- Email: [email protected]
The Surgical Treatment of Chronic Open-Angle Glaucoma*
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D A V I D 0 . HARRINGTON
creasing blood flow in the nerve. The more stenosis caused by disease and the less the blood flow in the arterioles of the optic nerve, the less intraocular pressure is re quired to change the normal ratio and the more vulnerable are the nerve-fiber bundles. This is, perhaps, the only way to account for the findings in what has come to be known as low-tension glaucoma. There is ample anatomic evidence of the existence of localized nerve-fiber bundles in the optic nerve all the way back to the
chiasm, and there is increasing evidence of the vulnerability of the vascular supply of the optic nerve to disease and the aging process. While the nerve fiber bundle defect in the visual field is still an essential diagnostic sign in glaucoma, it may also now be consid ered as diagnostic, in a broader sense, of disease within the optic nerve and most par ticularly of pathologic involvement of its vascular system. 384 Post Street (8).
REFERENCES
1. Dubois-Poulsen, A , and Hagis, C.: Is the Bjerrum scotoma extraocular in origin? X V I I Cone. Ophth, 2:1136-1144, 1964. 2. Dubois-Poulsen, A . : Reproduction experiméntale du ressant rönne et du scotome de Bjerrum. Ann. ocul, 189:37-52, 1956. 3. : Pathogénie du scotome de Bjerrum. Ann. ocul, 189 :174-185, 1956. 4. Kearns, T. P , and Rucker, C. W . : Arcuate defects in the visual fields due to chromaphohe adenoma of the pituitary gland. Am. J . Ophth, 45:505-507 (Apr.) 1958. 5. Harrington, D. O.: The pathogenesis of the glaucoma field. X V I I I Cone. Ophth, 1:919-929, 1958. Also Am. J . Ophth., 4 7 :177-185 (May Pt. I I ) 1959. 6. : Pathogenesis of the glaucomatous visual field defects: Individual variations in pressure sensitivity. V. Conf. Glaucoma, Josia Macy J r . Foundation, 1960. 7. Hoyt, \V. F . : Anatomic considerations of arcuate scotomas associated with lesions of the optic nerve and chiasm. Bull. Johns Hopkins Hosp, 3:57-71 (Aug.) 1962. 8. Traquair, H. M.: The nerve fiber bundle defect. Tr. Ophth. Soc. U. Kingdom, 64:23, 1944. 9. Hedges, T. R , and Scheie, H. G.: Visual field defects in exophthalmos. Arch. Ophth, 54:885-892 (Dec.) 1955. 10. Petersen, H. P . : Colloid bodies with defects in field of vision. Acta ophth, 35 :243-272, 1957. 11. Lansche, R. K , and Rucker, C. W . : Progression of defects in visual fields produced by hyaline bodies in optic discs. Arch. Ophth, 58:115-121 (July) 1957. 12. Richardson, I . H , Alderfer, Η. Η , and Reid, J . D.: Response of eye and brain to microemboli. Ann. Int. Med, 57:1013, 1962. 13. Hollenhorst, R. W , Lensink, E. R , and Whishant, T. P . : Experimental embolization of the retinal arterioles. Tr. Am. Ophth. S o c , 60 :316, 1962. 14. McBrien, D. J , Bradley, R. D , and Ashton, N.: The nature of retinal emboli in stenosis of the internal carotid artery. Lancet, 1 :696-699, 1963. 15. Cogan, D. G , Kuwabara, T , and Moser, Η.: Fat emboli in the retina following angiography Arch Ophth, 71:308-313 (Mar.) 1964.
THE
SURGICAL
TREATMENT H.
O F CHRONIC OPEN-ANGLE SAUL
SUGAR,
Detroit,
It is generally accepted today that angleclosure glaucoma and congenital glaucoma are diseases for which surgical treatment is specifically indicated. On the other hand, * From the Sinai Hospital of Detroit and Wayne State University College of Medicine.
GLAUCOMA*
M.D.
Michigan
we have been led to believe that chronic open-angle glaucoma is only to be treated medically. I believe that we have neither reached that happy day when we know all the answers to this disease, certainly not from an etiologic viewpoint, nor do we yet have a therapeutic armamentarium adequate
CHRONIC OPEN-ANGLE G L A U C O M A
for all cases of this disease. W e are, there fore, in the position in which we must look promptly to surgical treatment in cases of chronic open-angle glaucoma in which the medical therapy does not adequately control the raised intraocular pressure and does not prevent additional functional damage. This has been particularly emphasized by the conclusions of Drance based on his recent studies on the diurnal variation in intraocu lar pressure in treated glaucoma. He found that one third of medically treated glauco matous eyes with an intraocular pressure of 19 mm Hg applanation or less during office visits had peaks of intraocular pressure of 24 mm Hg or more, some up to 37 mm Hg. Half of these peaks occurred at 10:00 P . M . and 6:00 A . M . ) 1
During the past quarter century an inter esting change has taken place in the surgical methods of treating chronic open-angle glaucoma. A statistical study made at the Illinois Eye and Ear Infirmary for the years 1931 to 1945 showed that the use of the corneoscleral trephination fell from 60 percent in 1931 to about five percent in 1945, while iridencleisis rose from 40 per cent to about 62 percent between these years. Cyclodialysis comprised 33 percent of glaucoma procedures in 1945 but, because of its unpredictability, has decreased in popu larity since then and, with some exceptions, is reserved for use in aphakic glaucoma. It is my impression that between 1945 and 1957 iridencleisis became the most popular operation for open-angle glaucoma, and that corneoscleral trephination declined so sharply in popularity in some cities that ophthal mology residents today are often quite un familiar with the procedure. During the past six years, it has become apparent that we must add a new major heading, the limbosclerectomies, to iriden cleisis and cyclodialysis as antiglaucoma pro cedures. The limbosclerectomies are all de rivatives of one of our oldest anterior lip sclerectomy procedures, the Lagrange scle rectomy, and consist of the Lagrange opera 2
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tion itself, the cautery sclerectomies of Preziosi and Scheie, posterior lip sclerecto my, anterior lip sclerectomy, and limboscleral trephination, as well as various combina tions and modifications of these proce dures. I believe it is important to realize that all of these various methods are de signed to produce the same anatomic result, namely, a subconjunctival fistulizing tract through the sclerolimbus without damage to the ciliary body insertion. The differences in the operations are chiefly in the techniques used to achieve the anatomic goal. These op erations include peripheral iridectomy, the purpose of which, primarily, is to prevent iris prolapse into the sclerectomy opening. 8
If all of these operations have essentially the same goal, then why not use a single procedure? This would be an excellent idea except that each of us has a technique which appears to be easier and more effective in our own hands. Scheie prefers the cautery sclerectomy while I prefer the limboscleral trephination. Iliff and Haas may prefer the posterior lip sclerectomy while some Euro peans still prefer the Lagrange procedure. I believe that there are certain factors which may be considered in evaluating these proce dures: ( 1 ) technical difficulty, ( 2 ) late in fection, and ( 3 ) tension control. Technical difficulties are much the same in all of these procedures. In only one, the anterior lip sclerectomy, is there much dan ger of buttonholing the conjunctiva. Late infection has been considered in a previous paper. It should not be as frequent in any of the limbosclerectomies as in corneoscleral trephination. Tension control deserves par ticular consideration here. It may be dis cussed under the following headings: ( a ) a nonleaking cover flap, ( b ) the size of the sclerectomy opening, ( c ) the location of the limbosclerectomy in relation to the angle re cess, and ( d ) limitation of the area of sub conjunctival filtration surrounding the scle rectomy. a. A leak-proof cover of conjunctiva, to gether with its intact Tenon's capsule, is es5
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sential for any of the filtering procedures. This is usually best accomplished by incis ing the conjunctiva and Tenon's capsule separately. The conjunctiva is incised at or above the superior rectus insertion and Tenon's capsule anterior to the insertion. Both are brought down together as a flap and then folded back over the upper cornea. After the sclerectomy is performed, the flap is securely sutured. I prefer a continuous fine catgut suture in two layers, beginning in Tenon's capsule on one side and continu ing back into the conjunctival layer after completion of the first layer. b. The size of the sclerectomy opening is important. It should be large enough to per mit a patent filtering tract, yet not so exces sive in area as to result in hypotony. Let us consider this in relation to trephination as an example. With a 1.5-mm trephine, the area of sclerectomy resulting from removal of a complete button is 1.76 sq mm in size. With a 2.0-mm trephine, the area excised with a total button would be 3.14 sq mm. I believe this is excessive in area and, for this reason, I prefer to hinge the button pos teriorly and transect it, removing the anter ior half of the button. The excised area is then 1.57 sq mm. The wider 2.0-mm halfmoon shape is probably less likely to be plugged than is a smaller 1.5-mm round opening. With a posterior lip sclerectomy or a cau tery scerectomy the same considerations apply, depending on the size of the inner most opening. A 4.0 mm by 1.0 mm incision would be excessive and would lead to hypot ony. Scheie's recent advice on modification of his original technique is valuable in lim iting the size of the sclerectomy and thereby avoiding the excessive hypotony which was common with the earlier method. The Hildreth cautery is applied to the sclera 1.0 mm behind the limbus and parallel to it. A scratch incision is made through the cauter ized area perpendicularly, approximately 5.0- to 6.0-mm long, directed toward the an terior chamber angle. The cautery is again 6
