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Some Essentials of Glioma of the Retina with a Case Report
LIMITATIONS OF SLITLAMP MICROSCOPY
cornea which has been removed from the eye possesses a double refraction, which is designated as genuine and which is an indication of its crystallin lattice structure. Without such crystal line structure no genuine double re fraction could be present in such a cornea. This also applies to the lens. Suitable investigation to decide these questions is indispensable. In addition it does not seem out of the question to obtain certain differences in the re sulting Roentgen diffraction picture in various corneas and under varying general conditions. In this way one may arrive at certain differential diagnostic criteria, which are typical of many local and general pathologic states. If these observations are crowned with success, a new and grateful prospective would be revealed, and the microscopy of the living eye for the investigation of the intraocular molecular structures would be further advanced.
171
Whether it will be possible to take advantage of the property of the reflec tion of the Roentgen rays in the crystalline lattices' and individual layers of the living ocular media and to fix photographically, and by compari son in a differential diagnostic sense, to properly evaluate the various inter ference pictures of the reflected wave surface obtained under healthy and dis eased conditions, the future alone must disclose. In concluding this discussion of a greater extension of the use of the slitlamp, may the science of ophthal mology, after successful experiments at a not too distant date, enjoy to the utmost the fruits of these new and ex tremely promising methods of exami nation. I wish to embrace this opportunity of expressing my thanks to Dr. Clar ence King of Cincinnati for his invalu able assistance in preparing this article for publication in English.
REFERENCES.
1. Die Mikroskopie des lebenden Auges Band 1, Berlin, J. Springer, 1920. 2. American Journal of Ophthalmology, August 1925, p. 666. 3. Die Bedeutung des Gitterstruktur in den lebenden Augenmedien fiir die Theorie der subjektiven Farbenerscheinungen. E. Bircher, Bern (Schweiz) 1922. 4. Die ultra und polarizationsmikroskopische Erforschung des lebenden Auges an der Gullstrandschen Spaltlampe. E. Bircher, Bern (Schweiz) 1921. 5. For further particulars on this subject see my book Diathermie und Lichtbehandlung des Auges Leipzig, J. C. Vogel, 1919. 6. Klinische Monatsblatter fiir Augenheilkunde, May-June, 1923. 7. Die normale Histologie des lebenden Glaskorpers Bilder. Archiv fiir Ophthalmologie 96. 1918. 8. Die Mikroskopie des lebenden Auges. Band 2. Berlin, J. Springer, 1922. 9. Archiv fiir Ophthalmologie, 1924, vol. CIV, p. 113. 10. Quoted by L. Graetz, Die Elektrizitat. 17 Auflage, 1914.
SOME ESSENTIALS OF GLIOMA OF T H E RETINA W I T H A CASE REPORT. C. W .
RUTHERFORD,
M.D.
INDIANAPOLIS, INDIANA.
An eyeball removed before there was extraocular extension or metatasis contained a growth presenting the different characteristics of socalled glioma of the retina. The whitish reflex from one pupil was noticed when three and one-half months old.
