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An Operation for Chronic Primary Glaucoma*
AN OPERATION FOR CHRONIC PRIMARY GLAUCOMA* GONIODIALYSIS COMBINED WITH SCLERECTOMY AND IRIS INCLUSION JOSEPH LAVAL,
M.D.
New York I am sure most eye surgeons have done this operation in part many times. The sclerectomy, the iris inclusion, the goniodialysis-—all these have been done by many surgeons. I am suggesting only that all of these be done at one time and also that the incision be made by the ab externo route as originally advocated by Ernst Fuchs. The operation is indicated for cases of chronic primary glaucoma either with or without acute exacerbations. It can also be used for the intractable borderline case of secondary glaucoma; that is, the case which is difficult to classify as true primary glaucoma and in which often more than one operation has been done with no permanent control of tension. This operation has been done at Mt. Sinai Hospital and at the Manhattan Eye, Ear, and Throat Hospital on a total of 50 eyes of 43 patients, 20 of whom were men and 23, women. The ages ranged from 43 to 79 years. The duration of the glaucoma varied from 1 year to at least 8 years before operation. The tension before operation with, miotics varied from 30 mm. Hg to 80 mm. Hg (Schätz). The visual fields varied from almost normal to telescopic, with various sizes of paracentral scotomas and enlarged blindspots extending almost to fixation. In no case was the field made worse or the visual acuity impaired by the operation. No patients developed lenticular opacities as a result of the operation. Visual acuity before operation ranged from 5/400 to 20/20. Some cases have been followed for three * Presented with moving pictures before the Eye Section of the New York Academy of Medicine December IS, 1947; the Los Angeles Society of Ophthalmology and Otolaryngology and the Los Angeles Ophthalmological Society, March 9, 1948; the International College of Surgeons, Rome, Italy, May 18, 1948.
years, and some for only one month. Three patients had had prior operations for relief of tension in eyes operated on by the method described in this paper. Of these three cases, one was a failure after 8 months with this operation. Any case which needed miotics after the operation more than 3 times a day to keep the tension normal was considered a failure. The one failure was in a Negro who had syphilis and whose right eye was lost following several unsuccessful operations to control the tension, including cyclodiathermy. The left eye had one operation for glaucoma with no reduction in tension, following which the operation I shall describe was performed by the surgeon in charge of the case. The tension was controlled for 8 months but then rose again and could not be controlled with miotics. OPERATIVE PROCEDURE
The operative procedure is simple and requires no great amount of surgical skill. It can be done under intravenous or local anesthesia. On the day of the operation, I use no miotics, in this way making it easier to withdraw the iris from the wound. In the cases done under local anesthesia, I use a lid block according to Van Lint's technique, two sutures through the upper lid, and one through the superior rectus. No suture is- needed for the lower lid. Two cc. of 2-percent novocain with adrenalin are injected retrobulbarly above and also some subconjunctivally above, ballooning up the conjunctiva between the limbus and the upper f ornix. The incision is made one centimeter above the limbus and rather wide, as one does for a trephination. Tenon's capsule is also opened rather wide. As one approaches to within 5 mm. of the limbus the incision goes through all the layers down to sciera. This
634
OPERATION FOR PRIMARY GLAUCOMA incision must also be made wide to avoid a small nitration area which would stand out like a knuckle. The dissection is carried down to the comeoscleral margin and here à partial splitting of the cornea, as for a trephination, may be performed, only it does not have to be carried into corneal tissue for any considerable distance. With a keratome or a knife, a S-mm. incision is made through sciera, 2 mm. above the comeoscleral margin. This line is scratched deeper and deeper until the uveal tissue is reached. If scierai bleeding is annoying, it is easily controlled by applying thrombin topical on an applicator. Then an iris repositor is inserted through the wound, hugging the under surface of the sciera. If the repositor does not enter easily, the incision with the keratome is repeated, going a bit deeper this time. The repositor is tried again and, as it enters, it is placed gently into the anterior chamber, entering through the iris angle. The repositor is swung gently from side to side opening the angle over as great an area as possible. With a Stevens scissors, two incisions are made 3 mm. apart at right angles to the original scierai incision going down to the comeoscleral margin. This piece of sciera is then picked up in toothed forceps and excised. The iris is then gently grasped with iris forceps near the pupillary margin and, with a gentle side to side swaying motion it is carefully, gently, and very slowly withdrawn through the scierai wound until the black pupillary portion is visible. One incision is made through half of the withdrawn iris to the pupil and this pillar allowed to recede. The other portion of the iris, which is still in the iris forceps, is allowed to lie on the sciera just as it falls. No attempt is made to straighten the iris or to place the pigmented layer of the iris against the sciera. The conjunctiva is now closed with a
635
i
Fig. 1 (Laval). The ab externo scierai incision ■is made 5 mm. long with the point of a keratome 2 mm. above the comeoscleral margin until the uveal tissue is reached.
