70-
%o-
2
2
2
•b X •
%-
X
X 5r • • 20/ /20
20/ /30
&
* * / S
••
/
% • "'*
*/
** s •
/
Fig. 3 (Nadel). This graph com pares the best preoperative visual acuity in 80 eyes with the visual acuity one year after surgery, x in dicates lens extraction one year after and xx indicates lens extrac tion two years after glaucoma sur gery.
^r
AC
•
%
%o%o-
\
AC
*. •
AC = Angle Closure Glc. x = Lens Extraction
1 r——i 1 1— 2 20/ 20/ 2 % 0 ^/ZOQ % /40 /50 Before Operation
2
1 %Q
VOL. 62, NO. 5
SCLEROTOMY WITH CAUTERY
mm Hg had outflow facilities of 0.20 or greater. The mean of the successes was 0.29, and the range from 0.18 to 0.45. Only 20 of these eyes were studied prior to sur gery while in a relatively steady-state on medication. Sixteen had a facility of outflow less than 0.12; four had a facility greater than 0.12, including one case of possible hypersecretion glaucoma. Thus, this study, as several earlier ones, shows the principal mode of action of the operation to be an im provement in outflow two to three times greater than the preoperative facility. In five eyes requiring miotic therapy to maintain tensions between 17 and 20 mm Hg, the outflow facilities ranged from 0.08 22
959
to 0.16. Probably, this indicates a small con tribution made by the surgical procedure. These patients belong to the group of qualified successes. In one eye with a pressure of 19 mm Hg, the outflow facility was 0.18. This patient never was placed on miotics because pres sures remained below 20 mm Hg. Tonography performed one year later, two years after surgery, indicated a pressure of 18 mm Hg and an outflow facility of 0.23, sup porting the classification of this patient as a success. COMPLICATIONS
Serious complications specifically related
Results of Sclerotomy with Cautery-C vs. Pc
20
o o
I8i
•
ook
16 I4H
\r
• tr**.
12
i t IO 86420 '
n - 26 eyes, Iyear post-op r=7 • P<20 o P>20 i
1
.04
.08
1
1
1
.12
.16
.20
I
l
I
l
1
1
I
.24
.28
.32
.36
.40
44
.48
Outflow Facility Fig. 4 (Nadel). This graph summarizes the tonographic results obtained in 26 eyes one year after surgery.
960
AMERICAN JOURNAL OF OPHTHALMOLOGY
to surgery occurred in four eyes of this se ries. One case of endophthalmitis began as an infection of a thin, cystic (at one time, leaking) filtering bleb four years after suc cessful surgery. Unfortunately, the patient delayed reporting to the clinic for two weeks. Judging from the history, the infec tion started as a catarrhal conjunctivitis ac companied by pain behind the eye and in the forehead. Though the infection was brought under control, the eye became phthisic. The second patient began to show clinical signs of infection on the second day after surgery and was treated successfully with antibiotics. The end-result was a well-func tioning sclerostomy. The third serious complication occurred in a patient with chronic glaucoma in both eyes, probably related to a bilateral granulomatous uveitis which followed an extracapsular lens extraction in one eye eight years earlier. Several months after the sclerotomy with cautery in one eye, the uveitis recurred in both eyes. Despite vigorous treatment with steroids, both eyes went into atrophy. A similar complication in a fourth case may not have been related to the scleral cau tery. The patient, aged 56 years, underwent a scleral cautery in one eye one week after a posterior lip sclerectomy had been per formed on the other eye. The sclerectomy was unsuccessful and five months later, a combined anterior lip sclerectomy and iridencleisis was performed on the same eye. Shortly thereafter, the patient developed a severe bilateral uveitis suggestive of sympa thetic ophthalmia. After a long downhill course, useful vision in both eyes was lost. No specimens were obtained for pathologic study. Complications of lesser magnitude were encountered in several other eyes. There were two cases of vitreous loss at the time of surgery. One patient maintained postop erative pressures below 20 mm Hg, while the other remained uncontrolled despite
NOVEMBER, 1966
