ON THE TECHNIQUE IN EXTRALIMBAL TANGENTIAL PUNCH FORCEPS SCLERECTOMY

FOR CHRONIC GLAUCOMA HY

S. HOLTH OSLO (NORWAY)

(FROM AN ADDHESS GIVEN AT THE 6TH SCANDINAVIAN OPHTHALMOLOGICAL CONGRESS IK COPENHAGEN, J U N E 29, 1925)

I do not operate for chronic glaucoma where, by personal examination several times a year, I find that the tension con- limes normal with miotics, and where the visual field and the vision have not been impaired. I have patients having been under my personal control for 11 years who have not been operated upon, and .I know of cases where the miotic treatment has been successful for more than 20 years.

Time must show whether Seidel’s suggestion of making an ordinary complete iridectomy (without the addition of sclerec- tomy) can bring about a normal tension without the continua- tion of miotics in such cases. l am inclined to suggest to try a small basal iridectomy as in fig. 2, 10 or 12, but of course without sclerectomy; if later on there should appear an in- crease of tension, m. sphincter is uninjured and miotics can act as well as before.

I will make some supplementary remarks to my address made at our 5th congress in Stockholm in 1921 about the operation I generally use for uncomplicated chronic glaucoma, viz. the eslralimhal tangential punch forceps sclerectomy.

A s to the nomenclature, the word ntungentialx is certainly characteristic of the technique, but I think ))ertraZiznbul(c is more important.

The blades of the eye speciilum must be short parallel to

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the palpebral fissiire in order to keep this fissure well opem vertically during the operation. Two blepharostates from Mai- son Luer, 104 Boulevard St-Germain, Paris VIe. are very good, \ iz. Panas’s modification of the blepharostate of Mellinger ( h e r ’ s catalogue fig. 222) and that of dr. Pley (ibidem. fig. 224 bis).

The extralimbal incision. In my illustration of 1921 (see this article: fig. 2, 10) can be seen that the keratome incision is obliqire, the temporal end being 1.5 mm, and the nasal end being 2.5 mm from the limbus. Professor Hagen has lately pointed out to me that this obliquity of my keratome incision i s not mentioned in the letter-press of my paper of 1921, a fact which I much regret. Mr. Hagen agrees with me that th(- oblique keratome incision greatly facilitates the introduction of the 1 mm punch forceps. For :I long time I have made the Lrratome incision, which must never be any longer than 4 inm I the ciliary body must not be damaged), more oblique, always 0.5 nini from the limbus temporally, and nasally with an oidinary depth of the anterior chamber from 2 to 2.5 nim from the limbus, with a shallower chamber only 1.5 mm; when the anterior chamber has nearly disappeared I prefer iriden- cleisis cum iridotomia meridionali.

The tangential sclerecfomy ciit can easily be made 1 X 3 mm in one cut with my improved 1 mm broad punch forceps of 1023 (fig. 1 j with the upper surface of the lower blade curved lcngthways and with marks 4 mm from the end of both blades; these marks may be superfluous, for when the lower blade is completely introduced into the chamber the excision automat- ically becomes 1 y 3 mm.

I always combine the operation with iridectomy, a complete one when thcre is at the same time a quickly progressive ciltaract, but as (I rille a small and basal one (fig. 2, 10 and 12). The basal iridectomy ought to be very peripheric and minimal.’)

l) I demonstrated a man of fifty from Chicago on whom I had made my operation on each eye 5 and 6 weeks previously; the minimal irideclomy opening in the right eye was visible as in fig. 2, 12, but in the left eye the opening was completely hidden behind the sclera.

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I. l o obtain this a 1 per cent solution 01 eseriii is dropped on the eye an hour before the aperation. Cocain is not used for the anaesthesia but holocain 1 per cent, or diocain, beginning with 0.3 per cent and continuing with a 1 per cent solution. '1'0 be quite sure of a complete anaesthesia of the iris, I make, after Duverger (Morax does so in all intraocular operations), a retrobulbar injection of novocain (generally only 2 ccm of a 2 per cent solution); due to the instillation of eserin before lhe operation, the minimal contents of suprarenin in the novo- cain tabloids ,do not cause any adrenalin mydriasis. The punc- fion for the retrobulbar novocain injection is not made through the conjunctiva but through the skin of the lid near the outer lower corner of the orbital margin. To prevent posterior syne- chiae I apply a drop of a 0.2 per cent scopolamin solution (rarely 1 per cent atropin)' the next day and continue with this daily for about a week.