Fig. 2 (Laval). An iris repositor is then placed in the wound, hugging the inner scierai surface, and gently continued forward until the repositor enters the anterior chamber. The repositor is then moved from side to side freeing the angle (gonio-dialysis).
636
JOSEPH LAVAL
Fig. 5 (Laval). A scierai tongue 2 by 5 mm. has been excised. This has been made extra large for purposes of demonstration but in actual practice does not exceed 1 by 3 mm.
Fig. 3 (Laval). Two incisions, 3 mm. apart, are then made in the sciera toward the corneoscleral margin for a distance of 1 mm.
cut quite short. One drop of 1-percent atropine is instilled and the eye bandaged. EXPERIMENTAL OBSERVATIONS
running silk suture; a knot is tied at both ends and the bites are taken rather closely together. In this way a tight closure is obtained and the ends of the suture can be
I was curious to know what structures my iris repositor traversed as it passed from the scierai incision, 2-mm. above the corneoscleral margin into the anterior chamber. Accordingly, I obtained a normal globe from the Eye-Bank, made the scierai incision, and
Fig. 4 (Laval). This piece of sciera is cut off with scissors giving a scierai opening measuring 3 by 1 mm.
Fig. 6 (Laval). The iris is withdrawn until the black pupillary seam is seen ; then it is cut half-way across.
OPERATION FOR PRIMARY GLAUCOMA inserted along the path of the repositor a piece of black silk suture material. The eye was fixed in Bouin's solution, sectioned, and stained with hematoxylin-eosin. Figure 9 shows the site of the scierai ab externo incision, (S) the suture material entering the sciera and passing through the ligamentum pectinatum ( L ) . In other words, the goniodialysis succeeds in cutting the trabeculas and freeing any anterior peripheral synechias, if present. A filtration tract is thereby formed connecting the anterior chamber through the angle with the outer surface of the globe. This tract is kept patent by the inclusion of iris tissue in the entire length of the channel. The length of the tract is cut in half by removing a 1-mm. piece of sciera, thus bringing the opening in the sciera near the filtration angle. Furthermore, by withdrawing and cutting the iris after the sclerectomy, the iris is cut directly at its root.
637
Fig. 8 (Laval). The conjunctival flap covers the iris.
regardless of the use of gonioscopy before the operation this procedure can still be carried out because the goniodialysis cuts through the filtration angle and any adhesions, if present; (4) by using the ab externo route for the scierai incision with the
Fig. 7 (Laval). The iris which is in the forceps is allowed to lie on the sciera as it falls ; no attempt is made to turn the pigment surface face up or down. SUMMARY
The operation is advocated because: (1) It is simple and requires no great amount of surgical skill; (2) a thick covering of the filtration area is obtained instead of a very thin covering as in a trephination; (3)
Fig. 9 (Laval). Section of eye fixed in Bouin's solution and stained with hematoxylin-eosin. (S) Site of incision. (L) Ligamentum pectinatum. (M) Scierai meshwork. (Sc) Schlemm's canal.