applied to the sclera over the lips to cause retraction of the wound edges for at least 1.0 mm, the posterior lip being more exten sively cauterized. The anterior chamber is entered with a sweep of the scalpel along its entire length. No further cautery is used. A peripheral iridectomy is then made and the conjunctival flap is replaced and sutured. It is evident from Scheie's description that the cautery sclerectomy operation is a sclerectomy in nearly the entire scleral thick ness but not quite. In the deepest layer it is really a sclerotomy, much like the incision in the iridencleisis operation. If the sclerecto my were through the entire thickness, the opening would, in effect, be too large in area. It is likely that the cautery of the an terior portion of the sclera, by the contrac ture it produces, draws the two deep layers apart, thus giving the effect of a sclerectomy. In each individual case it is impossible to determine exactly, or even approximately, the area of the fistulous tract in its deepest portion. c. The location of the limbosclerectomy in relation to the angle recess. It is essential for the maintenance of a patent channel that the anterior portion of the limbosclerectomy be in direct communication with the anterior chamber. This means that the anterior por tion of the limboscleral channel must be an terior to the posterior end of the angle re cess. In instances where peripheral anterior synechias are present, a false angle recess may be present and may be considerably forward of its normal position. It is, there fore, essential that the individual angle be studied both gonioscopically and by trans illumination of the limbus. The distance between the corneolimbal junction and the posterior wall of the angle recess averages 1.75 mm (varying between 1.2 and 2.6 mm) in the 12-o'clock meridian (as measured in the iris plane) in the eyes which I have measured anatomically. This distance is always less below and still less at the sides of the cornea. It also decreases as one deviates away from the 12-o'clock posi-
659
CHRONIC OPEN-ANGLE G L A U C O M A
tion. Clinically, when measured on the sur face of the globe with transillumination of the limbal area, there is usually about 2.5 mm between the corneolimbal junction and the posterior limit of the transilluminated chamber angle recess in the 12-o'clock posi tion. This means that there is about a 0.75mm transilluminated area between the sclerolimbal junction and the angle recess. Thus, if one were to remove a total trephine button at the 12-o'clock position with a 1.5mm trephine there would be little danger of failure to enter the anterior chamber. With a 2.0-mm button there would be a possible danger of injury to the ciliary body only where the dimensions were smaller than usual. However, by hinging the button pos teriorly and excising only the anterior half, I have been able to enter the anterior chamber in all of the cases to be described, using a 2.0-mm trephine, without damage to the cili ary body. The most important fact is that one has a reasonable amount of latitude in the normal eye in which to enter the anterior chamber. If the angle recess is shallow or the limbus is very narrow, one may have to make the anterior edge of the limbosclerectomy far ther forward. If the limbus is unusually wide, one must not use the corneolimbal junction as a landmark but should determine the proper position for the limbosclerectomy by transillumination. This position is usually such that the anterior edge of the limbo sclerectomy is about 1.5 mm anterior to the sclerolimbal junction. d. The area of subconjunctival filtration surrounding the sclerectomy is a factor of importance which we have thus far been unable to control. Perhaps one should avoid excessive baring of sclera on the sides of the filtering tract. The limbosclerectomies, as a group, are technically simpler to perform than is cor neoscleral trephination since they do not en tail corneal splitting and, except for anterior lip sclerectomy, avoid the danger of con junctival buttonholing. They are less likely
to cause injury to the lens because they are located farther back than in corneoscleral trephination. They are safer than corneo scleral trephination since they avoid the thin anterior bleb portion which is responsible for late infection in corneoscleral trephina tions. Because of the greater safety they may be used in eyes where age expectancy is considered to be long, as in congenital glaucoma, where goniotomy may not be pos sible, and in juvenile glaucoma. Having considered limbosclerectomies in general, I should like to discuss my favorite one—the limboscleral trephination. This op eration is essentially a return to the original type of so-called scleral trephination used by Fergus (1909) and Elliot (1909) in their early trephination operations. Some form of this procedure has been in use by individual ophthalmologists for many years but it has not received much attention or developed much of a following. In 1961, I first pre sented a study of 20 eyes in which a modified limboscleral trephination was per formed. The modifications were introduced ( 1 ) to avoid the dangers of the thin bleb produced with the corneoscleral trephination and its relatively high incidence of bleb rup ture, and late infection; ( 2 ) to limit, some what, the size of the limbosclerectomy open ing; and ( 3 ) to close the flap more effective ly. I have found it to be the most effective operation, in my hands, in chronic openangle glaucoma, in juvenile glaucoma and in reoperation for chronic angle-closure glau coma. 3
4
5
OPERATIVE
TECHNIQUE
After ballooning the conjunctiva with 1.0% Xylocaine, an incision about 12- to 16mm long, concentric with the limbus and be ginning just above or at the level of the su perior rectus insertion is made (fig. 1-A). An incision of the same dimensions is made separately in Tenon's capsule to bare sclera, anterior to the superior rectus insertion (fig. 1-B). With a cotton-tipped applicator, the flap is turned back over the cornea and the
660
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·'
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sclera is bared to the limbus (fig. 1-C). Then, the toe of a Desmarres knife or the rounded part of a No. 15 Bard-Parker scal pel blade is used to scrape the sclera and limbus bare to within 0.5 mm of the cor neolimbal junction for a distance of about 3.0 to 4.0 mm, leaving the Tenon's capsule insertion and subconjunctival connective tis sue intact (fig. 1-D).* The trephine is applied with its anterior tip about a third or a half mm behind the corneolimbal junction. If a 2.0 mm trephine is used at the 12-o'clock position, its center is at the sclerolimbal junction. A turn of the trephine is made so as to mark its position. The conjunctival flap is then replaced to as certain the correct location for application of the trephine. The flap is then reflected back again and the trephine is again applied. It is tilted forward slightly so that the Umboscleral disc will be hinged on its scleral side (fig. 1-E and F ) . The moment the trephine cuts through into the anterior chamber there is a sidden upward jerk of the upper pupil border, producing a pear-shaped pupil. This does not occur if an iridectomy has been done previously, if posterior synechias are present, or if the trephination is made slow ly and the trephine groove is observed fre quently. The latter procedure may produce a slow leak and prevent spontaneous iris pro lapse. One must also be careful, in using a newly sharpened trephine, to observe the depth of the trephine's cut so as not to go through the sclera too rapidly while pressing against the sclerolimbus. After the trephine is removed, the button of sclera is usually
Fig. 1 ( S u g a r ) . Technique of Iimboscleral treph ination. ( A ) Incision in conjunctiva just above or at level of superior rectus insertion. ( B ) In cision made separately in Tenon's capsule just be low superior rectus insertion. (C) Flap turned down, using cotton-tipped applicator to bare sclera. (D) Baring of limbus with toe of Desmarres knife or No. IS Bard-Parker scalpel blade to within 0.5 mm of the corneolimbal junction. ( E and F ) Application of trephine tilted forward to produce
* In some cases, it is necessary to use scissors to separate Tenon's capsule from the sclera. In other cases, especially in youngsters with excessively thick Tenon's capsule, a thin layer of the innermost Tenon's condensation is excised with scissors in the area of the trephination. posteriorly hinged button. (G) Iridectomy. ( H ) Transection of button, removing only anterior half. ( I ) Flap replaced and suture in Tenon's capsule. ( J ) Suture returning in conjunctival layer only.
CHRONIC OPEN-ANGLE G L A U C O M A
pushed upward in its unhinged portion by the prolapsing iris. One may use a 1.5- or 2.0-mm trephine, as desired. With a 1.5-mm trephine the en tire button may be removed. With the 2.0mm trephine, I usually cut the button transversely in half, removing only the an terior unhinged portion (fig. 1-G). If there is any bleeding in the early part of the trephination, either at the upper end of the button or from the anterior ciliary vessels just anterior to the superior rectus insertion, cautery is carefully applied to these, avoiding excess. In any case, if the hinged portion is located over the anterior portion of the ciliary body, or if peripheral anterior synechiae involve the functional pos terior two thirds of the trabecular wall, any desired portion of the button may be left behind so as to avoid disturbing these areas. In a similar way, one may limit the size of the opening by cutting across the button at any desired level, leaving the hinged frac tion in place. This might be desirable in a case of previously operated chronic angleclosure glaucoma where too large an open ing might lead to delay in reformation of the anterior chamber. The prolapsing iris is grasped with iris forceps and excised with the scissors blades held horizontally (fig. 1H).
