*SCLERAL TREPHIN1NQ IN THE TREATMENT OF ABSOLUTE GLAUCOMA

John Chiao-nan Chang Glaucoma, the hideous ''thief in the night", occurs between 2-3% among the attendances in the Government Ophthalmic Clinics in Hongkong. Should there be some reparable vision when first seen and diagnosed, the usual gamut of carbonic anhydrase and miotics were given. Operative interference were considered only if medical treatment fails to control the tension. suffering, something apparently needs be done. The usual treatment of absolute glaucoma is enucleation or retrobulbar injection of alcohol. Enucleation is safer, as it rules out glaucomas secondary to introacular growth, which is, in fact, very rare in our part of the world. However, most patients usually resent the idea of having an eye excised. For one, the expense of a prosthesis is not easily met by everyone. For another the technique of inserting or removing the prosthesis often cannot be mastered especially in the older age groups. The cosmetic appearance of an ill-fitting prosthesis or an empty socket without a prosthesis need only be imagined. Retrobulbar alcohol is another means to control the pain. Its effect is temporary and occasionally a muscle will be paralysed resulting in a horizontal or vertical strabismus. This paper presents an alternative surgical method which leaves the patient with his or her own mobile eye but with the tension lowered and symptoms relieved. It is in effect, an ocular decompression", comparable with cranial trephining in increased intracranial pressure. The Operation:Pre-operative-this operation is done as a clinic procedure. Preoperative premedication is not absolutely necessary. However in a few cases luminal and diamox were given one hour before operation. Pethidine may be given if the patient is extremely nervous. Operative Technique. 1. Aneihesia-local pantocaine instillation and retrobulbar injection. 2. Fixation suture-a 1 ' 0 " black silk suture is stitched to the sclera at the

Scleral trephining, R. E. The operator's left hand dabbing the extruding vitreous with a polyvinyl sponge while excising the former with de Wecker's scissors.

Unfortunately, there are times when the ophthalmologist is confronted with a case wherein the "thief" had apparently stolen everything from the house. This is the state of absolute glaucoma, a pathetic situation, a situation which the ophthalmologist does not wish to see. Yet, in view of the elevated tension, often extremely high, and the headaches the patient is

* A paper presented in the First Congress of the Asia-Pacific Academy of Ophthalmology held in Manila, October 10-13, 1060.

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SCLERAL T R E P H I N I N G IN THE TREATMENT OF ABSOLUTE G L A U C O M A

lateral inferior quadrant near the limbus. The cords are separated and the eye is pulled upwards and nasally exposing the lateralinferior quadrant into view. 3. Conjunctival and Tenon's incisionCrescentic and 9 mm. from the limbus, a incision, 10 mm. long is made through the conjunctival and Tenon's capsule by scissors. 4. Trephining-after retracting the wound with conjunctival hooks, a hole is drilled 7 mm. from limbus with a 2 mm. trephine (any type) right down into the globe with a few turns of the instrument. The anterior condensed vitreous often has a high viscosity. Dabbing with a plastic sponge (or cottonwool applicator) is necessary to break the viscosity so that it will keep on emerging after being snipped by de Wecker scissors. At least 1.5 cc. of vitreous must be released. At times, a sudden gush of posterior watery vitreous occurs. This is a good sign. 5. The conjunctival-tenon's flap is pulled over the Wound and sutured by a continuous mattress stitch. An antibiotic-steroid salve, is instilled. A monocular dressing is applied. Post-operative care:Cortisone drops and an antibiotic ointment are usually prescribed after first dressing. The drops are carried on for a week or so and gradually tapered off. Systemic steroid therapy may be given if desired. Results: Thirty-five cases of absolute glaucoma of various etiology with age varying from 17-75 years (27$, 8$), were operated using this technique. The results are tabulated as follows: * Successful-20 cases (57.1%). Criteria: (i) tension lowered for months (longest observaton 164 days) ( i i ) headache relieved.
*One case FJ74, failed after using 1 mm. trephine. Re-operation with 2 mm. trephine gave satisfactory results.

Partially successful-10 cases (28.6%) - this is a group of cases which showed their tension lowered on 1st dressings but follow-up is not sufficient duration. Partially failed-2 cases (5.7%)-These were 2 cases of irist bombe. Subsequent transfixations finally controlled the tension. 4 Failed-3 cases (8.5%) of phakolytic glaucoma showed no response to this operation. Summary: As a counterpart of cranial decompression, scleral trephining is indicated in cases of absolute glaucoma causing headaches and discomfort whereas the patient refuses enucleation. Using a 2 mm. trephine, a hole is made in the lateral inferior quadrant of the globe 7 mm. from the limbus. At least 1.55 cc. of vitreous is released. Some thirty-five cases have been operated upon with a great percentage of success. None resulted in sympathetic ophthalmia. This operation is now a routine procedure in the Government Ophthalmic Clinic, Kowloon, Hongkong. ACKNOWLEDGEMENT: I wish to thank Dr. G. C. Dansey-Browning, Ophthalmic Specialist, for his constant guidance and encouragement and the Hon. D.M.H.S. for permission to publish this article. References: Beard, C.H., Ophthalmic Surgery, 1910 Callahan, A., Surgery of the Eye, Diseases, 1956 Grimsdale-Brewerton, Ophthalmic Operations, 1937 Philps, S., Ophthalmic Operations 1950 Spaeth, E.B., Principles and Practice of Ophthalmic Surgery, 1948 Stallard, H.B., Eye Surgery, 1958 Wiener and Scheie, Surgery of the Eye 1952