638
JOSEPH LAVAL
keratome, the danger of injury to the lens is removed and one is also assured of making an unbeveled incision directly over the filtration angle; (5) the size of the scierai excision, which can be varied to suit the individual case, will be determined by the amount of tension with and without drops. ADDENDUM
It is of interest to note here that an article recently appearing in the Brazilian ophthalmic literature reports an operation of simple goniodialysis executed in a manner somewhat similar to the one I have described, but without sclerectomy and without iris inclusion. The author, R. Granville,2 performed the goniodialysis on 4 patients in 2 of whom the tension was satisfactorily controlled. To accept the concept that a goniodialysis alone will reduce intraocular pressure one would have to suppose that enough of the aqueous in the anterior chamber cannot get into Schlemm's canal because the fibrillas of the meshwork of the filtration angle are so thickened and closely woven to each other as to block the aqueous at (L) in Figure 9. The remainder of the fibrillas of the meshwork (the scierai meshwork—M) would have to be normal in thickness to permit the aqueous to reach Schlemm's canal (Sc), which must also be considered patent and functioning. The goniodialysis makes an opening in the thickened arc of fibers at (L) and permits the aqueous to get to ( M ) where the spaces in the meshwork are sufficient in number and size for the aqueous to get into Schlemm's canal (Sc). According to Barkan, 1 his technique of goniotomy for congenital glaucoma "makes the incision only in the meshwork of the filtration angle" and goes through the same thickened arc of fibers at ( L ) in Figure 9. The direction, of the incision in Barkan's
goniotomy is from the anterior chamber outward through the thickened area into the supposedly normal fibers of the scierai meshwork. Schlemm's canal is not incised and, again, one must suppose that Schlemm's canal is normal and that the aqueous has been kept from Schlemm's canal only by the thickened area of fibers of the meshwork at the filtration angle. Accordingly Barkan, in his goniotomy with the aid of a surgical contact glass, is accomplishing the same thing that I accomplish with the goniodialysis by the ab externo route (trabeculotomy as Barkan suggested). Believing this to be true, I have performed a goniodialysis over one third of the area of the filtration angle in a case of congenital glaucoma in which an earlier iris-inclusion operation had failed to control the tension. The incision in the sciera extended over one third of the circumference of the globe, 2 mm. behind the corneoscleral incision. The iris repositor was inserted and the iris angle freed over this entire area. The conjunctiva was sutured with a continuous plain catgut suture with a knot at each end to insure tight closure. There was no reaction and the tension fell from 40 mm. Hg (Schi^tz), before operation, to 20 mm. Hg (Schij&z), after the operation. It has remained at 15 mm. Hg (Schi^tz) for the past three months. Of course, this is an absurdly short observation period but time and more cases will give the verdict. Granville, the Brazilian ophthalmologist, was able to separate a large area of the angle through a 4-mm. scierai incision, but I found it difficult to manage and also quite indefinite of execution. My next case will have a series of three 5-mm. incisions about 5 mm. apart and, through these, the areas of goniodialysis can all be connected quite simply. 136 East 64th Street (21).
REFERENCES
1. Barkan, Otto: Technique of goniotomy. Arch. Ophth., 19:217 (Feb.) 1938. 2. Granville, R. : Goniodialise. Revista Brasileira de oftal., S :. No. 4 (June) 1947.
M.D.
New York I am sure most eye surgeons have done this operation in part many times. The sclerectomy, the iris inclusion, the goniodialysis-—all these have been done by many surgeons. I am suggesting only that all of these be done at one time and also that the incision be made by the ab externo route as originally advocated by Ernst Fuchs. The operation is indicated for cases of chronic primary glaucoma either with or without acute exacerbations. It can also be used for the intractable borderline case of secondary glaucoma; that is, the case which is difficult to classify as true primary glaucoma and in which often more than one operation has been done with no permanent control of tension. This operation has been done at Mt. Sinai Hospital and at the Manhattan Eye, Ear, and Throat Hospital on a total of 50 eyes of 43 patients, 20 of whom were men and 23, women. The ages ranged from 43 to 79 years. The duration of the glaucoma varied from 1 year to at least 8 years before operation. The tension before operation with, miotics varied from 30 mm. Hg to 80 mm. Hg (Schätz). The visual fields varied from almost normal to telescopic, with various sizes of paracentral scotomas and enlarged blindspots extending almost to fixation. In no case was the field made worse or the visual acuity impaired by the operation. No patients developed lenticular opacities as a result of the operation. Visual acuity before operation ranged from 5/400 to 20/20. Some cases have been followed for three * Presented with moving pictures before the Eye Section of the New York Academy of Medicine December IS, 1947; the Los Angeles Society of Ophthalmology and Otolaryngology and the Los Angeles Ophthalmological Society, March 9, 1948; the International College of Surgeons, Rome, Italy, May 18, 1948.