Fig. 3 (Sugar). Limboscleral trephination done on eye following quiescence after acute congestive attack of angle-closure glaucoma in which angle was nearly completely closed and base pressure was 35 mm Hg, but eye was entirely white.
It is important that the round shape of the pupil be restored. This is done by gently lifting the anterior lip to release the iris and then massaging the cornea with a cyclodialy sis spatula. After the conjunctival flap is re placed, a 6-0 catgut suture is used to close Tenon's capsule from one side to the other (fig. 1-1), then to return in the conjunctival layer (fig. 1-J). Finally, the two ends of the suture are tied together. The suture is locked at regular intervals during the suturing. Atropine is instilled and used for about 10 days post operatively. Local steroids are begun on the third day and continued for one to two weeks. It is my routine procedure to stop all short-acting miotics the day before surgery and all long-acting ones two to three days prior to operation. SUMMARY
Fig. 2 (Sugar). Typical limboscleral trephina tion for chronic open-angle glaucoma. The char acteristic noncystic bleb and its location are shown.
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TO
DATE
A total of 85 eyes were operated upon and observed for six to 53 months (table 1) ; the first 20 cases have now been fol lowed for 43 to 53 months. Of the over-all total, only one operation was done for con genital glaucoma. This was done in a case in which the fellow eye had a goniotomy at the
662
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SAUL
Fig. 4 (Sugar). Limboscleral trephination in five-year-old child with juvenile glaucoma. TABLE
1
E I G H T Y - F I V E LIMBOSCLERAL TREPHINATIONS: F O L L O W - U P F R O M S I X T O 53 M O N T H S
(Original series of 20 followed 43 to 53 months) Types of cases
No. Eyes
I. Congenital glaucoma, aged months II. Juvenile glaucoma a. angiomatosis, aged eight years 2 b. Axenfeld syndrome, aged 11 years 1 c. Advanced juvenile, aged 20 20 years (subsequent cataract extraction did not affect filtra tion) d. Young juvenile 2 III Chronic angle-closure glaucoma (no congestion) a. After failure of previous opera tions 1. After corneoscleral trephi nation 1 2. After peripheral iridectomy 5 3. After iridencleisis (2 eyes had two operations each, including iridencleisis) 3 b. Previously unoperated IV. Chronic open-angle glaucoma V. Secondary 2 a. Healed uveitis (open angles) b. Heterochromie cyclitis after failure of previous corneo scleral trephination 1 c. After failure of three cyclodi alyses in aphake following congenital cataract Fall with hemorrhage third day 1 d. Aniridia with dislocated colobomatous lens 1 TOTAL
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same time but the cornea was too cloudy for goniotomy in the second eye. Six eyes with juvenile glaucoma were op erated upon (figs. 4, 5, 6 and 7). One of these eyes (fig. 5-A) was obtained for his tologic study after the child was accidentally killed by a playmate. Nine trephinations were done for chronic angle-closure glaucoma after failure of other operations (figs. 8, 9 and 10) ; one was done on a previously unoperated eye with chronic angle-closure glaucoma (fig. 3 is such a case) ; 63 were done on eyes with chronic open-angle glaucoma; one was done in a case of heterochromic cyclitis after fail ure of a previous corneoscleral trephination (fig. 11) ; one following operation for con genital cataract was followed by three unsuc cessful cyclodialyses; and one for glaucoma in the presence of aniridia and a dislocated colobomatous lens. Of the total of 85 eyes, three with second ary glaucoma failed to show normalization of tension. One with Axenfeld's syndrome showed some impairment of filtration and one other juvenile showed late bleb failure. Two with open-angle glaucoma required 1% pilocarpine for control. A third was a late failure. The eyes with secondary glaucoma in which the operation failed were the one in
9
1 63 5
85
Fig. 5 (Sugar). Limboscleral trephination in 1 1 year-old child with Axenfeld syndrome with ju venile glaucoma.
CHRONIC OPEN-ANGLE G L A U C O M A
Fig. SA ( S u g a r ) . Area of trephination in eye of dentally killed by a playmate two years later. Nearl tion.
which three unsuccessful cyclodialyses were done and the one with aniridia and a dislocated colobomatous lens which acted as a ball-valve in the trephine opening. In the first case, a severe hyphema occurred on the third postoperative day, due to a fall. In the second case, a second trephination on the same eye failed to relieve the ball-valve effect. The eye with Axenfeld's syndrome had been operated upon two years previously by limboscleral trephination. The tension had been 42 mm Hg preoperatively and was
Fig. 6 ( S u g a r ) . Limboscleral trephination in 20-year-old patient with juvenile glaucoma.
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patient in Figure S obtained after the child was acci' a full button was removed at the time of the operanormal until two months later when it was 24 mm Hg. On October 3, 1962, it was 14 mm Hg by applanation but was 23 mm Hg on December 26, 1962. It was again normal on all occasions until September, 1963, when it was 24 mm Hg. This was the same on two subsequent visits and on January 13, 1964, 1.0% pilocarpine was started. On February 24, 1964, the tension was 26 mm Hg by applanation. Phospholine iodide ( 0 . 0 6 % ) was started. March 13, 1964, the tension was 20 mm Hg. Schiøtz tensions were nearly always normal at the time the elevated
Fig. 7 ( S u g a r ) . Limboscleral trephination in 10year-old child with nevus flammeus and presumed choroidal angiomatosis with glaucoma.
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Fig. 8 (Sugar). Limboscleral trephination in chronic angle-closure glaucoma following two un successful previous filtering procedures.
tensions were found by applanation. The highest Schiøtz reading was 21 mm Hg. Suction-cup studies on June 19, 1963, showed presuction tension of 14 mm Hg, immediate postsuction reading of 25 mm Hg and 22 mm Hg 15 minutes later. The percentage of decay was 37.5%. Tonography on the same day showed C to be 0.18, Po 21, Po/C 116 and F 1.98. Figures 5 and 5A show the clinical and histologic appearance of the bleb. The child was killed in an accident shortly after his last visit. The eyes were obtained for study and will be described elsewhere. The three operated eyes with chronic
Fig. 9 (Sugar). Limboscleral trephination in chronic angle-closure glaucoma following previous corneoscleral trephination.
open-angle glaucoma which were inadequately controlled were those of two Negro patients. In one of them the tension rose to 24 to 26 mm Hg repeatedly, first in the right eye six months postoperatively and then in the left eye after two and a half years (figs. 14, 15, 16 and 17). One of the secondary glaucoma cases following uveitis had been considered a failure because of a tension reading of 24 mm Hg (1955 scale) one month postoperatively. The patient was not seen for 18 months but was then controlled, with a tiny bleb and some filtration present. Continued intermittent follow-up showed a temporary tension rise during a short episode of recurrent iritis which was treated with steroids. In spite of the small number of failures, it must be remembered that, in any series of filtering operations, including this one, failure of conjunctival filtration, late infection, late cataract formation and other late complications will certainly occur. The indications so far are that they will be less than previously experienced by me with any other technique which I have used. As to the other postoperative complications (table 2 ) , one patient had a severe but temporary iritis and one had incarceration of a ciliary process in the trephine (figs. 12 and 1 3 ) . The tension remained normal but
Fig. 10 (Sugar). Limboscleral trephination following peripheral iridectomy for presumed subacute angle-closure glaucoma.
CHRONIC OPEN-ANGLE G L A U C O M A
the incarcerated tissue freed itself following a second trephination temporal to the first. Eight eyes had delayed reformation of the anterior chamber: two for four days, one for seven days, one for 10 days, and four for two days. There were nine postoperative hyphemas, none of which were significant. No cases of hypotony associated with visual decrease were encountered. None had ten sion readings less than that indicated by 12 scale units with the S.S-gm weight. No cases of late infection were found. In one patient, whose history will be pub lished elsewhere, leak without collapse of the bleb or anterior chamber occurred in each eye, one two months postoperatively, the other two and a half years later. This case is not included here because it was felt that these complications were not related to the limboscleral procedure but rather to the effect of long-continued high doses of ster oids on filtering conjunctival blebs. A late postoperative complication, cata ract formation, which may be attributable to the lowered intraocular pressure, occurred in both eyes of one patient in the juvenile TABLE 2
665
Fig. 11 ( S u g a r ) . Limboscleral trephination in patient with heterochromic cyclitis and glaucoma following unsuccessful corneoscleral trephination.
group, a 20-year-old man who developed ca taracts one year after limboscleral trephina tion. An attempt was made to compare the type of bleb and the course of change in its size after limboscleral trephination with a pre viously studied group of eyes on which cor neoscleral trephinations and iridencleises had been done. Since all of the eyes in both series had been photographed stereoscopically, at from one to three month inter vals immediately postoperatively and at least 10
COMPLICATIONS OF 85 LIMBOSCLERAL TREPHINATIONS
1 1 2 1 1
2 1 1 8
0 9 2 0
adult late failure of bleb adult, two eyes, late failure of control after six months and two and a half years. Each eye con trolled with 1 % pilocarpine juvenile late failure of bleb severe but temporary postoperative uveitis incarceration of ciliary process on second post operative day due to effort at stool. Second trephination succeeded in releasing ciliary process cases of secondary glaucoma following iritis— small blebs, one controlled failure in case of aniridia with dislocated colobomatous lens; lens acted as ball-valve. Repeated with same result aphakic glaucoma after three cyclodialyses. Fall on third day with severe hemorrhage. Failure delayed reformation of anterior chamber 4 two days 2 four days 1 seven days 1 ten days hypotony with visual impairment. None had tension readings less than 12/5.5 hyphema, postoperative; none were significant cataract late infection
Fig. 12 ( S u g a r ) . Prolapse of ciliary process into limboscleral trephination on second postoperative day.