In the study 'of malignant intra ocular tumors, one must consider him self fortunate when he obtains a speci men that has attained the exact stage which shows all of the essential char acteristics belonging to a particular type. In the present case it was pos sible to study the essential details of glioma of the retina in a single low
power field. There was no evidence of extraocular extension or metastasis. The enucleated globe was sent me by Dr. E. E. Holland of Richmond, Indiana, who supplied the following history. "D. M. C , age four months, weight fifteen pounds, well nourished. The ascertainable family and past per sonal history was negative. When
172
C. W. RUTHERFORD
the child was three and a half months old the parents noticed a peculiar ap pearance in the right pupil. The gen-eral examination was negative; no pathology was found except in the right eye, which was blind. The eyeballs were of equal promi nence, and their movements in the or bits were normal. There was no con gestion in either eye. The tension was the same in both eyes. The irides were clear and of the same color and pat tern, and both lenses were transparent. The media and fundus of the left eye were clear and normal. The pupils were unequal;. the right was larger, sluggish in reacting to light, and of limited movement. The left pupil was normal in size and reaction. The right pupil showed a whitish reflex, while the left had the usual red reflex. Focal illumination of the right pupil showed, behind the lens, a vellowish rounded mass, upon the anterior surface of which were seen three blood vessels and their branches. The mass seemed to occupy most of the vitreous cham ber; it was motionless and had a solid appearance. The eye was enucleated promptly. The patient left the hospital on the fourth day, and made an uneventful postoperative recovery. Frequent ob servations have been made over a period of nine months following the operation, and no evidence of recur rence, or of other manifestations of ill health have been noted. The specimen, received in formalin solution, measured 2 0 x 1 9 x 1 8 mm., and weighed 3.7 gms. Orientation, right eyeball. There was a bulging of the lower part, and misplacement of the insertions of the muscles; other wise the surface showed no pathology. The cornea was horizontally oval, 11x10 mm. The anterior chamber was shallow. The pupil was round, 5.5 mm. in diameter. The lens was opaque, as occurs in fixation, and the anterior Y figure was conspicuous. Nothing was visible behind the lens. By transillumination a mass was lo cated in the lower part of the globe. MACROSCOPIC EXAMINATION.
The globe was divided obliquely in the vertical plane. A quantity of watery fluid escaped. The photograph1
of the divided globe was made before the specimen was hardened in alcohol. A solid mass in each half of the eye swung free from detached retina. The sclera showed no changes except a slight thinning below. The cornea was thickened. In the right half the lens protrudes into the pupil, due to an acci dent in manipulation; the true position of the lens is seen in the left half. The cut surfaces of the cornea show certain white spots which were not found in the sections; these were likely lime particles washed from the tumor (where they are seen also). The iris was crowded forward. The ciliary body was small, but regular in the pars plicata, and normal in the pars plana where the meridional striations were easily seen. No defects were found in the choroid, except a bleached area in the lower posterior part. The retina was attached only at the papilla and the ora serrata, and was the whole support of the tumor. The stump of the optic nerve was enlarged. The tumor measured 12 mm. anteroposteriorly, and 8.5 mm. in diameter. It was of a grayish yellow color, and both the natural and cut surfaces ap peared to be cheesy or granular. The natural surface suggested a capsule, which was not identified microsco pically. Differentiation when the retina is de tached: A tumor of the retina is merged with the detached retina, while the latter merely overlies any growth arising from the choroid. The exudate from metastatic choroiditis fills the vitreous chamber; when fixed in formalin it becomes translucent and takes on a delicate green color; the mass of the exudate shrinks in alcohol hardening. Subretinal fluid does not form a tumor. Embryonal connective tissue in the vitreous does not so com pletely detach the retina if at all, and would lie inside the retinal sac, as would a cysticercus. MICROSCOPIC.
The halves were hardened in alcohol and serial sections, 6 mu. thick, were cut. Examination by low power re vealed the nature of the growth, and exhibited the various processes which characterize gliomas of the retina. Tubules, occurring in groups*, were the
AMERICAN JOURNAL OF OPHTHALMOLOGY
^Hi"o>:^
* ™"°»- WPKIw^M: i.