years, and some for only one month. Three patients had had prior operations for relief of tension in eyes operated on by the method described in this paper. Of these three cases, one was a failure after 8 months with this operation. Any case which needed miotics after the operation more than 3 times a day to keep the tension normal was considered a failure. The one failure was in a Negro who had syphilis and whose right eye was lost following several unsuccessful operations to control the tension, including cyclodiathermy. The left eye had one operation for glaucoma with no reduction in tension, following which the operation I shall describe was performed by the surgeon in charge of the case. The tension was controlled for 8 months but then rose again and could not be controlled with miotics. OPERATIVE PROCEDURE
The operative procedure is simple and requires no great amount of surgical skill. It can be done under intravenous or local anesthesia. On the day of the operation, I use no miotics, in this way making it easier to withdraw the iris from the wound. In the cases done under local anesthesia, I use a lid block according to Van Lint's technique, two sutures through the upper lid, and one through the superior rectus. No suture is- needed for the lower lid. Two cc. of 2-percent novocain with adrenalin are injected retrobulbarly above and also some subconjunctivally above, ballooning up the conjunctiva between the limbus and the upper f ornix. The incision is made one centimeter above the limbus and rather wide, as one does for a trephination. Tenon's capsule is also opened rather wide. As one approaches to within 5 mm. of the limbus the incision goes through all the layers down to sciera. This
634
OPERATION FOR PRIMARY GLAUCOMA incision must also be made wide to avoid a small nitration area which would stand out like a knuckle. The dissection is carried down to the comeoscleral margin and here à partial splitting of the cornea, as for a trephination, may be performed, only it does not have to be carried into corneal tissue for any considerable distance. With a keratome or a knife, a S-mm. incision is made through sciera, 2 mm. above the comeoscleral margin. This line is scratched deeper and deeper until the uveal tissue is reached. If scierai bleeding is annoying, it is easily controlled by applying thrombin topical on an applicator. Then an iris repositor is inserted through the wound, hugging the under surface of the sciera. If the repositor does not enter easily, the incision with the keratome is repeated, going a bit deeper this time. The repositor is tried again and, as it enters, it is placed gently into the anterior chamber, entering through the iris angle. The repositor is swung gently from side to side opening the angle over as great an area as possible. With a Stevens scissors, two incisions are made 3 mm. apart at right angles to the original scierai incision going down to the comeoscleral margin. This piece of sciera is then picked up in toothed forceps and excised. The iris is then gently grasped with iris forceps near the pupillary margin and, with a gentle side to side swaying motion it is carefully, gently, and very slowly withdrawn through the scierai wound until the black pupillary portion is visible. One incision is made through half of the withdrawn iris to the pupil and this pillar allowed to recede. The other portion of the iris, which is still in the iris forceps, is allowed to lie on the sciera just as it falls. No attempt is made to straighten the iris or to place the pigmented layer of the iris against the sciera. The conjunctiva is now closed with a
635
i
Fig. 1 (Laval). The ab externo scierai incision ■is made 5 mm. long with the point of a keratome 2 mm. above the comeoscleral margin until the uveal tissue is reached.
Fig. 2 (Laval). An iris repositor is then placed in the wound, hugging the inner scierai surface, and gently continued forward until the repositor enters the anterior chamber. The repositor is then moved from side to side freeing the angle (gonio-dialysis).
636
JOSEPH LAVAL
Fig. 5 (Laval). A scierai tongue 2 by 5 mm. has been excised. This has been made extra large for purposes of demonstration but in actual practice does not exceed 1 by 3 mm.
Fig. 3 (Laval). Two incisions, 3 mm. apart, are then made in the sciera toward the corneoscleral margin for a distance of 1 mm.
cut quite short. One drop of 1-percent atropine is instilled and the eye bandaged. EXPERIMENTAL OBSERVATIONS
running silk suture; a knot is tied at both ends and the bites are taken rather closely together. In this way a tight closure is obtained and the ends of the suture can be
I was curious to know what structures my iris repositor traversed as it passed from the scierai incision, 2-mm. above the corneoscleral margin into the anterior chamber. Accordingly, I obtained a normal globe from the Eye-Bank, made the scierai incision, and
Fig. 4 (Laval). This piece of sciera is cut off with scissors giving a scierai opening measuring 3 by 1 mm.
Fig. 6 (Laval). The iris is withdrawn until the black pupillary seam is seen ; then it is cut half-way across.
OPERATION FOR PRIMARY GLAUCOMA inserted along the path of the repositor a piece of black silk suture material. The eye was fixed in Bouin's solution, sectioned, and stained with hematoxylin-eosin. Figure 9 shows the site of the scierai ab externo incision, (S) the suture material entering the sciera and passing through the ligamentum pectinatum ( L ) . In other words, the goniodialysis succeeds in cutting the trabeculas and freeing any anterior peripheral synechias, if present. A filtration tract is thereby formed connecting the anterior chamber through the angle with the outer surface of the globe. This tract is kept patent by the inclusion of iris tissue in the entire length of the channel. The length of the tract is cut in half by removing a 1-mm. piece of sciera, thus bringing the opening in the sciera near the filtration angle. Furthermore, by withdrawing and cutting the iris after the sclerectomy, the iris is cut directly at its root.