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Fig. 13 (Sugar). Same eye as in Figure 12 fol lowing release of prolapse by traction on sclera while doing second trephination temporally. Both remained functioning.
once each year after the first year, these photographs served for comparison. The predominant bleb type was a noncystic succulent one (fig. 2 ) . In 12 of the 85 eyes (14 percent) some small cystic areas were found, nearly all after a period of at least a year. In contrast, previous cases of corneoscleral trephination after the same pe riod nearly all showed cystic areas (95 per cent). Following iridencleisis the cystic area appeared in 30 percent. Of the 80 eyes in which limboscleral treph inations were done for other than second ary glaucoma, 51 showed an increase in the size of the bleb, 20 showed no change dur ing the period of four to 51 months of ob
Fig. 14 (Sugar). Right eye of patient one week following limboscleral trephination in March, 1961. The bleb is small.
servation and nine showed a decrease in the size of the bleb. The latter nine included the total of four cases which had cataract ex traction subsequent to the trephination. In two others the immediate postoperative bleb was very large and subsequently decreased to normal size. Two others were in the pa tient who required 1.0% pilocarpine for control. Thus, 63 percent of limboscleral trephination blebs in glaucomas other than secondary showed an increase in bleb size, as compared to 40 percent following cor neoscleral trephination or iridencleisis. In the five eyes operated upon for second ary glaucoma, the bleb decreased in size in three unsuccessful cases and in one which was successful and increased in size in one successful case reoperated for heterochromic cyclitis glaucoma. DISCUSSION
The greatest advantage of limboscleral trephination over corneoscleral trephination is in avoiding conjunctival buttonholing, lens injury and late infection. In addition, it may be used in congenital and juvenile glau coma where corneoscleral trephination is not usually advisable because of the danger of late infection. I have had the opportunity to
Fig. IS ( S u g a r ) . The same eye as in Figure 14 on September 20, 1963, at which time tension was elevated to 26 mm Hg. The eye has been normal since the patient was put on 1.0% pilocarpine every four hours. The bleb is the same as in Figure 14.
CHRONIC OPEN-ANGLE G L A U C O M A
use the limboscleral trephination only once since this series began, in an eye with hydrophthalmia in which the corneal opacity was too great to do a goniotomy, using a surgical contact lens, as was done on the fellow eye. It was successful without complication. Scheie has found this to be true in a larger series of cases. In juvenile glaucoma, two failures resulted. In most of the others, the blebs are what I consider ideal for antiglaucoma filtration. Recently, Scheie compared his results in 69 eyes on which (what Scheie calls trephinations without corneal splitting, and I call limboscleral trephination) were done, with 162 eyes in which the cautery sclerectomy operation was used. He found 97-percent success in the trephined eyes and 86-percent in the control eyes on which cautery sclerectomies were done. Scheie's operative procedure differs from that which I have described in that a l.S-mm complete trephine hole is made. If the patient was myopic a 1.0-mm trephine was used in some cases. Scheie compared the complications in the two groups and found delayed reformation of the anterior chamber greater in cautery sclerectomies and hypotony greater in the trephined group. In the cautery sclerectomy group the chamber reformed within three days in 95 of 162 eyes. In 44 it was reformed by the end of a week. In nine eyes it
667
6
Fig. 16 ( S u g a r ) . Left eye of same patient as in Figure 14 following limboscleral trephination in January, 1961. The bleb is small.
Fig. 17 ( S u g a r ) . Same eye as in Figure 16 photographed in September, 1963, at which time tension was 24 to 26 mm Hg. Tension has been normal since on 1.0% pilocarpine every four hours. The bleb remains much as it was nearly three years previously.
took 10 days and in seven eyes the chamber reformed in two weeks or longer. In the trephined group, one patient had delayed reformation of the anterior chamber for 18 days. Other cases occurred but were not specifically enumerated. In regard to hypotony, Scheie found it in 30 percent of the trephined eyes but found no disc or macular edema. His criterion for hypotony was a tension reading of under 8.0 mm Hg with a 5.5-gm weight (Schiøtz). I disagree with Scheie's conclusions about the greater incidence of hypotony after limboscleral trephination. M y own definition of hypotony does not depend on a tension of 8.0/5.5, since I have seen lower tension in perfectly normal eyes, but requires the presence of edema of the disc or macula with some visual disturbance. Certainly in regard to the postoperative period, there is no question but that delay in reformation of the anterior chamber is associated with greater hypotony than when the chamber is promptly formed. In the late postoperative period I do not believe there is any significant difference in the incidence of hypotony between the members of the limbosclerectomy group. The indications for the limbosclerectomies, in general, appear to be broader than
Η. S A U L
668
the title of this paper would indicate. Both Scheie and I have found them least valua ble in glaucoma secondary to uveitis; and each of us has used his preferred limbosclerectomy in congenital glaucoma, juvenile glaucoma, chronic angle-closure glaucoma and in reoperations in phakic eyes, as well as in its chief indication, chronic open-angle glaucoma. Scheie and ΐ disagree on the use of these operations in acute angle-closure glaucoma. He used the cautery sclerectomy with 90 percent success in 51 cases. I have preferred to use iridencleisis in those cases of acute angle-closure where peripheral iridectomy is not expected to be adequate, because there is less danger of failure of reformation of the 9
SUGAR
anterior chamber and malignant glaucoma with this operation than when a limbosclerectomy of any type is used. In spite of the differences in our personal preferences, I wish to emphasize that the results with Iimbosclerectomies of all types appear, in general, to give us operative re sults which are so superior to those we ob served before their use that we can now offer surgical help for glaucoma with great er confidence than ever before. I wish to emphasize, again, that all the Iimbosclerecto mies have the same anatomic goal; the differences are chiefly in the techniques which are used to achieve that goal. 18140 San Juan
(21).
REFERENCES
1. Draiice, S. M.: Diurnal variation of intraocular pressure in treated glaucoma. Arch. Ophth, 70:302, 1963. 2. 3. The III,
Sugar, H. S.: The Glaucomas. New York, Hoeber, 1957, ed. 2. Benedict, VV. L.: Sclerocorneal trephining (Elliot's operation). Tr. Sect. Ophth. A M A , 1940, p. 133; corneoscleral trephine operation. In Eye Digest published by Gailey Eye Foundation, Bloomington, 1:3, 1952.
4. Sugar, H. S.: Limboscleral trephination. Am. J . Ophth, 52 :29, 1961. 5. Sugar, H. S , and Zekman, T.: Late infection of filtering conjunctival scars. Am. T. Ophth, 4 6 : 1 5 5 , 1958. 6. Scheie, H. G.: Filtering operations for glaucoma: A comparative study. Am. J . Ophth, 53:571, 1962. 7. Sugar, H. S . : Some recent advances in the surgery of glaucoma. Am. I. Ophth, 5 4 : 9 1 7 , 1962. Also Bull. N.Y. Acad. Med, 3 9 :3, 1963. 8. McPherson, S. D , Tr.: Anterior-posterior lip sclerectomy for open-angle glaucoma. Arch. Ophth, 70:651,1963. 9 . Scheie, H. G.: Results of peripheral iridectomy with scleral cautery in congenital and juvenile glau coma. Arch. Ophth, 6 9 : 1 3 , 1963. 10. Sugar, H. S.: The course of change in size of successful filtering cicatrices Am. J . Ophth, 4 9 :
DISTAL INVOLVEMENT OF T H E E X T R E M I T I E S TN OCULAR M Y O P A T H Y * EIJIRO SATOYOSHI, M . D ,
KEIRO MURAKAMI,
MASAO KINOSHITA, M . D ,
Tokyo,
M.D,
HISAYUKI KOWA,
A N D JUNZO TORII,
M.D,
M.D.