Vol. 9. Plate 3
rawwsrs
173
GUOMA OF THE RETINA
dominant figures demonstrated. Each tubule constituted a blood channel with out endothelium. Surrounding the blood column the tumor cells prolifer ate abundantly, forming a cell mantle around the tubule. The rapid proliferative process crowds the older cells from the blood stream, until they are no longer sufficiently nourished. There is first a loss of the scanty in tercellular substance, so that the cells fall apart. Then the cells lose_ their cytoplasm, and later the nuclei dis integrate. These changes are marked by a gradual loss of staining power. As dissolution progresses, areas of necrosis are formed, and these stain faintly if at all. As necrosis proceeds to liquefaction, calcareous deposits are formed in these areas. If a cross sec tion of a tubule is examined under high power 5 , it is found to be formed of spoke like cells containing little cytoplasm, and very large oval or ob long nuclei. The figure is called a rosette, and has not been described in connection with any other tissue ex cept that found in gliomata of the retina, and in the retinas of some un developed eyes. The tips of the cells within the lumen unite to form a base ment membrane (Verhoeff, R. L. O. H. Reports, Vol. XV, Part iv.) The tubular character may exist in dependently of rosettes. A specimen from Prof. E. Fuchs' clinic shows tubules and other glioma characteris tics, but no rosettes; and was described (American Lecture Tour Notes, 1922) as having had its origin from the inner nuclear layer of the retina (See also A. Fuchs, Atlas Histopathology of the Eye, 1924, Plate 41, Fig. 2, and Dis cussion). Knapp (Intraocular Tumors, English Ed., 1869) suggests that the nearer the origin is to the optic nerve, the more abundant are the ("Ears of maize") rosette formations. That ob servation holds true for this tumor, as its origin was located 1.5 to 2 mm. be low the margin of the papilla. This fragment 7 had the appearance as tho the main tumor mass had been torn from it, and a corresponding defect in the outer layer of the tumor was found in another section. This location suggests a probable
origin from the rod and cone layer, and some investigators assert that only those tumors arising from this layer will show rosettes. Parsons (Patho logy of the Eye) doubts the influence of the layer of origin on this peculiar figure. Underlying the site of origin the choroid is greatly thickened by edema. Pigment is absent in this area. As the choroid is traced forwards pro gressively better preserved fragments of choroidal and retinal pigment cells are found, and anteriorly the pigment is in a fairly normal condition. There is no true stroma in the tumor. An occasional trabecular band 7 is seen, probably the cord like remnant of a blood vessel. Some sections show parts of retinal vessels having endothelial linings. It is surprising how ab ruptly the retina may be invaded by the tumor growth. A section8 dis plays the various retinal layers clearly, and almost immediately all detail is lost in a mass of tumor cells. METASTASIS.
In part, the mode of transmission de pends on the loss of intracellular sub stance and the liberation of individual cells. These tumor cells resemble the cells in the nuclear layers of the retina. If the free cell possesses vitality and is deposited where it can be nourished, it may initiate a new proliferation. Thus, other ocular structures may become in volved secondarily, or the cells may migrate to distant organs and tissues of the body. This process accounts for metastatic growths at distances from the parent mass. The lymph stream is the principal carrier, altho the blood stream may not be unimpor tant. In this specimen small clumps of tumor-cells were found lying on the choroid, and on other free surfaces in side the eye. No sections were cut to show the venae vorticosae or the emissaria, and no statement can be made as to their tumor cell content. No such cells were found in the angle of the anterior chamber or in the canal of Schlemm. The pigment layer of the iris was in part adherent to the anterior lens cap sule. This may have resulted from a low grade inflammation, or from pres sure. Otherwise the iris looked nor-
174
C. W. RUTHERFORD
mal; so also the ciliary body and Descemet's membrane. While the brain may be invaded by direct exten sion along the optic nerve, detached cells may be carried there along the spaces of the nerve sheaths. No clumps of tumor cells were found in the nerve,
or in its sheaths in this specimen. In the central canal containing the central vessels, many isolated cells were found; these looked like lymphocytes. At times it is difficult to distinguish free tumor cells from lymphocytes. Penway Building.
T H E OPERATIONS FOR GLAUCOMA. SAMUEL A. DURR,
M.D.
SAN DIEGO, CALIFORNIA.
The better known operations for glaucoma are compared with reference to their relative value in different types of cases. The conclusions reached are based on a survey of the literature regarding the different procedures. Thesis submitted for the degree of M. S. in Ophthalmology at the University of Pennsylvania.
