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RAC
EN LE CATAR CT
Being a complete report ofthe papers and discussions
presented before the C hicago Ophthalmological
Society, N ovember 20 , I 9 ] I .
EDIT ED BY
HA R R Y W. WOODRUFF, M. D.
Pr esident of the C hicago Op hthalmological Society; P r ofessor of Op h thalmologyin the C hicago E ye, E ar
, N ose and T hr oat C ollege; Surgeon to the
I llinois C har itable E ye and E ar I nfirmary.
21] lluztratph
CHIC A GOC LEV E LA N D PR ESS
I 9 I 2
C levelandCh icago
1 9 1 2
INTRODUCT ION .
The contents of this book represent 3 Sympos ium on the
E xt raction of Senile Cataract which formed the program of the
meeting of the C hicago Ophthalmological Society , N ov . 2 0 , 1 9 1 1 .
The president was instructed by the society to appoint a commirtee to arrange for the publ icat ion of the papers and discussions . This committee was composed of three members , Drs .
W . A . Fisher, Casey Wood,and Chas . H . Beard . The editor
acknow ledges his indebtedness to these members , and also toDr . J . Herbert Claiborne
,who edited a similar volume in 1 908
which represented the work of the Ophthalmological Section ofthe N ew Y ork Academy of Medicine.
While there are many steps in the operation under discussionupon which there may never be an absolute unanimity of opinion, much can be learned from the methods ofdifierent operators .
The operation of intracapsular extraction may never be universally adopted in this country . It has , however , done much toawaken thought and shows the possibil ity of improvement in an
almost perfected operation . It has,as the contents of th is book
wil l show , brought out in almost every paper some reference toa change of more or less importance in technic .T he editor has taken the l iberty of commenting upon the dif
ferent papers either by making additions of h i s own or by quotations from well known authors .Jol iet, 111. H . W . W .
O O O O OOO O O O O O O O O
OO O O O O O
Wm . B . Gamb le, M .
CHAPTER I I .
T H E INC IS ION .Wm . H . Wi lder , M .
Dodd,M .
CHAPTER II I .
T H E IRIDECTOMY . Casey Wood , M .
D i scuss ion Willis O . Nance, M .
CHAPTER IV .
T H E CAPSULOTOMY W . A . Fisher, M .
Discu ss ion Harry S . Gradle , M .
CHAPTER V .
T H E DELIV ERY OF THE LENS Derrick T . Vail , M .
D i scuss ion . R ichard J . T ivnen,M .
CHAPTER VI .
T H E TOILET Chas . H . Beard . M .
D i scuss ion E . J . Gardiner , M .
CHAPTER VII .
COMPLICATIONS AND AFTER-TREATMENT . . D . W . Greene, M .
D iscussion Cassius D . Wescott , M .
CHAPTER VIII .
GENERAL D ISCUSSION Ol iver Tydings , M .
W . Franklin Col eman , M .
Geo . F . Suker, M .
Heman H . Brown , M .
Henry B . Y oung,M .
.U
F?
s
c
o
p
e
COLLABORATORS.
THOS FAITH ,M . D .
,CHICAGO .
Professor of Ophthalmology in the Chicagoand Throat Col lege . Ocul is t and Auri st to St .pital .
WM . E . GAMBLE, B . S. , M . D .,CHICAGO .
Professor Cl in ical Ophthalmology and Associate Profes sor ofOphthalmology
,Col lege of Physicians and Surgeons , Medical
Department,University of I l l inois .
WM . H . VV I LDE R,A . M .
,M . D. ,
CH ICAGO .
Professor and Head of Department of Ophthalmology , RushMedical Col lege ( in affil iat ion with Univers ity of Chicago ) Pro
fessor Of Ophthalmology , Chicago Polycl inic ; Surgeon I l l inoi sCharitable E ye and E ar Infi rmary ; Ophthalmic Surgeon , Presbyterian Hospital .
CASEY A . WOOD, M . D CHICAGO .
Pix-President of the American Academy ofMedicine , of theAmerican Academy of Ophthalmology and of the Ch icago Ophthalmological Society. Consulting Ophthalmic Surgeon CookCounty Hospital , Attending Ophthalmic Surgeon to St . Luke’sHospital , etc .
OSCAR Donn,M . D CHICAGO.
Surgeon I ll inois Charitable E ye and E ar Infirmary. Ocul istto Augu stana Hospital .
WI LLIS O . NANCE,M . D .
,CHICAGO .
Surgeon I llinois Charitable E ye and E ar Infirmary late Ocul i st and Aurist to Cook County Hospital Secretary Ch icago Ophthalmological Society .
HARRY S . GRA DLE,A . B.
,M . D . ,
CH ICAGO .
Professor of Ophthalmology at the Chicago E ye, E ar , Noseand Throat College .
DERRICK T . VA IL,M . D .
,CI N CINNATI, O .
Ophthalmo logist to the C incinnati Munic ipal Hospital ; Clinical Professor Ophthalmology to the Ohio-Miami Medical College
,University of Cincinnati
,etc .