Japan
Ocular myopathy is a primary muscle disease which involves not only the extraocular but also the facial and masticatory groups ~ „ . , ι . «. . , ,, . * r r o m the Department of Medicine, Toho Uni-
of muscles and, on occasion, produces weakness in the muscles of the pharynx and lary n x . " Weakness of the extremities, particularly' in the proximal groups, has also a r •
versity School of Medicine.
been d e s c r i b e d .
T
1
10
r
1117
In
the
two
cases
of
D A V I D 0 . HARRINGTON
creasing blood flow in the nerve. The more stenosis caused by disease and the less the blood flow in the arterioles of the optic nerve, the less intraocular pressure is re quired to change the normal ratio and the more vulnerable are the nerve-fiber bundles. This is, perhaps, the only way to account for the findings in what has come to be known as low-tension glaucoma. There is ample anatomic evidence of the existence of localized nerve-fiber bundles in the optic nerve all the way back to the
chiasm, and there is increasing evidence of the vulnerability of the vascular supply of the optic nerve to disease and the aging process. While the nerve fiber bundle defect in the visual field is still an essential diagnostic sign in glaucoma, it may also now be consid ered as diagnostic, in a broader sense, of disease within the optic nerve and most par ticularly of pathologic involvement of its vascular system. 384 Post Street (8).
REFERENCES
1. Dubois-Poulsen, A , and Hagis, C.: Is the Bjerrum scotoma extraocular in origin? X V I I Cone. Ophth, 2:1136-1144, 1964. 2. Dubois-Poulsen, A . : Reproduction experiméntale du ressant rönne et du scotome de Bjerrum. Ann. ocul, 189:37-52, 1956. 3. : Pathogénie du scotome de Bjerrum. Ann. ocul, 189 :174-185, 1956. 4. Kearns, T. P , and Rucker, C. W . : Arcuate defects in the visual fields due to chromaphohe adenoma of the pituitary gland. Am. J . Ophth, 45:505-507 (Apr.) 1958. 5. Harrington, D. O.: The pathogenesis of the glaucoma field. X V I I I Cone. Ophth, 1:919-929, 1958. Also Am. J . Ophth., 4 7 :177-185 (May Pt. I I ) 1959. 6. : Pathogenesis of the glaucomatous visual field defects: Individual variations in pressure sensitivity. V. Conf. Glaucoma, Josia Macy J r . Foundation, 1960. 7. Hoyt, \V. F . : Anatomic considerations of arcuate scotomas associated with lesions of the optic nerve and chiasm. Bull. Johns Hopkins Hosp, 3:57-71 (Aug.) 1962. 8. Traquair, H. M.: The nerve fiber bundle defect. Tr. Ophth. Soc. U. Kingdom, 64:23, 1944. 9. Hedges, T. R , and Scheie, H. G.: Visual field defects in exophthalmos. Arch. Ophth, 54:885-892 (Dec.) 1955. 10. Petersen, H. P . : Colloid bodies with defects in field of vision. Acta ophth, 35 :243-272, 1957. 11. Lansche, R. K , and Rucker, C. W . : Progression of defects in visual fields produced by hyaline bodies in optic discs. Arch. Ophth, 58:115-121 (July) 1957. 12. Richardson, I . H , Alderfer, Η. Η , and Reid, J . D.: Response of eye and brain to microemboli. Ann. Int. Med, 57:1013, 1962. 13. Hollenhorst, R. W , Lensink, E. R , and Whishant, T. P . : Experimental embolization of the retinal arterioles. Tr. Am. Ophth. S o c , 60 :316, 1962. 14. McBrien, D. J , Bradley, R. D , and Ashton, N.: The nature of retinal emboli in stenosis of the internal carotid artery. Lancet, 1 :696-699, 1963. 15. Cogan, D. G , Kuwabara, T , and Moser, Η.: Fat emboli in the retina following angiography Arch Ophth, 71:308-313 (Mar.) 1964.
THE
SURGICAL
TREATMENT H.
O F CHRONIC OPEN-ANGLE SAUL
SUGAR,
Detroit,
It is generally accepted today that angleclosure glaucoma and congenital glaucoma are diseases for which surgical treatment is specifically indicated. On the other hand, * From the Sinai Hospital of Detroit and Wayne State University College of Medicine.
GLAUCOMA*
M.D.
Michigan
we have been led to believe that chronic open-angle glaucoma is only to be treated medically. I believe that we have neither reached that happy day when we know all the answers to this disease, certainly not from an etiologic viewpoint, nor do we yet have a therapeutic armamentarium adequate
CHRONIC OPEN-ANGLE G L A U C O M A
for all cases of this disease. W e are, there fore, in the position in which we must look promptly to surgical treatment in cases of chronic open-angle glaucoma in which the medical therapy does not adequately control the raised intraocular pressure and does not prevent additional functional damage. This has been particularly emphasized by the conclusions of Drance based on his recent studies on the diurnal variation in intraocu lar pressure in treated glaucoma. He found that one third of medically treated glauco matous eyes with an intraocular pressure of 19 mm Hg applanation or less during office visits had peaks of intraocular pressure of 24 mm Hg or more, some up to 37 mm Hg. Half of these peaks occurred at 10:00 P . M . and 6:00 A . M . ) 1
During the past quarter century an inter esting change has taken place in the surgical methods of treating chronic open-angle glaucoma. A statistical study made at the Illinois Eye and Ear Infirmary for the years 1931 to 1945 showed that the use of the corneoscleral trephination fell from 60 percent in 1931 to about five percent in 1945, while iridencleisis rose from 40 per cent to about 62 percent between these years. Cyclodialysis comprised 33 percent of glaucoma procedures in 1945 but, because of its unpredictability, has decreased in popu larity since then and, with some exceptions, is reserved for use in aphakic glaucoma. It is my impression that between 1945 and 1957 iridencleisis became the most popular operation for open-angle glaucoma, and that corneoscleral trephination declined so sharply in popularity in some cities that ophthal mology residents today are often quite un familiar with the procedure. During the past six years, it has become apparent that we must add a new major heading, the limbosclerectomies, to iriden cleisis and cyclodialysis as antiglaucoma pro cedures. The limbosclerectomies are all de rivatives of one of our oldest anterior lip sclerectomy procedures, the Lagrange scle rectomy, and consist of the Lagrange opera 2
657
tion itself, the cautery sclerectomies of Preziosi and Scheie, posterior lip sclerecto my, anterior lip sclerectomy, and limboscleral trephination, as well as various combina tions and modifications of these proce dures. I believe it is important to realize that all of these various methods are de signed to produce the same anatomic result, namely, a subconjunctival fistulizing tract through the sclerolimbus without damage to the ciliary body insertion. The differences in the operations are chiefly in the techniques used to achieve the anatomic goal. These op erations include peripheral iridectomy, the purpose of which, primarily, is to prevent iris prolapse into the sclerectomy opening. 8
If all of these operations have essentially the same goal, then why not use a single procedure? This would be an excellent idea except that each of us has a technique which appears to be easier and more effective in our own hands. Scheie prefers the cautery sclerectomy while I prefer the limboscleral trephination. Iliff and Haas may prefer the posterior lip sclerectomy while some Euro peans still prefer the Lagrange procedure. I believe that there are certain factors which may be considered in evaluating these proce dures: ( 1 ) technical difficulty, ( 2 ) late in fection, and ( 3 ) tension control. Technical difficulties are much the same in all of these procedures. In only one, the anterior lip sclerectomy, is there much dan ger of buttonholing the conjunctiva. Late infection has been considered in a previous paper. It should not be as frequent in any of the limbosclerectomies as in corneoscleral trephination. Tension control deserves par ticular consideration here. It may be dis cussed under the following headings: ( a ) a nonleaking cover flap, ( b ) the size of the sclerectomy opening, ( c ) the location of the limbosclerectomy in relation to the angle re cess, and ( d ) limitation of the area of sub conjunctival filtration surrounding the scle rectomy. a. A leak-proof cover of conjunctiva, to gether with its intact Tenon's capsule, is es5
Η. S A U L S U G A R
658
sential for any of the filtering procedures. This is usually best accomplished by incis ing the conjunctiva and Tenon's capsule separately. The conjunctiva is incised at or above the superior rectus insertion and Tenon's capsule anterior to the insertion. Both are brought down together as a flap and then folded back over the upper cornea. After the sclerectomy is performed, the flap is securely sutured. I prefer a continuous fine catgut suture in two layers, beginning in Tenon's capsule on one side and continu ing back into the conjunctival layer after completion of the first layer. b. The size of the sclerectomy opening is important. It should be large enough to per mit a patent filtering tract, yet not so exces sive in area as to result in hypotony. Let us consider this in relation to trephination as an example. With a 1.5-mm trephine, the area of sclerectomy resulting from removal of a complete button is 1.76 sq mm in size. With a 2.0-mm trephine, the area excised with a total button would be 3.14 sq mm. I believe this is excessive in area and, for this reason, I prefer to hinge the button pos teriorly and transect it, removing the anter ior half of the button. The excised area is then 1.57 sq mm. The wider 2.0-mm halfmoon shape is probably less likely to be plugged than is a smaller 1.5-mm round opening. With a posterior lip sclerectomy or a cau tery scerectomy the same considerations apply, depending on the size of the inner most opening. A 4.0 mm by 1.0 mm incision would be excessive and would lead to hypot ony. Scheie's recent advice on modification of his original technique is valuable in lim iting the size of the sclerectomy and thereby avoiding the excessive hypotony which was common with the earlier method. The Hildreth cautery is applied to the sclera 1.0 mm behind the limbus and parallel to it. A scratch incision is made through the cauter ized area perpendicularly, approximately 5.0- to 6.0-mm long, directed toward the an terior chamber angle. The cautery is again 6