The multiplicity of operations de signed for the relief of glaucoma, would indicate either that the ideal op eration has not yet been devised, or that in so protean a disease, no one operation is applicable to all cases. In this paper, an attempt is made to com pare the merits of the better known op erative procedures, and to determine for certain types of cases, which mode of surgical intervention promises the best results. Iridectomy, as first practiced by von Graefe, has received comparatively lit tle attention in recent literature, prob ably because it is so well established that comment seems superfluous. No author takes exception to iridectomy, in acute congestive glaucoma, altho other procedures have been suggested. However, it maintains its position as the orthodox treatment. Woodruff recommends using it not only here, but in chronic glaucoma as well, reserving the more modern operations for cases in which iridectomy fails. Parker also mentions iridectomy as the operation of choice, and Abadie concurs in this view. Axenfeld believes that iridec tomy and cyclodialysis are less danger ous than the various sclerectomies, and does one or the other, hoping that a more radical maneuvre will be un necessary. Barkan does an iridectomy in acute glaucoma, as well as in the chronic form, where the field of vision is fairly good, and central vision well preserved. Weeks upholds iridectomy in all early cases, where advanced sclerosis has not yet occurred, and as an alternate operation in glaucoma fol lowing cataract extraction, de Schwein-
itz uses iridectomy in acute cases, in glaucoma due to swelling of the lens, and in iritis following other glaucoma operations. Bourgeois contends as does Elliot, that a filtering scar is the chief factor in reducing tension, no matter what operation is done. The trephine operation of Elliot has inspired more discussion than any of the others, and it is used practically to the exclusion of all others by some men, especially in the British empire. Gifford feels that the results from trephining and iridotasis are about the same, altho the former may be safer. Barkan employs a trephine in glau coma simplex, and in chronic glaucoma with markedly reduced fields. Odoneal reports a case in which a trephine was done on one eye, and an iridotasis on the other. The latter remained quiet, while the tension of the trephined eye rose, after an initial fall. MacCallan reported a series of 911 trephines with one late infection. He used a 2 mm. trephine, excising only one-half of the disc. Clegg reported one series of 250 cases, operated by the same technic. There was one case of iridocyclitis, fol lowing loss of the disc in the anterior chamber and one of panophthalmitis. The results were satisfactory in 80% of the cases, against 62% or less with iridectomy. He does an iridectomy only in old patients, with acute or subacute glaucoma. In another series of 259 trephined eyes, the results were as follows: Acute glaucoma; improved 70%, stationary 25% and worse 5%. In the subacute cases the figures were 47, 42 and 11%, while in simple glau coma they were poorest, 32, 48 and
cornea which has been removed from the eye possesses a double refraction, which is designated as genuine and which is an indication of its crystallin lattice structure. Without such crystal line structure no genuine double re fraction could be present in such a cornea. This also applies to the lens. Suitable investigation to decide these questions is indispensable. In addition it does not seem out of the question to obtain certain differences in the re sulting Roentgen diffraction picture in various corneas and under varying general conditions. In this way one may arrive at certain differential diagnostic criteria, which are typical of many local and general pathologic states. If these observations are crowned with success, a new and grateful prospective would be revealed, and the microscopy of the living eye for the investigation of the intraocular molecular structures would be further advanced.
171
Whether it will be possible to take advantage of the property of the reflec tion of the Roentgen rays in the crystalline lattices' and individual layers of the living ocular media and to fix photographically, and by compari son in a differential diagnostic sense, to properly evaluate the various inter ference pictures of the reflected wave surface obtained under healthy and dis eased conditions, the future alone must disclose. In concluding this discussion of a greater extension of the use of the slitlamp, may the science of ophthal mology, after successful experiments at a not too distant date, enjoy to the utmost the fruits of these new and ex tremely promising methods of exami nation. I wish to embrace this opportunity of expressing my thanks to Dr. Clar ence King of Cincinnati for his invalu able assistance in preparing this article for publication in English.
REFERENCES.
1. Die Mikroskopie des lebenden Auges Band 1, Berlin, J. Springer, 1920. 2. American Journal of Ophthalmology, August 1925, p. 666. 3. Die Bedeutung des Gitterstruktur in den lebenden Augenmedien fiir die Theorie der subjektiven Farbenerscheinungen. E. Bircher, Bern (Schweiz) 1922. 4. Die ultra und polarizationsmikroskopische Erforschung des lebenden Auges an der Gullstrandschen Spaltlampe. E. Bircher, Bern (Schweiz) 1921. 5. For further particulars on this subject see my book Diathermie und Lichtbehandlung des Auges Leipzig, J. C. Vogel, 1919. 6. Klinische Monatsblatter fiir Augenheilkunde, May-June, 1923. 7. Die normale Histologie des lebenden Glaskorpers Bilder. Archiv fiir Ophthalmologie 96. 1918. 8. Die Mikroskopie des lebenden Auges. Band 2. Berlin, J. Springer, 1922. 9. Archiv fiir Ophthalmologie, 1924, vol. CIV, p. 113. 10. Quoted by L. Graetz, Die Elektrizitat. 17 Auflage, 1914.