RICHAR D". T I V N E N ,M . D . , CH ICAGO .
Ocu l ist and Auri st,Mercy Hospital ; Ass istant Surgeon I ll i
nois Charitable E ye and E ar Infirmary ; Instructor in Ophthalmology and O tology , Northw es tern Univers i ty M edi cal
Schoo l ; Consu l t ing O cu l is t and Au ri s t to Mary Thom psonHospi tal ; Member Of Consu l t ing Staff Of th e Cook C oun tvHosp i tal .
CHAS . H . BEARD,M . D . , CH ICAGO.
Surgeon to the Ill inois Charitable E ye and E ar Infirmary ;Ocu l i st to the Pas savant Memorial Hospital ; E x-Pres ident ofthe Chicago Ophthalmological Society .
E DW IN J .GARDINER
,M . D .
,CH ICAGO .
Professor Ophthahnology,Chicago E ye, E ar , Nose and
Throat College .
DUFF W . GREENE, M . A .,M . D DAYTON , O .
Ocu l ist and Aurist to St . E lizabeth Hospital ; Ocul i st andAuri st to the National Mil itary Homes ; Ocul i st and Aurist to theOhio Soldiers’ and Sailors ’ Orphans’ Home , etc .
Throat College ; Ophthalmologi st to Columbus Hospital .
CASS IU S D . WESCOTT,M . D CH ICAGO .
Attending Ophthalmologi s t S t . Luke’s Hospital ; ConsultingOphthalmologi st St . Anthony Hospital .
HENRY B . Y OUNG, A . M . ,M . D .
,BURLINGTON
,I A .
Member of the Facul ty Burl ington Hospital and Mercy Hospital Training Schools for Nurses ; Ocul ist E . I . D ivis ion C .
, B .
Q. R . R .
OLIVER TYDINGS,M . D .
, CH ICAGO .
Profes sor of Ophthalmology,Otology
,Rhinology and Laryng
ology, Chicago E ye, E ar , Nose and Throat Coll ege .
GEORGE FRANC IS SUK ER,M . D .
,CHICAGO .
Professor of Ophthalmology , Post-Graduate Medical School ;Consult ing Ophthalmologi st , Mary Thompson Hospital ; Attending Ophthalmologist , Chicago Refuge for Girl s ; Pres ident ofAmer ican Academy of Ophthalmology and Oto—Laryngology ;
, S ecretary Chicago Medical Society .
2 .
-Verhoeff’s mod ified iridec tomy .
3.
—Capsu lotomy . Cystotome in posit ion4 .
—Capsu le forceps in posit ion .
5 .
-Tooke capsu le forceps in posit ion6 .
— 3Fisher 5 capsul e forceps7 .
—Fisher ’s capsu le forceps in posit ion8 .
— Fisher ’s l ight .
9 .
—Fisher ’s l id retractorI O .
— E xpu lsion of the lens ; first step in Smith method .
I I .
—Fisher ’s capsu le forceps in position ; patient lookingat cei l ing
1 2 .
—Fisher ’s l id retractor in posit ion13.
— Show ing the correc t pose for the assistant in expos ing the eyebal l for del ivery of the lens
I 4 .
—Show ing the lens-nucleus escaping through woundas a resu lt of proper pressure w ith elbow of lens
1 5 .
—S ide V iew Of above .
1 6 .
-Show ing convenience of removmg lens from woundafter del ivery by u sing same lens-hook that ef
fec ted del iveryI 7 .
— Show ing Knapp ’s method of ridding the pupil spaceof soft
'
cor tex after nuc l eus has been del ivered .
1 8.
— S ide view i l lustrat ing how the nuc leus may be suc
cessfully del ivered in unru ly pati ents .
1 9 .
— Show ing where the bu lbou s tip of the lens-hook isapplied in the first effort at del ivery in the capsu le .
2 0 .
— Il lustrat ing deep pressure being appl ied below thelens and toward the depth of the eye to cause upright del ivery .
2 I .
-Steps in the del ivery of the lens2 2 .
—Steps in the del ivery Of the lens2 3.
—Show ing combined pressure in case the lens doesnot glide upwards out ofwound
2 4 .
—I llustrat ing the lens—spoon introduced a short distance behind the lens to afford a background fo rpressure to rel ieve a threatening vitreous
2 5 .
— Il lustrat ing how b y increasing tension of the vitreous w ith the added pressure of the spoon belowthe cornea a “ stubborn” lens may be started fromits bed and a successfu l and “dry del ivery effected
C H A PT E R I .
THE PREPARATION .
BY THOMAS FAITH,M . D .
,CH ICAGO .
The preparation for the operation of cataract extraction maybe separated into four divi sions
,viz . , the general preparation of
the pat ient ; the preparation of the field of operation ; the preparat ion of the operator and assi stants ; and the preparation of theinstruments . While all four divisions of the subject are of theutmost impo rt ance , the first
,the general preparation of the
pat ient,i s the one most commonly neglected , and I am firmly con
v inced that i t i s often the most important contributing factor inthe succes s or failure of the operation .
