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Year : 1973  |  Volume : 21  |  Issue : 3  |  Page : 117-120

Evaluation of scleral cautery with peripheral iridectomy (Scheie's operation) for glaucomas


Department of Ophthalmology, Institute of Post-Graduate Medical Education and Research and S.S.K.M. Hospital, Calcutta, India

Correspondence Address:
G N Seal
Department of Ophthalmology, Institute of Post-Graduate Medical Education and Research and S.S.K.M. Hospital, Calcutta
India
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Source of Support: None, Conflict of Interest: None


PMID: 4500002

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How to cite this article:
Seal G N, Das M K. Evaluation of scleral cautery with peripheral iridectomy (Scheie's operation) for glaucomas. Indian J Ophthalmol 1973;21:117-20

How to cite this URL:
Seal G N, Das M K. Evaluation of scleral cautery with peripheral iridectomy (Scheie's operation) for glaucomas. Indian J Ophthalmol [serial online] 1973 [cited 2021 May 8];21:117-20. Available from: https://www.ijo.in/text.asp?1973/21/3/117/31397

Table 1

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Table 1

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The procedure was first employed by PREZIOSI. [2] He used a galvano­cautery puncture to enter the anterior chamber at the limbus at 12 o'clock after turning a conjunctival flap down over the cornea as for trephining. The tip of the cautery wire (0.5 mm. dia­meter) was applied at dull red heat to the limbus with several light quick touches until the anterior chamber was entered obliquely. Peripheral iridectomy was done only in those cases where the iris prolapsed through the puncture.

This method was developed by SCHEIE [3] when it was noted that a filtering cicatrix occurred following simple iridectomy in a case of early narrow-angle glaucoma in which Hildreth cautery was applied to the incision for haemostasis. The above observation was pursued further and a modern technique of scleral cautery with peripheral iridectomy was des­cribed with its advantages over other filtering operations. [3] Later on, some modification was done so that the scleral cut was made through an area previously lightly stroked with the cautery and then, the lips of the wound were touched with the cautery before the anterior chamber was finally entered with a knife. [5]

The principle of the procedure is the same as that of the operation of PREZIOSI [2] but with some differences in details. Here, a much less intense heat is applied and the cautery does not enter the anterior chamber. An iridectomy is always done. The technique is very simple and safe. Little bleeding occurs which is especi­ally advantageous in hyperaemic eyes. The operation leaves the pupil round and the filtering cicatrix is usually flat and diffuse.

This simple procedure has been employed by us in S.S.K.M. Hospital attached to the Institute of Post­Graduate Medical Education & Re­search, Calcutta, for several years. In our technique, the electro-cautery has been replaced by Wordsworth's ball­pointed thermo-cautery heated red-hot in the flame of a spirit lamp.


  Materials and Method Top


The present study was undertaken on all types of glaucoma seen in the glaucoma clinic of our Department of Ophthalmology, from March 1964 to May 1972. There were 55 eyes in the series of which 22 eyes had angle­closure glaucoma, 28 eyes had open­angle glaucoma and 5 eyes secondary glaucoma. In each case, detailed assessment was done before surgery and following that, the case was kept under observation for a period of 6-8 months.

OPERATIVE TECHNIQUE: A large flap of Tenon's capsule with conjunc­tiva was reflected down to the limbus as in trephining. Blunt dissection was done to expose to sclera at the limbus. Before making the scleral incision, the tip of the thermo-cautery was applied to the superficial sclera along the proposed line of the ab­externo incision. The proposed horizontal incision of about 5 mm long was then made just adjacent to the clear cornea. It should be made through the cauterized area, perpen­dicular to the surface of the globe using a Bard-Parker knife with a No. 15 blade. The cautery was applied once or twice within the lips of the scleral wound. The edges of the incision gape upon application of the cautery. Depth of the wound was touched with the tip of the cautery as the incision was deepened with the knife. The anterior chamber was entered with a final sweep of the knife along the whole length of the incision and a peripheral iridectomy done. Following iridectomy, the iris was reposited and the conjunc­tiva) flap and Tenon's capsule replac­ed and sutured with a continuous silk stitch. Guttae atropine was instilled and both eyes bandaged. Locally a steroid ointment was applied from the third post-operative day.


  Observation Top


The intra-ocular tension is said to be controlled when repeated tonometry shows 20 mm Hg or less without miotics during the assessment period (6 to 8 months). When the tension falls below 10 mm Hg, we define it as "hypotony". If the tension re­mains above 25 mm Hg even with miotics, we consider the case as failure from the surgical point of view.

Out of the 55 eyes operated, the intra-ocular tension was controlled in 51 eyes (92.7%) of which 3 eyes developed hypotony (5.417o); 4 eyes (7.3%) did not respond to the procedure and were considered to be failures. The operation was tried in 2 eyes of haemorrhagic glaucoma (following central retinal vein throm­bosis) but in both the cases, it was unsuccessful. One aphakic glaucomat­ous eye was operated upon with success. In both the eyes of a case of juvenile glaucoma, the procedure was successful in controlling the tension. In angle-closure glaucoma, successful control was achieved in 21 out of 22 cases, whereas 27 out of 28 cases with open-angle glaucoma were controlled. Angle-closure group included several cases where the operation was done in the acute con­gestive phase without any difficulty.