SOME ESSENTIALS OF GLIOMA OF T H E RETINA W I T H A CASE REPORT. C. W .
RUTHERFORD,
M.D.
INDIANAPOLIS, INDIANA.
An eyeball removed before there was extraocular extension or metatasis contained a growth presenting the different characteristics of socalled glioma of the retina. The whitish reflex from one pupil was noticed when three and one-half months old.
In the study 'of malignant intra ocular tumors, one must consider him self fortunate when he obtains a speci men that has attained the exact stage which shows all of the essential char acteristics belonging to a particular type. In the present case it was pos sible to study the essential details of glioma of the retina in a single low
power field. There was no evidence of extraocular extension or metastasis. The enucleated globe was sent me by Dr. E. E. Holland of Richmond, Indiana, who supplied the following history. "D. M. C , age four months, weight fifteen pounds, well nourished. The ascertainable family and past per sonal history was negative. When
172
C. W. RUTHERFORD
the child was three and a half months old the parents noticed a peculiar ap pearance in the right pupil. The gen-eral examination was negative; no pathology was found except in the right eye, which was blind. The eyeballs were of equal promi nence, and their movements in the or bits were normal. There was no con gestion in either eye. The tension was the same in both eyes. The irides were clear and of the same color and pat tern, and both lenses were transparent. The media and fundus of the left eye were clear and normal. The pupils were unequal;. the right was larger, sluggish in reacting to light, and of limited movement. The left pupil was normal in size and reaction. The right pupil showed a whitish reflex, while the left had the usual red reflex. Focal illumination of the right pupil showed, behind the lens, a vellowish rounded mass, upon the anterior surface of which were seen three blood vessels and their branches. The mass seemed to occupy most of the vitreous cham ber; it was motionless and had a solid appearance. The eye was enucleated promptly. The patient left the hospital on the fourth day, and made an uneventful postoperative recovery. Frequent ob servations have been made over a period of nine months following the operation, and no evidence of recur rence, or of other manifestations of ill health have been noted. The specimen, received in formalin solution, measured 2 0 x 1 9 x 1 8 mm., and weighed 3.7 gms. Orientation, right eyeball. There was a bulging of the lower part, and misplacement of the insertions of the muscles; other wise the surface showed no pathology. The cornea was horizontally oval, 11x10 mm. The anterior chamber was shallow. The pupil was round, 5.5 mm. in diameter. The lens was opaque, as occurs in fixation, and the anterior Y figure was conspicuous. Nothing was visible behind the lens. By transillumination a mass was lo cated in the lower part of the globe. MACROSCOPIC EXAMINATION.
The globe was divided obliquely in the vertical plane. A quantity of watery fluid escaped. The photograph1
of the divided globe was made before the specimen was hardened in alcohol. A solid mass in each half of the eye swung free from detached retina. The sclera showed no changes except a slight thinning below. The cornea was thickened. In the right half the lens protrudes into the pupil, due to an acci dent in manipulation; the true position of the lens is seen in the left half. The cut surfaces of the cornea show certain white spots which were not found in the sections; these were likely lime particles washed from the tumor (where they are seen also). The iris was crowded forward. The ciliary body was small, but regular in the pars plicata, and normal in the pars plana where the meridional striations were easily seen. No defects were found in the choroid, except a bleached area in the lower posterior part. The retina was attached only at the papilla and the ora serrata, and was the whole support of the tumor. The stump of the optic nerve was enlarged. The tumor measured 12 mm. anteroposteriorly, and 8.5 mm. in diameter. It was of a grayish yellow color, and both the natural and cut surfaces ap peared to be cheesy or granular. The natural surface suggested a capsule, which was not identified microsco pically. Differentiation when the retina is de tached: A tumor of the retina is merged with the detached retina, while the latter merely overlies any growth arising from the choroid. The exudate from metastatic choroiditis fills the vitreous chamber; when fixed in formalin it becomes translucent and takes on a delicate green color; the mass of the exudate shrinks in alcohol hardening. Subretinal fluid does not form a tumor. Embryonal connective tissue in the vitreous does not so com pletely detach the retina if at all, and would lie inside the retinal sac, as would a cysticercus. MICROSCOPIC.