applied to the sclera over the lips to cause retraction of the wound edges for at least 1.0 mm, the posterior lip being more exten sively cauterized. The anterior chamber is entered with a sweep of the scalpel along its entire length. No further cautery is used. A peripheral iridectomy is then made and the conjunctival flap is replaced and sutured. It is evident from Scheie's description that the cautery sclerectomy operation is a sclerectomy in nearly the entire scleral thick ness but not quite. In the deepest layer it is really a sclerotomy, much like the incision in the iridencleisis operation. If the sclerecto my were through the entire thickness, the opening would, in effect, be too large in area. It is likely that the cautery of the an terior portion of the sclera, by the contrac ture it produces, draws the two deep layers apart, thus giving the effect of a sclerectomy. In each individual case it is impossible to determine exactly, or even approximately, the area of the fistulous tract in its deepest portion. c. The location of the limbosclerectomy in relation to the angle recess. It is essential for the maintenance of a patent channel that the anterior portion of the limbosclerectomy be in direct communication with the anterior chamber. This means that the anterior por tion of the limboscleral channel must be an terior to the posterior end of the angle re cess. In instances where peripheral anterior synechias are present, a false angle recess may be present and may be considerably forward of its normal position. It is, there fore, essential that the individual angle be studied both gonioscopically and by trans illumination of the limbus. The distance between the corneolimbal junction and the posterior wall of the angle recess averages 1.75 mm (varying between 1.2 and 2.6 mm) in the 12-o'clock meridian (as measured in the iris plane) in the eyes which I have measured anatomically. This distance is always less below and still less at the sides of the cornea. It also decreases as one deviates away from the 12-o'clock posi-
659
CHRONIC OPEN-ANGLE G L A U C O M A
tion. Clinically, when measured on the sur face of the globe with transillumination of the limbal area, there is usually about 2.5 mm between the corneolimbal junction and the posterior limit of the transilluminated chamber angle recess in the 12-o'clock posi tion. This means that there is about a 0.75mm transilluminated area between the sclerolimbal junction and the angle recess. Thus, if one were to remove a total trephine button at the 12-o'clock position with a 1.5mm trephine there would be little danger of failure to enter the anterior chamber. With a 2.0-mm button there would be a possible danger of injury to the ciliary body only where the dimensions were smaller than usual. However, by hinging the button pos teriorly and excising only the anterior half, I have been able to enter the anterior chamber in all of the cases to be described, using a 2.0-mm trephine, without damage to the cili ary body. The most important fact is that one has a reasonable amount of latitude in the normal eye in which to enter the anterior chamber. If the angle recess is shallow or the limbus is very narrow, one may have to make the anterior edge of the limbosclerectomy far ther forward. If the limbus is unusually wide, one must not use the corneolimbal junction as a landmark but should determine the proper position for the limbosclerectomy by transillumination. This position is usually such that the anterior edge of the limbo sclerectomy is about 1.5 mm anterior to the sclerolimbal junction. d. The area of subconjunctival filtration surrounding the sclerectomy is a factor of importance which we have thus far been unable to control. Perhaps one should avoid excessive baring of sclera on the sides of the filtering tract. The limbosclerectomies, as a group, are technically simpler to perform than is cor neoscleral trephination since they do not en tail corneal splitting and, except for anterior lip sclerectomy, avoid the danger of con junctival buttonholing. They are less likely
to cause injury to the lens because they are located farther back than in corneoscleral trephination. They are safer than corneo scleral trephination since they avoid the thin anterior bleb portion which is responsible for late infection in corneoscleral trephina tions. Because of the greater safety they may be used in eyes where age expectancy is considered to be long, as in congenital glaucoma, where goniotomy may not be pos sible, and in juvenile glaucoma. Having considered limbosclerectomies in general, I should like to discuss my favorite one—the limboscleral trephination. This op eration is essentially a return to the original type of so-called scleral trephination used by Fergus (1909) and Elliot (1909) in their early trephination operations. Some form of this procedure has been in use by individual ophthalmologists for many years but it has not received much attention or developed much of a following. In 1961, I first pre sented a study of 20 eyes in which a modified limboscleral trephination was per formed. The modifications were introduced ( 1 ) to avoid the dangers of the thin bleb produced with the corneoscleral trephination and its relatively high incidence of bleb rup ture, and late infection; ( 2 ) to limit, some what, the size of the limbosclerectomy open ing; and ( 3 ) to close the flap more effective ly. I have found it to be the most effective operation, in my hands, in chronic openangle glaucoma, in juvenile glaucoma and in reoperation for chronic angle-closure glau coma. 3
4
5
OPERATIVE
TECHNIQUE
After ballooning the conjunctiva with 1.0% Xylocaine, an incision about 12- to 16mm long, concentric with the limbus and be ginning just above or at the level of the su perior rectus insertion is made (fig. 1-A). An incision of the same dimensions is made separately in Tenon's capsule to bare sclera, anterior to the superior rectus insertion (fig. 1-B). With a cotton-tipped applicator, the flap is turned back over the cornea and the
660
Η.
·'
SUGAR
sclera is bared to the limbus (fig. 1-C). Then, the toe of a Desmarres knife or the rounded part of a No. 15 Bard-Parker scal pel blade is used to scrape the sclera and limbus bare to within 0.5 mm of the cor neolimbal junction for a distance of about 3.0 to 4.0 mm, leaving the Tenon's capsule insertion and subconjunctival connective tis sue intact (fig. 1-D).* The trephine is applied with its anterior tip about a third or a half mm behind the corneolimbal junction. If a 2.0 mm trephine is used at the 12-o'clock position, its center is at the sclerolimbal junction. A turn of the trephine is made so as to mark its position. The conjunctival flap is then replaced to as certain the correct location for application of the trephine. The flap is then reflected back again and the trephine is again applied. It is tilted forward slightly so that the Umboscleral disc will be hinged on its scleral side (fig. 1-E and F ) . The moment the trephine cuts through into the anterior chamber there is a sidden upward jerk of the upper pupil border, producing a pear-shaped pupil. This does not occur if an iridectomy has been done previously, if posterior synechias are present, or if the trephination is made slow ly and the trephine groove is observed fre quently. The latter procedure may produce a slow leak and prevent spontaneous iris pro lapse. One must also be careful, in using a newly sharpened trephine, to observe the depth of the trephine's cut so as not to go through the sclera too rapidly while pressing against the sclerolimbus. After the trephine is removed, the button of sclera is usually
Fig. 1 ( S u g a r ) . Technique of Iimboscleral treph ination. ( A ) Incision in conjunctiva just above or at level of superior rectus insertion. ( B ) In cision made separately in Tenon's capsule just be low superior rectus insertion. (C) Flap turned down, using cotton-tipped applicator to bare sclera. (D) Baring of limbus with toe of Desmarres knife or No. IS Bard-Parker scalpel blade to within 0.5 mm of the corneolimbal junction. ( E and F ) Application of trephine tilted forward to produce
* In some cases, it is necessary to use scissors to separate Tenon's capsule from the sclera. In other cases, especially in youngsters with excessively thick Tenon's capsule, a thin layer of the innermost Tenon's condensation is excised with scissors in the area of the trephination. posteriorly hinged button. (G) Iridectomy. ( H ) Transection of button, removing only anterior half. ( I ) Flap replaced and suture in Tenon's capsule. ( J ) Suture returning in conjunctival layer only.
CHRONIC OPEN-ANGLE G L A U C O M A
pushed upward in its unhinged portion by the prolapsing iris. One may use a 1.5- or 2.0-mm trephine, as desired. With a 1.5-mm trephine the en tire button may be removed. With the 2.0mm trephine, I usually cut the button transversely in half, removing only the an terior unhinged portion (fig. 1-G). If there is any bleeding in the early part of the trephination, either at the upper end of the button or from the anterior ciliary vessels just anterior to the superior rectus insertion, cautery is carefully applied to these, avoiding excess. In any case, if the hinged portion is located over the anterior portion of the ciliary body, or if peripheral anterior synechiae involve the functional pos terior two thirds of the trabecular wall, any desired portion of the button may be left behind so as to avoid disturbing these areas. In a similar way, one may limit the size of the opening by cutting across the button at any desired level, leaving the hinged frac tion in place. This might be desirable in a case of previously operated chronic angleclosure glaucoma where too large an open ing might lead to delay in reformation of the anterior chamber. The prolapsing iris is grasped with iris forceps and excised with the scissors blades held horizontally (fig. 1H).