Fig. 1. Holth's improved 1 mm.broad punch forceps 1923 (The Brit. J. of Ophth. 1924, p. 269) for extralimbal tangential punch forceps sclerectomy in chronic glaucoma; the upper surface of the lower blade is made concave lengthways and both blades have on the upper side a black mark 4 mm from the end.

Fabricants: John Weiss & Son, Ltd., 287, Oxford Street, London, W. 1.

I attach great importance to the size, shape, and position 0 1 the conjunctiaal flap in relation to the sclerectomy opening for the way the aqueous takes later on in the subconjunctiva. I n fig. 2, 1-12, are shown different forms of conjunctival flaps in sclerectoniies for glaucoma. I do nbt give the figure showing the technique of Lagrange 1906 with the large incision by a Graefe cataract knife and sclerectomy by curved scissors, bc- cause he has abandoned this proceeding long ago; I saw him

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perform it in Oxford 1910. Years ago he has adopted the punch forceps, because, as he says himself, it cuts better; it allows of course of a much shorter incision with the Graefe knife. Lagrange's present operation is shown in fig. 2, 3 and 4 and is, as will be seen, identical with one of the two procee- dings I published at the Congress of the SociCtC FranGaise d'Ophthalmologie 1909 (Bulletins et MCmoires 1909, p. 332, fig. 6; and this article fig. 2. 1).

8 1. H o l t h

2. (3 Holth

Ploi 1900 P h i 1909

5 . 8 E l l i o t 6 . 0 H o l t h

1909 1910 (Decembei') (0xFoi.d)

f+-k '9. De LietoVollaro

1922

Dupuy Du temps Chr. FBentzen

1913

c 10. 0 Holth

1921

rL3 3. 0 Lagrange 4.

19 14 - 1'125 La pro nge.

1914- 1925

7 Elliot 8. Elliot I913 19 I8

11. E.Lindgren 12. Holth 1921 19eJ

(rned EAsk *I)

sutur)

1921

Fig. 2, 1-12. Several conjunctival flaps in sclerectomies for glaucoma.

After the incisions for the different conjunctival flaps a lizie indicating a deep scar appears; this scar line forms the upper

5

limit of the oedematous conjunctival cushion, and prevents fur- 1 her passage this way into the subconjunctiva. For this reason the ends of the incision ought not to be near the limbus as in Holth’s conjunctival flap in the short incision with the Graefe knife of 1909 (fig. 2, 1) or in the present operation of Lagrange (fig. 2, 3 and 4). The ends of the incision must by no means reach quite up to the limbus as in Elliot’s flap, December 1909 (fig. 2, 5) which, as shown in my address in Oxford 1910 may result in a rupture of the thin conjunctival blister (See The Ophthalmoscope 1911, p. 490). In the flap of Dupuy-Dutemps 1013 (fig. 2, 9 ) where the conjunctiva is loosened in the lim- hus and after the sclerectomy is drawn down by sutures, there is certainly no scar line upwards, but the subconjunctival scar area, anatomically stated by me, also prevents the subcon- junctival passage of the aqueous. I have shown that this sub- conjunctival scar area may be broken by the aqueous (Bericht ophth. Gesellschaft, Heidelberg 1913, p. 365, fig. 9) which afterwards may pass outwards through the walls of the thin epithelial blister. In this way I explain Seidel’s green fluores- cein colouring of the scar area, very often observed after the sclero-corneal trephining. In a single case, I have seen, after the extralimbal sclerectomy, the fluorescein test positive as some few fine scattered green spots; this was less than three months after an operation in 1920. In eleven persons operated upon one or several years previously, the fluorescein test was quite negative; I did not use holocain ansesthesia before the instillation of fluorescein.