The halves were hardened in alcohol and serial sections, 6 mu. thick, were cut. Examination by low power re vealed the nature of the growth, and exhibited the various processes which characterize gliomas of the retina. Tubules, occurring in groups*, were the
AMERICAN JOURNAL OF OPHTHALMOLOGY
^Hi"o>:^
* ™"°»- WPKIw^M: i.
Vol. 9. Plate 3
rawwsrs
173
GUOMA OF THE RETINA
dominant figures demonstrated. Each tubule constituted a blood channel with out endothelium. Surrounding the blood column the tumor cells prolifer ate abundantly, forming a cell mantle around the tubule. The rapid proliferative process crowds the older cells from the blood stream, until they are no longer sufficiently nourished. There is first a loss of the scanty in tercellular substance, so that the cells fall apart. Then the cells lose_ their cytoplasm, and later the nuclei dis integrate. These changes are marked by a gradual loss of staining power. As dissolution progresses, areas of necrosis are formed, and these stain faintly if at all. As necrosis proceeds to liquefaction, calcareous deposits are formed in these areas. If a cross sec tion of a tubule is examined under high power 5 , it is found to be formed of spoke like cells containing little cytoplasm, and very large oval or ob long nuclei. The figure is called a rosette, and has not been described in connection with any other tissue ex cept that found in gliomata of the retina, and in the retinas of some un developed eyes. The tips of the cells within the lumen unite to form a base ment membrane (Verhoeff, R. L. O. H. Reports, Vol. XV, Part iv.) The tubular character may exist in dependently of rosettes. A specimen from Prof. E. Fuchs' clinic shows tubules and other glioma characteris tics, but no rosettes; and was described (American Lecture Tour Notes, 1922) as having had its origin from the inner nuclear layer of the retina (See also A. Fuchs, Atlas Histopathology of the Eye, 1924, Plate 41, Fig. 2, and Dis cussion). Knapp (Intraocular Tumors, English Ed., 1869) suggests that the nearer the origin is to the optic nerve, the more abundant are the ("Ears of maize") rosette formations. That ob servation holds true for this tumor, as its origin was located 1.5 to 2 mm. be low the margin of the papilla. This fragment 7 had the appearance as tho the main tumor mass had been torn from it, and a corresponding defect in the outer layer of the tumor was found in another section. This location suggests a probable
origin from the rod and cone layer, and some investigators assert that only those tumors arising from this layer will show rosettes. Parsons (Patho logy of the Eye) doubts the influence of the layer of origin on this peculiar figure. Underlying the site of origin the choroid is greatly thickened by edema. Pigment is absent in this area. As the choroid is traced forwards pro gressively better preserved fragments of choroidal and retinal pigment cells are found, and anteriorly the pigment is in a fairly normal condition. There is no true stroma in the tumor. An occasional trabecular band 7 is seen, probably the cord like remnant of a blood vessel. Some sections show parts of retinal vessels having endothelial linings. It is surprising how ab ruptly the retina may be invaded by the tumor growth. A section8 dis plays the various retinal layers clearly, and almost immediately all detail is lost in a mass of tumor cells. METASTASIS.
