"Zentmeyer and Posey: In simple glaucoma central vision increased in 60 per cent; remained the same in 20 per cent; diminished in 20 per cent.
"Wygodski: Inflammatory glaucoma, 37 cases; improvement, 76 per cent; unimproved, 5 per cent; deterioration, 19 per cent. Sub-acute (chronic inflammatory), 147 cases; improvement 10 per cent; unimproved (condition the same as before iridectomy), 40 per cent; deterioration, 30 per cent; blindness, 20 per cent. Cases operated on at an early stage gave 85 per cent of good results. Simple glaucoma, 104 cases; improvement, O.96 per cent; condition as before, 10.5 per cent; deterioration, 52 per cent; amaurosis, 36.5 per cent.
"Hahnloser and Sidler: One hundred seventy-two eyes observed not less than ten years after operation; acute inflammatory, 31 eyes; good results, 64 per cent; relatively good, 13 per cent; blind 23 per cent; chronic inflammatory, 37 eyes; good result, 29.9 per cent; relatively good, 27 per cent; blind, 43 per cent; simple glaucoma, 76 eyes; good results, 42 per cent; relatively good, 28.9 per cent; blind, 28.9 per cent."
As far as the Lagrange procedure is concerned, you will remember that after eserinization an oblique incision is made through the sclera by means of a narrow Graefe knife and a large conjunctival flap secured. This is obtained by making a peripheral section of the sclero-corneal margin with the knife and, as soon as the edge of the knife reaches the upper limit of the anterior chamber, it is turned backward and brought out through the sclera obliquely. The conjunctival flap thus formed is turned back over the cornea, and the fragment of sclera that is left attached to the cornea is removed by means of a fine pair of delicate curved scissors. Following this an iridectomy is performed. The conjunctival flap is now replaced and a bandage applied.
This operation opens a large filtration passage for the intra-ocular fluids and the prompt healing of the wound with its mucous covering prevents prolapse of the iris.
Under no circumstances must iris be left between the lips of the wound.
Although Lagrange advocated iridectomy in all cases in his first communication, he no longer judges the procedure to be necessary in all instances, reserving it for cases in which for any reason, such as hypertension, prolapse is to be feared.
While Lagrange holds that it is necessary to open the anterior chamber, Bettremieux thinks that a removal of but a portion of the thickness of the sclera suffices. His procedure is as follows: After raising a flap of conjunctiva from the neighborhood of the limbus a medium sized needle, curved and flattened towards its point and firmly grasped in a needle holder, is thrust superficially into the sclera tangentially to the upper edge of the cornea, so as to become fixed in the capsule of the eyeball. A small shaving of the sclera, about ½ mm. thick, 1½ to 2 mm. broad and from 2 to 3 mm. long, is then excised by means of a narrow Graefe knife. The scleral slip is then freed from the conjunctiva at each end and the mucous membrane brought together over the wound by fine catgut sutures.
As you are well aware, numerous operators regard the Lagrange operation as superior to the iridectomy of von Graefe because they believe there is filtration through the newly formed tissue between the lips of the operative wound. Among those of many observers the conclusions of Ballantyne may be quoted: "The results of sclerectomy vary according to the degree of hypertension of the eye operated on. Three varieties of cicatrix are distinguishable according to the amount of sclera excised: (1) that in which there is mere thinning of the sclera owing to the excised portion not reaching the posterior surface of the cornea (conjunctiva smoothly covers the cicatrix); (2) that represented by a subconjunctival fistulette, due to excision of the whole thickness of the sclera, in an eye with moderate tension (the conjunctiva lies smoothly over the cicatrix); (3) the fistulous cicatrix with an ampulliform elevation of the overlying conjunctiva, resulting from excision of the whole thickness of the sclera in an eye the seat of high tension. In cases of high tension, even a simple sclerectomy will allow ample filtration, owing to the gaping of the wound, while in cases without elevation of the tension, sclerectomy will be quite ineffectual. Lagrange therefore proposes the following rules of procedure: (a) If tensions is normal to +1, do sclerectomy without iridectomy, the amount of sclera excised being inversely proportionate to the degree of hypertension. (b) If tension is +1 to +3, do sclerotomy-iridectomy, the iridectomy being added to avoid entanglement of the iris. Lagrange does not recommend his operation for acute glaucoma. It is especially adapted for cases of chronic simple glaucoma."
During the past ten years or more I have been doing a modification of the Lagrange operation, the details of which (The Operative Treatment of Glaucoma with Special Reference to the Lagrange Method, The Canadian Medical Association Journal, November, 1911) I have elsewhere published.