miotic therapy. A posterior lip sclerectomy on the latter patient's other eye also was complicated by loss of vitreous and high postoperative tensions. In two eyes of the series, inadvertent per forations of the conjunctival flaps occurred during surgery. Both eyes were reoperated within the week and turned out successes in terms of pressure control. In 28 of the 110 eyes, the restoration of the anterior chamber was delayed for peri ods of five to 22 days. This did not affect the final result as measured in terms of pressure. Similarly, of the 15 cases of hyphema of more than three days' duration, 14 later were characterized as successes. Thirteen eyes had consistent postopera tive tensions below 9.0 mm Hg, without the eyeground or acuity changes characteristic of hypotony. This number of cases was too small for a study of the relationship between hypotony and lens changes. FAILURES
Of the 10 failures in this series, six were recognized shortly after surgery when pres sures remained at their preoperative levels. The other four showed a progressive rise in tensions during the first three months after surgery, indicating gradual closure of the fistulizing tract. The specific mechanism of failure could not be identified from a review of the records or from re-examination of the patients. Most eyes in this category showed obliteration of the bleb and closure of the sclerostomy by fibrosis, with or without incarceration of the ciliary processes. The response of the 10 failures to further therapy is shown in Table 3. Only one pa tient turned out an unqualified success after a second operative procedure; in this case, a posterior lip sclerectomy. The others re mained difficult to control despite intensive medical therapy. DISCUSSION
The results of sclerotomy with cautery,
SCLEROTOMY WITH CAUTERY
VOL. 62, NO. S TABLE 3
OUTCOME OF PATIENTS WHOSE INITIAL SCLEROTOMY WITH CAUTERY WAS A FAILURE
Pressure (mm Hg) <20
<25
25-30
>30
Reoperation
1
2*
0
1*
Medical R*
0
0
3
3
* With medical Rx The status of each patient is indicated according to his condition at the time of his last clinic visit.
74% success after one year, in this series of 110 eyes, surgically treated by the resident staff, compares favorably with those ob tained in other large series reported by Scheie,12'13 Leopold,5 Tyner and associ ates15'16 and Bounds and co-workers1 in the United States, and by Miller, 7 Malbran and Malbran,6 and Guinan2 in other coun tries. The Infirmary series, with its pre ponderance of cases with relatively short follow-up periods, probably presents an ac curate picture of the major events of the first year after surgery. The similar percentage of success in Negro and in white patients seems to refute the widely held opinion that the results of fistulizing operations generally are poorer in the Negro. Other factors, such as the high percentage of females, may obscure the race factor. The possibility of a different response to surgery between males of the two races will have to be investigated in a larger series before definite conclusions can be stated. The poor response of the 15 eyes of this series with acute angle-closure glaucoma probably is related to the far-advanced, ne glected state of the glaucoma in 13. The pa tients had had symptoms of acute angleclosure for periods ranging from six weeks to six months prior to their initial clinic visit. Visual acuity, as well as the general condition of their eyes, was poor at the time of surgery. Only seven responded favorably and few recovered useful vision. This does
961
not refute the opinion of other authors that scleral cautery is indicated when permanent damage to the angle results from an acute episode of closure. Among the patients treated at the In firmary, 27 of 80 eyes showed a sig nificant visual loss one year after surgery. Analysis of the 52 eyes followed for two or more years reveals that the progres sion of cataractous changes became slower after the first year in most patients with ini tial visual loss. Those with no change in vi sion during the first year maintained their acuity. Though the decrease in visual acuity may be exaggerated in this series because manifest refractions were performed under difficult clinic conditions, it appears that sclerotomy with cautery, like other fistuliz ing procedures, affects the vision of a large number of patients. The occurrence of late infections has been reported by other observers. Scheie,13 for example, noted four instances of late post operative endophthalmitis among 215 cases. These complications emphasize the impor tance of making the patient aware of the dangers inherent in a thin-walled bleb. Careful attention to the simple rules of ocu lar hygiene and the prompt use of antibiotics may prevent the intraocular spread of infec tion in a bleb. In general, the iritis or iridocyclitis which occurs immediately after surgery is of mod erate degree and subsides after topical ad ministration of steroids for three or four weeks. This reaction is sufficient, however, to cause posterior synechiae (noted in 75% of cases reported by MpTler7) so that the use of mydriatics following surgery seems indicated. The operative complications of hyphema and delayed reformation of the anterior chamber had no demonstrable effect on the control of tensions or on visual acuity in these 110 eyes. Only one case, with a flat chamber for 22 days, required a posterior sclerotomy and air injection to reform the