Fig. 3 (Sugar). Limboscleral trephination done on eye following quiescence after acute congestive attack of angle-closure glaucoma in which angle was nearly completely closed and base pressure was 35 mm Hg, but eye was entirely white.
It is important that the round shape of the pupil be restored. This is done by gently lifting the anterior lip to release the iris and then massaging the cornea with a cyclodialy sis spatula. After the conjunctival flap is re placed, a 6-0 catgut suture is used to close Tenon's capsule from one side to the other (fig. 1-1), then to return in the conjunctival layer (fig. 1-J). Finally, the two ends of the suture are tied together. The suture is locked at regular intervals during the suturing. Atropine is instilled and used for about 10 days post operatively. Local steroids are begun on the third day and continued for one to two weeks. It is my routine procedure to stop all short-acting miotics the day before surgery and all long-acting ones two to three days prior to operation. SUMMARY
Fig. 2 (Sugar). Typical limboscleral trephina tion for chronic open-angle glaucoma. The char acteristic noncystic bleb and its location are shown.
661
OF R E S U L T S
TO
DATE
A total of 85 eyes were operated upon and observed for six to 53 months (table 1) ; the first 20 cases have now been fol lowed for 43 to 53 months. Of the over-all total, only one operation was done for con genital glaucoma. This was done in a case in which the fellow eye had a goniotomy at the
662
Η.
SAUL
Fig. 4 (Sugar). Limboscleral trephination in five-year-old child with juvenile glaucoma. TABLE
1
E I G H T Y - F I V E LIMBOSCLERAL TREPHINATIONS: F O L L O W - U P F R O M S I X T O 53 M O N T H S
(Original series of 20 followed 43 to 53 months) Types of cases
No. Eyes
I. Congenital glaucoma, aged months II. Juvenile glaucoma a. angiomatosis, aged eight years 2 b. Axenfeld syndrome, aged 11 years 1 c. Advanced juvenile, aged 20 20 years (subsequent cataract extraction did not affect filtra tion) d. Young juvenile 2 III Chronic angle-closure glaucoma (no congestion) a. After failure of previous opera tions 1. After corneoscleral trephi nation 1 2. After peripheral iridectomy 5 3. After iridencleisis (2 eyes had two operations each, including iridencleisis) 3 b. Previously unoperated IV. Chronic open-angle glaucoma V. Secondary 2 a. Healed uveitis (open angles) b. Heterochromie cyclitis after failure of previous corneo scleral trephination 1 c. After failure of three cyclodi alyses in aphake following congenital cataract Fall with hemorrhage third day 1 d. Aniridia with dislocated colobomatous lens 1 TOTAL
1 6
SUGAR
same time but the cornea was too cloudy for goniotomy in the second eye. Six eyes with juvenile glaucoma were op erated upon (figs. 4, 5, 6 and 7). One of these eyes (fig. 5-A) was obtained for his tologic study after the child was accidentally killed by a playmate. Nine trephinations were done for chronic angle-closure glaucoma after failure of other operations (figs. 8, 9 and 10) ; one was done on a previously unoperated eye with chronic angle-closure glaucoma (fig. 3 is such a case) ; 63 were done on eyes with chronic open-angle glaucoma; one was done in a case of heterochromic cyclitis after fail ure of a previous corneoscleral trephination (fig. 11) ; one following operation for con genital cataract was followed by three unsuc cessful cyclodialyses; and one for glaucoma in the presence of aniridia and a dislocated colobomatous lens. Of the total of 85 eyes, three with second ary glaucoma failed to show normalization of tension. One with Axenfeld's syndrome showed some impairment of filtration and one other juvenile showed late bleb failure. Two with open-angle glaucoma required 1% pilocarpine for control. A third was a late failure. The eyes with secondary glaucoma in which the operation failed were the one in
9
1 63 5
85
Fig. 5 (Sugar). Limboscleral trephination in 1 1 year-old child with Axenfeld syndrome with ju venile glaucoma.
CHRONIC OPEN-ANGLE G L A U C O M A
Fig. SA ( S u g a r ) . Area of trephination in eye of dentally killed by a playmate two years later. Nearl tion.
which three unsuccessful cyclodialyses were done and the one with aniridia and a dislocated colobomatous lens which acted as a ball-valve in the trephine opening. In the first case, a severe hyphema occurred on the third postoperative day, due to a fall. In the second case, a second trephination on the same eye failed to relieve the ball-valve effect. The eye with Axenfeld's syndrome had been operated upon two years previously by limboscleral trephination. The tension had been 42 mm Hg preoperatively and was
Fig. 6 ( S u g a r ) . Limboscleral trephination in 20-year-old patient with juvenile glaucoma.
663
patient in Figure S obtained after the child was acci' a full button was removed at the time of the operanormal until two months later when it was 24 mm Hg. On October 3, 1962, it was 14 mm Hg by applanation but was 23 mm Hg on December 26, 1962. It was again normal on all occasions until September, 1963, when it was 24 mm Hg. This was the same on two subsequent visits and on January 13, 1964, 1.0% pilocarpine was started. On February 24, 1964, the tension was 26 mm Hg by applanation. Phospholine iodide ( 0 . 0 6 % ) was started. March 13, 1964, the tension was 20 mm Hg. Schiøtz tensions were nearly always normal at the time the elevated
Fig. 7 ( S u g a r ) . Limboscleral trephination in 10year-old child with nevus flammeus and presumed choroidal angiomatosis with glaucoma.
664
Η. S A U L S U G A R
Fig. 8 (Sugar). Limboscleral trephination in chronic angle-closure glaucoma following two un successful previous filtering procedures.
tensions were found by applanation. The highest Schiøtz reading was 21 mm Hg. Suction-cup studies on June 19, 1963, showed presuction tension of 14 mm Hg, immediate postsuction reading of 25 mm Hg and 22 mm Hg 15 minutes later. The percentage of decay was 37.5%. Tonography on the same day showed C to be 0.18, Po 21, Po/C 116 and F 1.98. Figures 5 and 5A show the clinical and histologic appearance of the bleb. The child was killed in an accident shortly after his last visit. The eyes were obtained for study and will be described elsewhere. The three operated eyes with chronic
Fig. 9 (Sugar). Limboscleral trephination in chronic angle-closure glaucoma following previous corneoscleral trephination.
open-angle glaucoma which were inadequately controlled were those of two Negro patients. In one of them the tension rose to 24 to 26 mm Hg repeatedly, first in the right eye six months postoperatively and then in the left eye after two and a half years (figs. 14, 15, 16 and 17). One of the secondary glaucoma cases following uveitis had been considered a failure because of a tension reading of 24 mm Hg (1955 scale) one month postoperatively. The patient was not seen for 18 months but was then controlled, with a tiny bleb and some filtration present. Continued intermittent follow-up showed a temporary tension rise during a short episode of recurrent iritis which was treated with steroids. In spite of the small number of failures, it must be remembered that, in any series of filtering operations, including this one, failure of conjunctival filtration, late infection, late cataract formation and other late complications will certainly occur. The indications so far are that they will be less than previously experienced by me with any other technique which I have used. As to the other postoperative complications (table 2 ) , one patient had a severe but temporary iritis and one had incarceration of a ciliary process in the trephine (figs. 12 and 1 3 ) . The tension remained normal but
Fig. 10 (Sugar). Limboscleral trephination following peripheral iridectomy for presumed subacute angle-closure glaucoma.
