As stated in this paper I have modified the procedure to the extent of removing all the conjunctiva attached to the borders of the operative wound. I admit that this intervention exposes the root of the iris and the ciliary body, but I have never yet had the slightest infection of the wound. I attribute this freedom from sepsis to careful cleansing of the conjunctival sac and to other pre-operative precautions, but especially to the use, before and after the operation, of White's ointment—a preparation of 1-3000 mercuric chloride in sterile vaseline. One cannot use sublimate in such a strong watery solution, but the vaseline seems to modify it and to allow of such slow absorption that it is not only a non-irritant but a most excellent antiseptic application in operations on the eye.
In any event the result of the Lagrange operation proper, as well as my modification of it, is to produce a drainage-oedema about the incisional wound which persists almost indefinitely. In many cases this swelling amounts to a bleb which may be increased by massage of or pressure upon the eyeball. The efficacy of the operation in lowering intra-ocular tension is to some extent measured by the degree and the constancy of this epibulbar oedema; indeed, I suspect that the most successful examples are those in which sclera fistulae, minute or otherwise, form as a sequel of the operation.
My object in excising the conjunctiva about the sclero-corneal flap, is to delay union of the wound edges, to widen the bridge of loose cicatricial tissue between them, to prevent such a complete growth of the endothelium as would cover the wound and block the exit of fluids, and to insure intra-ocular rest.
In cases of chronic increase of intra-ocular tension associated with a quiet uveitis or an iridokeratitis, when the patient exhibits traces of old synechiae, or where there is danger of their re-formation, I do not hesitate to use atropia as long as the wound of operation has not healed.
To the present time I have done 72 operations of the sort and have seen no reason to alter the opinion of it expressed in the article mentioned. Whatever objection may in the future arise—and I freely confess that it seems to be fraught with the dangers that many of my colleagues have pointed out as probable—I have so far not seen a single case of infection of the wound of operation. While I believe the anti-glaucomatous results to be excellent, I may also claim that the operation is of the simplest character; and it is easy of performance and the resulting filtration-scar is large and (perhaps) more permeable to the changed intra-ocular fluids than the quicker healing wounds of the usual Lagrange and Elliot procedures.
It is regarded by most operators as desirable that there should not be long delayed healing of the operative wound, and the fact that the conjunctiva covers the incision is often spoken of as an advantage, partly because it shields the large open area produced by the Lagrange incision from infection.
My experience of this modified operation continues to be that it is necessary to clear the neighborhood of the operation wound entirely of conjunctiva. If the down-growth of epithelium into the operative wound is permitted the effects are by no means as pronounced, and the eventual lowering of tension is not as permanent as they otherwise would be.
Another matter: I am satisfied that the delayed filling of the wound by connective tissue is desirable in most cases of chronic glaucoma. A complete drainage of the intra-ocular fluids that results from long delayed union of the wound edges, allows the interior of the eye to regain, as far as possible, the status quo ante. On the other hand the comparatively early closure of the wound (or the termination of free drainage and minus tension) tends to re-establish the status glaucamatosus. Whether these desirable results are to be realized or not will, of course, depend upon a future experience larger than I have yet had. This modification of the Lagrange operation seems to be a radical one and I do not expect its adoption until the results of an extended trial are carefully recorded and reported.
Quite recently several operators, who have been in a position to do so, have contrasted the results obtained by the Elliot method and those following the Lagrange procedure. Probably the most important of these observations is the experience of Meller (Die Sklerektomie nach Lagrange und die Trepanation nach Elliot) set forth in a paper read by him at the last meeting of the Deutsche Naturforscher und Aertze. In this report Meller gives an account of 389 sclerectomies following the usual Lagrange procedure. Twelve per cent of the cases were of acute glaucoma; 61.5 per cent of chronic inflammatory glaucoma, and 9 per cent of simple glaucoma. The rest of the operations were done in other forms of the disease. In more than half the cases the usual iridectomy was performed; in 30 per cent the procedure was peripheral; in 4 per cent there was no iridectomy. The patients were studied during a period of five years. In more than half the instances there was a pale, cystic, oedematous cicatrix; in 11 per cent the scar was ectatic, and in the remainder the field of operation was quite flat. The form of the scar was described in most instances, but it was not noticed that there was a definite relation between the cicatrical formation and the intra-ocular tension. In 70 per cent of the cases a good result followed the operation, but in 10 per cent the result was decidedly unsatisfactory. Cloudiness of the lens set in in 4 per cent of the cases, while posterior synechiae developed in the great majority of them. In 2.3 per cent the eye was attacked by iridocyclitis and in 3.4 per cent enucleation was found to be necessary. Six eyes became atrophic but were not, for various reasons, removed. One and three-tenths per cent of the eyes operated on were lost from late infection. Vitreous was lost in 6.2 per cent. Two eyes became blind from expulsive hemorrhage. The large majority of these complications arose in the eyes operated on for chronic glaucoma. There were fewer eyes lost following the operation for glaucoma simplex than in the other forms of the disease. Recurrences were noticed in 11.3 per cent of all the cases; in simple glaucoma 14.3 per cent as against the acute and chronic forms with 6 per cent. A return of the glaucoma was noticed in 7 per cent of the pale, oedematous, post-operative scars, in 16 per cent of the flat cicatrices, and in 24 per cent of the ectatic variety. Considerable stress is laid upon the fact of the marked softness of the eyes after each operation. There were histological examinations made of the eyeballs in 11 cases, in which the position of the incision and excision, the development of the scar tissue, and the appearance of the complications were duly set forth. The operator then gave a history of over 178 trepanations after the Elliot method and compares them with the procedure of Lagrange. He concludes that the Elliot trephining operation is less dangerous, is more likely to be followed by the development of a cystic scar, and leads to loss of the eye in only 2.4 per cent of the eyes operated on. In Elliot's cases the percentage of relapse was more noticeable than in the Lagrange cases where no iridectomy was done. This observer concludes that the method of Elliot is to be preferred to that of Lagrange, and that in the former case iridectomy is an important factor in obtaining a favorable result. This being the case one cannot truthfully say that trephining alone can take the place of the old Graefe iridectomy. On the other hand, trephining may with advantage be employed instead of iridectomy for cases difficult or dangerous under the latter method.
Whatever difference of opinion was noticeable at the Vienna meeting, all of those present, especially Meller, the reader of the paper just quoted, were decidedly of the opinion that the Elliot operation is in every respect the one best adapted to buphthalmia, or congenital glaucoma.