I have never seen any late infection after the extralimbal’ ptinch forceps sclerectomy, not even in a case where thr eye, iicarly two years after the operation, was attacked by an acute peumococcus conjunctivitis; as I believe, because the sclerec- tomy defect was protected by a thick conjunctiva.

The conjunctival flaps, after my operation 1910 (fig. 2, 6) and after Elliot’s operations 1913 and 1918 (fig. 2, 7 and 8 ) give too large subconjunctival scar areas.

At the ophthalmological congress in Stockholm, four years ago, dr. E. Lindgren told me that he had performed my extra-

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limbal tangential sclerectomy through a subconjunctival tunnel (iig. 2, l l ) , as in my iridencleisis operations and as in my punch forceps sclerectomy fig. 2, 2 (1909). I liked the idea because the subconjunctival scar area would be small; but I have not used this subconjunctival tunnel myself, because - perhaps wrongly - I feared a cutting of the conjunctiva with the punch forceps during the sclerectomy. I have however iiiade a shorter incision than formerly, oblique by upwards and outwards, dissecting the conjunctiva with the scissors only up to 2 mm nasally past the vertical meridian through the centre of the pupil (see the punctuated part in fig. 2, 12). I have hitherto closed the conjunctival incision with two ordinary sutures; but I will now try the suture indicated by professor Fritz Ask (fig. 2, 12) by which the conjunctiva is drawn tem- porally along the sclerectomy defect, which by this means gets into direct communication with unimpaired conjunctiva. It is easier to make, in my operation, on account of the distalice Il-om the limbus of the sclerectomy defect, than in sclero-cor- neal trephining.

I do not consider the sclerectomy as a panacea against all forms of glaucoma. Also other glaucoma operations, e. g. irid- encleisis, have their indications.

Among the 52 glaucoma operations which I have performed iii my private practice from 12th April 1920 to tlie end 0 1 De- (*ember 1924, there are 4 ordinary complete iridectomies (with- out sclerectomy) , eleven iridencleisis cum iridotomia meridio- nali, and 37 extralimbal tangential sclerectomies, always com- hined with an iridectomy; the later, as a rule, has been a mi- nimal basal one only. I recommend this extralimbal sclerec- tomy only in those cases of uncomplicated chronic glaucoma which by many are called glaucoma simplex.

After 32 of my 37 extraliinbal sclerectomies a normal ten- sion is accomplished without miotics (= 86,2 percent), stated 6 months up to several years after the operation.

When subacute phenomena supervene in cases of chronic glaucoma and the anterior chamber has become very shallow

or has nearly disappeared I prefer iridencleisis cum iridotomia meridionali.

In infantile glaucoma (buphthdmus) the sclerectomy ope- ning generally closes in the course of some weeks, months, or a t most a few years, after which generally an increase of ten- sion reappears. According to my earlier experiences I propose in buphthalmus an iridencleisis cum iridotomia transversali.

n Fig. 3.

(for buphthalmus; always to be performed below the cornea, because the eyes 'are rotated upwards during the necessary general anesthesia).

Iridencleisis cum iridotoinia transuersali.

On account of the rotation upwards of the eyes during the general anaesthesia, always necessary in children, the operation ought to be performed downwards; the subconjunctival tunnel and the extralimbal incision - 2,5 mm from the limbus - are made simultaneously with the keratome below the inferior border of the cornea. The operation can be made nearly without any issue of the aqueous; the transversal clip in the iris is malde subconjunctivally under the iris forceps and without using my double conjunctival hook. The next day one drop of atropin solution is instilled; generalIy it is not necessary to repeat this the following days. When discharged from the hospital the patient is advised 20 instill a 2 per cent pilocarpin solution twice a day, for six months or more. In many cases a Bfiltra- tion scare(( will then have been formed anid the miotics may be tliscontinued. I am inclined to dissualde from re-operation, which ought not to be performed if the tension can be kept normal and if the functions remain unaltered by continued application of miotics.