962
AMERICAN JOURNAL OF OPHTHALMOLOGY
anterior chamber. Scheie 12 reported three cases among 162 in which this procedure was deemed necessary. I n general, he re served it for patients in whom the chamber remained flat for longer than two weeks after surgery. One feature brought out by this series is the information obtained from tonography. According to tracings made one year after surgery in 26 eyes, an outflow facility less than 0.20 probably indicates partial or in complete function of the fistulizing tract. Eyes with outflow facilities greater than 0.20 tend to maintain such facilities during succeeding postoperative years. Nine of 10 patients followed with tonography for two and three years after surgery showed the same pressure and outflow relationships. Only one demonstrated a decrease in the fa cility of outflow, though tensions remained below 20 mm H g without miotics. Thus, tonography not only confirms clinical suc cess but indicates more accurately the func tion of the sclerostomy. CONCLUSIONS
1. Sclerotomy with cautery or iridectomy with scleral cautery (Scheie) is a filtering procedure with a high incidence of success in the hands of surgeons of varying experi ence. Of the 110 eyes reported in this series, 7 4 % were maintained at consistent Schijzftz tensions below 20 m m H g one year after surgery. Those patients with successful re sults continued to have low tensions for as long as six years after surgery. 2. T h e surgical procedure is suitable for patients with both open-angle and angle-clo sure (acute and chronic) glaucoma, with equal chance of success in Negroes and Cau casians. 3. Tonography is valuable in corroborat ing clinical success and in identifying patients
NOVEMBER, 1966
with barely adequate fistulizing tracts. 1855 West Taylor Street (60612) ACKNOWLEDGMENT
I am grateful to Dr. Peter C. Kronfeld for his advice and recommendations during this study. REFERENCES
1. Bounds, G. W., Jr., et al.: Peripheral iridecto my with scleral cautery. Am. J. Ophth. 58:84, 1964. 2. Guinan, P. M.: Peripheral iridectomy with scleral cautery: Scheie's operation for glaucoma. Tr. Ophth. Soc. U. Kingdom, 81: 713, 1961. 3. Kronfeld, P. C : The effects of topical ste roid administration on intraocular pressure and aqueous outflow after fistulizing operations. Tr. Am. Ophth. Soc. 62:375, 1964. 4. Laval, J.: Results of surgery in patients with tubular fields due to glaucoma. Arch. Ophth. 63:850, 1960. 5. Leopold, I. H.: Fistulizing operations for glaucoma: Their complications. J. Internat. Coll. Surg. 33:171, 1960. 6. Malbran, J., and Malbran, E.: Surgical man agement of primary glaucoma. Am. J. Ophth. 47 :34, 1959. 7. Miller, P. M.: Sclerotomy with cautery and iridectomy for glaucoma. Acta Ophth. 41:151, 1963. 8. Preziosi, C. L.: The electro-cautery in the treatment of glaucoma. Brit. J. Ophth. 8:414, 1924. 9. Riise, P.: Long-term prognosis in glaucoma surgery. Am. J. Ophth. 45:807, 1958. 10. Scheie, H. G.: Retraction of scleral wound edges: As a fistulizing procedure for glaucoma. Am. J. Ophth. 45:220 (Apr. Pt. II), 1958. 11. : Peripheral iridectomy with scleral cautery for glaucoma. Arch. Ophth. 61:291, 1959. 12. : Filtering operations for glaucoma. Am. J. Ophth. 53 :571, 1962. 13. : Iridectomy with scleral cautery. Tr. Ophth. Soc. U. Kingdom, 84:127, 1964. 14. Shaffer, R. N.: Open-angle glaucoma. Symposium: Indications for surgery in glaucoma. Tr. Am. Acad. Ophth. Otolaryngol. 67:457-493, 1963. 15. Tyner, G. S., et al.: Peripheral iridectomy with scleral cautery: A report on the operative treatment of 42 eyes with glaucoma. Arch. Ophth. 64:268, 1960. 16. Tyner, G. S., and Arnold, C. O.: Periph eral iridectomy with scleral cautery: A report on the operative treatment of 72 eyes with glaucoma. Arch. Ophth. 68 :581, 1962.