In majority of cases, reformation of the anterior chamber occurred within 3 days. Formation of the anterior chamber was delayed in 8 eyes which remained shallow from 6 to 7 days and in 5 eyes, the chamber did not reform before 2 weeks. In all these eyes, it subsequently reformed without any surgical intervention.

Hyphaema developed in 3 eyes due to seepage of blood through the fistula from flap-bleeding (usually traumatic)., In all these eyes, it was absorbed with­in few days. In one eye, the iris was herniated through the scleral fistula and came to lie in the subconjunctival tissue producing a prominent round pigmented cicatrix. The filtering cicatrix, however, was quite effective in controlling the tension.

In majority of the eyes, the forma­tion of the filtering bleb occurred between 5 to 7 days. In 4 eyes, it took about 2 to 3 weeks for the bleb to form properly. The bleb was diffuse in nature and had a thick conjunctival covering.

Hypotony which occurred in 3 eyes appeared to be innocuous. No oedema of the disc or retina develop­ed in these eyes. The vision was affected as a direct result of hypotony in one eye where rapid cataractous changes developed within three months.


  Discussion Top


Scleral cautery with peripheral iridectomy is a simple operative procedure which gives fairly good results. It can be performed when­ever a filtration operation is indicated - both close-angle and wide-angle glaucomas. It is more simple and safer than other fistulizing procedures because the incision is made through an area rendered avascular by cauteri­zation. The filtering cicatrix produc­ed in this operation is usually diffuse and thick which probably minimizes the risk of late infection.

The procedure is especially useful in neglected acute congestive glaucoma [5] and in the eyes where previous surgery has failed to lower the tension. It may also be tried in aphakic glaucoma and in selected cases of congenital glaucoma as a re-opera­tive procedure.

Control of pressure claimed by dif­ferent ophthalmic surgeons varies from 80 to 90%. HAMIDA SAIDUZZAFAR [1] et al reported 106 cases of primary glaucoma operated by this procedure and claimed 87.7% success in con­trolling the tension. Our percentage of success in this series stands at 92.7 (close-angle group 95.4% and wide­angle 96.4%). We have come across only 3 cases of hypotony (5.4%) in the series which is much lower than 15% reported by SCHEIE. [4] We have not encountered any rare complication like malignant glaucoma, late endo­phthalmitis or vitreous loss through the fistula. Only rare complication which occurred in one eye is the herniation of the iris tissue through the wound with updrawing of the pupil

The operation has several advan­tages over other fistulizing procedures. They include: (a) Incidence of compli­cations is less, (b) Duration of hospital-stay is less, (c) Bleb is thicker and so the chance of late infection is minimum, (d) No chance of sym­pathetic ophthalmia since the iris tissue is not incarcerated in the wound, (e) Re-operation can easily be per­formed if required, (f) Cataract extrac­tion is easier to perform if required.

Our conclusion as regards this procedure is that it is a easier and at the same time, effective method in controlling the intra-ocular tension in different types of glaucoma, especially the primary ones.


  Summary Top


Scheie's operation was performed on 55 eyes of different types of glaucoma using a ball-pointed thermo­cautery of Wordsworth instead of an electric one.

The procedure was simple and easier to perform and results were as good as other filtering operations. It can be done in all types of primary glaucoma and is especially useful for eyes with neglected acute narrow-angle glaucoma and for re-operations where other procedures have failed.

Post-operative complications were few and the incidence of hypotony was low. The pressure was controlled in 92.7% of the eyes operated in this series. Its advantages over other procedures and the post-operative complications are discussed.

 
  References Top

1.
Hamida Saiduzzafer, J. S. Pradhan & R. Gogi: Peripheral Iridectomy with Scleral Cautery (a simple technique), J.A.I. Ophthal. Soc. 17: 11-13 (1969).  Back to cited text no. 1
    
2.
Preziosi, C. L.: The electro-cautery in the treatment of Glaucoma, Brit. J. Ophthal. 8: 414-417, (1924).  Back to cited text no. 2
    
3.
Scheie, H. G.: Retraction of scleral wound edges: As a fistulizing pro­cedure for glaucoma. Am. J. Ophthal. 45: 220 (1958).  Back to cited text no. 3
    
4.
Scheie, H. G.: Filtering Operations for Glaucoma: A comparative study, Am. J. Ophthal. 53: 571-590 (1962).  Back to cited text no. 4
    
5.
Scheie, H. G.: Iridectomy with scleral cautery: Current status. Trans. Ophthal. Soc. U.K. 84: 127­137, (1964).  Back to cited text no. 5
    


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