637
Fig. 8 (Laval). The conjunctival flap covers the iris.
regardless of the use of gonioscopy before the operation this procedure can still be carried out because the goniodialysis cuts through the filtration angle and any adhesions, if present; (4) by using the ab externo route for the scierai incision with the
Fig. 7 (Laval). The iris which is in the forceps is allowed to lie on the sciera as it falls ; no attempt is made to turn the pigment surface face up or down. SUMMARY
The operation is advocated because: (1) It is simple and requires no great amount of surgical skill; (2) a thick covering of the filtration area is obtained instead of a very thin covering as in a trephination; (3)
Fig. 9 (Laval). Section of eye fixed in Bouin's solution and stained with hematoxylin-eosin. (S) Site of incision. (L) Ligamentum pectinatum. (M) Scierai meshwork. (Sc) Schlemm's canal.
638
JOSEPH LAVAL
keratome, the danger of injury to the lens is removed and one is also assured of making an unbeveled incision directly over the filtration angle; (5) the size of the scierai excision, which can be varied to suit the individual case, will be determined by the amount of tension with and without drops. ADDENDUM
It is of interest to note here that an article recently appearing in the Brazilian ophthalmic literature reports an operation of simple goniodialysis executed in a manner somewhat similar to the one I have described, but without sclerectomy and without iris inclusion. The author, R. Granville,2 performed the goniodialysis on 4 patients in 2 of whom the tension was satisfactorily controlled. To accept the concept that a goniodialysis alone will reduce intraocular pressure one would have to suppose that enough of the aqueous in the anterior chamber cannot get into Schlemm's canal because the fibrillas of the meshwork of the filtration angle are so thickened and closely woven to each other as to block the aqueous at (L) in Figure 9. The remainder of the fibrillas of the meshwork (the scierai meshwork—M) would have to be normal in thickness to permit the aqueous to reach Schlemm's canal (Sc), which must also be considered patent and functioning. The goniodialysis makes an opening in the thickened arc of fibers at (L) and permits the aqueous to get to ( M ) where the spaces in the meshwork are sufficient in number and size for the aqueous to get into Schlemm's canal (Sc). According to Barkan, 1 his technique of goniotomy for congenital glaucoma "makes the incision only in the meshwork of the filtration angle" and goes through the same thickened arc of fibers at ( L ) in Figure 9. The direction, of the incision in Barkan's
goniotomy is from the anterior chamber outward through the thickened area into the supposedly normal fibers of the scierai meshwork. Schlemm's canal is not incised and, again, one must suppose that Schlemm's canal is normal and that the aqueous has been kept from Schlemm's canal only by the thickened area of fibers of the meshwork at the filtration angle. Accordingly Barkan, in his goniotomy with the aid of a surgical contact glass, is accomplishing the same thing that I accomplish with the goniodialysis by the ab externo route (trabeculotomy as Barkan suggested). Believing this to be true, I have performed a goniodialysis over one third of the area of the filtration angle in a case of congenital glaucoma in which an earlier iris-inclusion operation had failed to control the tension. The incision in the sciera extended over one third of the circumference of the globe, 2 mm. behind the corneoscleral incision. The iris repositor was inserted and the iris angle freed over this entire area. The conjunctiva was sutured with a continuous plain catgut suture with a knot at each end to insure tight closure. There was no reaction and the tension fell from 40 mm. Hg (Schi^tz), before operation, to 20 mm. Hg (Schij&z), after the operation. It has remained at 15 mm. Hg (Schi^tz) for the past three months. Of course, this is an absurdly short observation period but time and more cases will give the verdict. Granville, the Brazilian ophthalmologist, was able to separate a large area of the angle through a 4-mm. scierai incision, but I found it difficult to manage and also quite indefinite of execution. My next case will have a series of three 5-mm. incisions about 5 mm. apart and, through these, the areas of goniodialysis can all be connected quite simply. 136 East 64th Street (21).
REFERENCES
1. Barkan, Otto: Technique of goniotomy. Arch. Ophth., 19:217 (Feb.) 1938. 2. Granville, R. : Goniodialise. Revista Brasileira de oftal., S :. No. 4 (June) 1947.