CHRONIC OPEN-ANGLE G L A U C O M A
the incarcerated tissue freed itself following a second trephination temporal to the first. Eight eyes had delayed reformation of the anterior chamber: two for four days, one for seven days, one for 10 days, and four for two days. There were nine postoperative hyphemas, none of which were significant. No cases of hypotony associated with visual decrease were encountered. None had ten sion readings less than that indicated by 12 scale units with the S.S-gm weight. No cases of late infection were found. In one patient, whose history will be pub lished elsewhere, leak without collapse of the bleb or anterior chamber occurred in each eye, one two months postoperatively, the other two and a half years later. This case is not included here because it was felt that these complications were not related to the limboscleral procedure but rather to the effect of long-continued high doses of ster oids on filtering conjunctival blebs. A late postoperative complication, cata ract formation, which may be attributable to the lowered intraocular pressure, occurred in both eyes of one patient in the juvenile TABLE 2
665
Fig. 11 ( S u g a r ) . Limboscleral trephination in patient with heterochromic cyclitis and glaucoma following unsuccessful corneoscleral trephination.
group, a 20-year-old man who developed ca taracts one year after limboscleral trephina tion. An attempt was made to compare the type of bleb and the course of change in its size after limboscleral trephination with a pre viously studied group of eyes on which cor neoscleral trephinations and iridencleises had been done. Since all of the eyes in both series had been photographed stereoscopically, at from one to three month inter vals immediately postoperatively and at least 10
COMPLICATIONS OF 85 LIMBOSCLERAL TREPHINATIONS
1 1 2 1 1
2 1 1 8
0 9 2 0
adult late failure of bleb adult, two eyes, late failure of control after six months and two and a half years. Each eye con trolled with 1 % pilocarpine juvenile late failure of bleb severe but temporary postoperative uveitis incarceration of ciliary process on second post operative day due to effort at stool. Second trephination succeeded in releasing ciliary process cases of secondary glaucoma following iritis— small blebs, one controlled failure in case of aniridia with dislocated colobomatous lens; lens acted as ball-valve. Repeated with same result aphakic glaucoma after three cyclodialyses. Fall on third day with severe hemorrhage. Failure delayed reformation of anterior chamber 4 two days 2 four days 1 seven days 1 ten days hypotony with visual impairment. None had tension readings less than 12/5.5 hyphema, postoperative; none were significant cataract late infection
Fig. 12 ( S u g a r ) . Prolapse of ciliary process into limboscleral trephination on second postoperative day.
666
Η. S A U L S U G A R
Fig. 13 (Sugar). Same eye as in Figure 12 fol lowing release of prolapse by traction on sclera while doing second trephination temporally. Both remained functioning.
once each year after the first year, these photographs served for comparison. The predominant bleb type was a noncystic succulent one (fig. 2 ) . In 12 of the 85 eyes (14 percent) some small cystic areas were found, nearly all after a period of at least a year. In contrast, previous cases of corneoscleral trephination after the same pe riod nearly all showed cystic areas (95 per cent). Following iridencleisis the cystic area appeared in 30 percent. Of the 80 eyes in which limboscleral treph inations were done for other than second ary glaucoma, 51 showed an increase in the size of the bleb, 20 showed no change dur ing the period of four to 51 months of ob
Fig. 14 (Sugar). Right eye of patient one week following limboscleral trephination in March, 1961. The bleb is small.
servation and nine showed a decrease in the size of the bleb. The latter nine included the total of four cases which had cataract ex traction subsequent to the trephination. In two others the immediate postoperative bleb was very large and subsequently decreased to normal size. Two others were in the pa tient who required 1.0% pilocarpine for control. Thus, 63 percent of limboscleral trephination blebs in glaucomas other than secondary showed an increase in bleb size, as compared to 40 percent following cor neoscleral trephination or iridencleisis. In the five eyes operated upon for second ary glaucoma, the bleb decreased in size in three unsuccessful cases and in one which was successful and increased in size in one successful case reoperated for heterochromic cyclitis glaucoma. DISCUSSION
The greatest advantage of limboscleral trephination over corneoscleral trephination is in avoiding conjunctival buttonholing, lens injury and late infection. In addition, it may be used in congenital and juvenile glau coma where corneoscleral trephination is not usually advisable because of the danger of late infection. I have had the opportunity to
Fig. IS ( S u g a r ) . The same eye as in Figure 14 on September 20, 1963, at which time tension was elevated to 26 mm Hg. The eye has been normal since the patient was put on 1.0% pilocarpine every four hours. The bleb is the same as in Figure 14.
CHRONIC OPEN-ANGLE G L A U C O M A
use the limboscleral trephination only once since this series began, in an eye with hydrophthalmia in which the corneal opacity was too great to do a goniotomy, using a surgical contact lens, as was done on the fellow eye. It was successful without complication. Scheie has found this to be true in a larger series of cases. In juvenile glaucoma, two failures resulted. In most of the others, the blebs are what I consider ideal for antiglaucoma filtration. Recently, Scheie compared his results in 69 eyes on which (what Scheie calls trephinations without corneal splitting, and I call limboscleral trephination) were done, with 162 eyes in which the cautery sclerectomy operation was used. He found 97-percent success in the trephined eyes and 86-percent in the control eyes on which cautery sclerectomies were done. Scheie's operative procedure differs from that which I have described in that a l.S-mm complete trephine hole is made. If the patient was myopic a 1.0-mm trephine was used in some cases. Scheie compared the complications in the two groups and found delayed reformation of the anterior chamber greater in cautery sclerectomies and hypotony greater in the trephined group. In the cautery sclerectomy group the chamber reformed within three days in 95 of 162 eyes. In 44 it was reformed by the end of a week. In nine eyes it
667
6
Fig. 16 ( S u g a r ) . Left eye of same patient as in Figure 14 following limboscleral trephination in January, 1961. The bleb is small.
Fig. 17 ( S u g a r ) . Same eye as in Figure 16 photographed in September, 1963, at which time tension was 24 to 26 mm Hg. Tension has been normal since on 1.0% pilocarpine every four hours. The bleb remains much as it was nearly three years previously.
took 10 days and in seven eyes the chamber reformed in two weeks or longer. In the trephined group, one patient had delayed reformation of the anterior chamber for 18 days. Other cases occurred but were not specifically enumerated. In regard to hypotony, Scheie found it in 30 percent of the trephined eyes but found no disc or macular edema. His criterion for hypotony was a tension reading of under 8.0 mm Hg with a 5.5-gm weight (Schiøtz). I disagree with Scheie's conclusions about the greater incidence of hypotony after limboscleral trephination. M y own definition of hypotony does not depend on a tension of 8.0/5.5, since I have seen lower tension in perfectly normal eyes, but requires the presence of edema of the disc or macula with some visual disturbance. Certainly in regard to the postoperative period, there is no question but that delay in reformation of the anterior chamber is associated with greater hypotony than when the chamber is promptly formed. In the late postoperative period I do not believe there is any significant difference in the incidence of hypotony between the members of the limbosclerectomy group. The indications for the limbosclerectomies, in general, appear to be broader than
Η. S A U L
668
the title of this paper would indicate. Both Scheie and I have found them least valua ble in glaucoma secondary to uveitis; and each of us has used his preferred limbosclerectomy in congenital glaucoma, juvenile glaucoma, chronic angle-closure glaucoma and in reoperations in phakic eyes, as well as in its chief indication, chronic open-angle glaucoma. Scheie and ΐ disagree on the use of these operations in acute angle-closure glaucoma. He used the cautery sclerectomy with 90 percent success in 51 cases. I have preferred to use iridencleisis in those cases of acute angle-closure where peripheral iridectomy is not expected to be adequate, because there is less danger of failure of reformation of the 9
SUGAR
anterior chamber and malignant glaucoma with this operation than when a limbosclerectomy of any type is used. In spite of the differences in our personal preferences, I wish to emphasize that the results with Iimbosclerectomies of all types appear, in general, to give us operative re sults which are so superior to those we ob served before their use that we can now offer surgical help for glaucoma with great er confidence than ever before. I wish to emphasize, again, that all the Iimbosclerecto mies have the same anatomic goal; the differences are chiefly in the techniques which are used to achieve that goal. 18140 San Juan
(21).
REFERENCES
1. Draiice, S. M.: Diurnal variation of intraocular pressure in treated glaucoma. Arch. Ophth, 70:302, 1963. 2. 3. The III,
Sugar, H. S.: The Glaucomas. New York, Hoeber, 1957, ed. 2. Benedict, VV. L.: Sclerocorneal trephining (Elliot's operation). Tr. Sect. Ophth. A M A , 1940, p. 133; corneoscleral trephine operation. In Eye Digest published by Gailey Eye Foundation, Bloomington, 1:3, 1952.
4. Sugar, H. S.: Limboscleral trephination. Am. J . Ophth, 52 :29, 1961. 5. Sugar, H. S , and Zekman, T.: Late infection of filtering conjunctival scars. Am. T. Ophth, 4 6 : 1 5 5 , 1958. 6. Scheie, H. G.: Filtering operations for glaucoma: A comparative study. Am. J . Ophth, 53:571, 1962. 7. Sugar, H. S . : Some recent advances in the surgery of glaucoma. Am. I. Ophth, 5 4 : 9 1 7 , 1962. Also Bull. N.Y. Acad. Med, 3 9 :3, 1963. 8. McPherson, S. D , Tr.: Anterior-posterior lip sclerectomy for open-angle glaucoma. Arch. Ophth, 70:651,1963. 9 . Scheie, H. G.: Results of peripheral iridectomy with scleral cautery in congenital and juvenile glau coma. Arch. Ophth, 6 9 : 1 3 , 1963. 10. Sugar, H. S.: The course of change in size of successful filtering cicatrices Am. J . Ophth, 4 9 :
DISTAL INVOLVEMENT OF T H E E X T R E M I T I E S TN OCULAR M Y O P A T H Y * EIJIRO SATOYOSHI, M . D ,
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M.D,
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Japan
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