In part, the mode of transmission de pends on the loss of intracellular sub stance and the liberation of individual cells. These tumor cells resemble the cells in the nuclear layers of the retina. If the free cell possesses vitality and is deposited where it can be nourished, it may initiate a new proliferation. Thus, other ocular structures may become in volved secondarily, or the cells may migrate to distant organs and tissues of the body. This process accounts for metastatic growths at distances from the parent mass. The lymph stream is the principal carrier, altho the blood stream may not be unimpor tant. In this specimen small clumps of tumor-cells were found lying on the choroid, and on other free surfaces in side the eye. No sections were cut to show the venae vorticosae or the emissaria, and no statement can be made as to their tumor cell content. No such cells were found in the angle of the anterior chamber or in the canal of Schlemm. The pigment layer of the iris was in part adherent to the anterior lens cap sule. This may have resulted from a low grade inflammation, or from pres sure. Otherwise the iris looked nor-
174
C. W. RUTHERFORD
mal; so also the ciliary body and Descemet's membrane. While the brain may be invaded by direct exten sion along the optic nerve, detached cells may be carried there along the spaces of the nerve sheaths. No clumps of tumor cells were found in the nerve,
or in its sheaths in this specimen. In the central canal containing the central vessels, many isolated cells were found; these looked like lymphocytes. At times it is difficult to distinguish free tumor cells from lymphocytes. Penway Building.
T H E OPERATIONS FOR GLAUCOMA. SAMUEL A. DURR,
M.D.
SAN DIEGO, CALIFORNIA.
The better known operations for glaucoma are compared with reference to their relative value in different types of cases. The conclusions reached are based on a survey of the literature regarding the different procedures. Thesis submitted for the degree of M. S. in Ophthalmology at the University of Pennsylvania.
The multiplicity of operations de signed for the relief of glaucoma, would indicate either that the ideal op eration has not yet been devised, or that in so protean a disease, no one operation is applicable to all cases. In this paper, an attempt is made to com pare the merits of the better known op erative procedures, and to determine for certain types of cases, which mode of surgical intervention promises the best results. Iridectomy, as first practiced by von Graefe, has received comparatively lit tle attention in recent literature, prob ably because it is so well established that comment seems superfluous. No author takes exception to iridectomy, in acute congestive glaucoma, altho other procedures have been suggested. However, it maintains its position as the orthodox treatment. Woodruff recommends using it not only here, but in chronic glaucoma as well, reserving the more modern operations for cases in which iridectomy fails. Parker also mentions iridectomy as the operation of choice, and Abadie concurs in this view. Axenfeld believes that iridec tomy and cyclodialysis are less danger ous than the various sclerectomies, and does one or the other, hoping that a more radical maneuvre will be un necessary. Barkan does an iridectomy in acute glaucoma, as well as in the chronic form, where the field of vision is fairly good, and central vision well preserved. Weeks upholds iridectomy in all early cases, where advanced sclerosis has not yet occurred, and as an alternate operation in glaucoma fol lowing cataract extraction, de Schwein-
itz uses iridectomy in acute cases, in glaucoma due to swelling of the lens, and in iritis following other glaucoma operations. Bourgeois contends as does Elliot, that a filtering scar is the chief factor in reducing tension, no matter what operation is done. The trephine operation of Elliot has inspired more discussion than any of the others, and it is used practically to the exclusion of all others by some men, especially in the British empire. Gifford feels that the results from trephining and iridotasis are about the same, altho the former may be safer. Barkan employs a trephine in glau coma simplex, and in chronic glaucoma with markedly reduced fields. Odoneal reports a case in which a trephine was done on one eye, and an iridotasis on the other. The latter remained quiet, while the tension of the trephined eye rose, after an initial fall. MacCallan reported a series of 911 trephines with one late infection. He used a 2 mm. trephine, excising only one-half of the disc. Clegg reported one series of 250 cases, operated by the same technic. There was one case of iridocyclitis, fol lowing loss of the disc in the anterior chamber and one of panophthalmitis. The results were satisfactory in 80% of the cases, against 62% or less with iridectomy. He does an iridectomy only in old patients, with acute or subacute glaucoma. In another series of 259 trephined eyes, the results were as follows: Acute glaucoma; improved 70%, stationary 25% and worse 5%. In the subacute cases the figures were 47, 42 and 11%, while in simple glau coma they were poorest, 32, 48 and