In the general preparat ion we must inc lude a w ide range ofexaminat ions in order to have our subj ect properly fortified forthe ordeal which he or she i s to undergo
,and for th i s reason the
p atient had best be under close Observat ion for some t ime beforehand
,or
,better st i l l
,should be in the hospital for a number of
days preceding the operation so that the various examinationsmay be made and repeated
,i f necessary
,and the patient kept
under more or less constant Observation .
T hese general examinations shou ld include the excretions ;kidneys and bowels ; the digestive tract ; the lungs ; throat , noseand ears ; the cardio-vascular system and blood . A l so the nervous system ; a close inquiry as to habits ; the use of drugs , alcohol ,snuff, etc . ; and the presence or history of lues .T he urinalysis should be complete , both microscopic and
c hem ical,including quantitative estimation of urea and indican
,
and of any pathological contents that may be present .The p resence of a large amount of indican
,of sugar in con
siderab le quantity, or of albumen , whi le they may not proh ibitthe operation , should be an indication for such treatment as w i l lreduce , i f not cause thei r disappearance , before proceeding to
operate . I f a l arge amount of indoxyl potass ium sulphate
the smal l intestine or some organic destructive disease .
The presence of sugar need not be a contra-indication foroperation
,but i t should first be reduced to the lowest amount
possible ; then , too ,the absence of, or diminut ion of, the acetone
bodies from the u rine of such pat ients i s important and shouldbe sought by every means . In thi s connect ion it i s w ell to remember that a nervous shock may cause the sudden output of sugarto be markedly increased ; as a resul t of a decrease in the oxidative powers of the body
,there is accordingly a great increase in
the oxybutyric acid output,and as there is always a retent ion in
proportion to the amount el iminated coma may ensue as the directeffect of the operation i f it proves to be a nervous shock to thepatient. We are al l also famil iar w ith the delayed healing
,low
grade inflammatory and nutrit ive changes, which may follow a
wound in a diabetic and we shou ld therefore see that thesepatients are in the very best condit ion poss ible before operat ingthem .
The presence of small amounts of albumen o r a few casts i snot necessarily of serious importance unless the pat ient also hasa high blood pressure , but shou ld put us on our guard fo r furtherpost-operat ive developments . A urine of low spec ific gravi tywhich may or may not be defic ient in quant ity shou ld always putus on the lookou t and cause u s to estim ate the amount of u reael iminated for we all know such cases do badly when put in bed ,and under such condit ions unless we are able to correc t the deficiency we shou l d not confine the pat ient to bed any more o r any
longer than is absolutely necessary . Ol iguria,however , may only
be the result of psychic depress ion and may there fore be of noimportanc e .
A know l edge of the degree of acidity or alkal inity Of the urinei s important , as i t might lead u s to investigate further , as to thepresence of attacks or renal colic
,vesical i rritabil ity and cyst it i s
,
the existence of prostatic enlargement , str icture , etc .,al l of which
should be known in order that we may be upon our guard forpost-operative troubles and thu s possibly prevent them .
The condit ion of the patient’s bowels should be ascertained,
and i f constipation exists they should be thoroughly emptied and
T H E PREPARATION 1 9
an attempt made to regu late them for a few weeks before operating. I f the bowel s are regular a s ingl e brisk cathartic shouldbe given a day or two before the operation . I f diarrhea i s presenta calomel purge and castor oil wil l u sual ly correct the troubleunless of a chronic type when the caus e must be ascertained , and ,i f possibl e
,removed before attempting operation ; for some of
these old people absolutely wil l not use a bed-pan, but wi l l get upand go to the toilet at the first opportunity in spite of warningsand a nurse .
The stomach and abdomen should be examined or at least acomplete history should be taken in order that we may know the
behavior of the digestive organs under various conditions anda fter certain foods are taken
,e . g.
,many O l d people cannot take
milk on account of stomach di stress and,as they term it, billous
ness others are attacked with indigest ion when eggs are taken ;and stil l others ( and there are many of these ) are absolutelyunab le to digest meats . A s these patients are usual ly old theyfrequently have formed ideas as to thei r diet , etc . , which ,although they may appear unreasonable to us , are rat ional enoughto them , and we should not disregard what seems to us to betheir whims, as exper ience often p roves to us that they are notaltogether fancie s .T he condit ion of the respiratory organs should always receive
attention . The lungs should be examined and the pat ient questioned as to the history of bronchiti s and asthma in particular
,
and i f either of these conditions are present they should. be treated
before proceeding to cataract operation . I f a cough exi sts it scause should be determined and , i f possibl e, removed ; and theinfluence o f posture upon the patient’s respiratory apparatus
should be inquired into . I f the respiratory condition is one wh ichcannot be cured in a reasonabl e time
,cough sedat ives and drugs
which wil l relax bronchial spasm may be used temporari ly unti lthe danger t ime has passed . I have only recently seen a case inwhich an apparently skil l ful ly performed operation came tonaught on accoun t of haste on the part Of the operator who didnot wait long enough to get the patient’s cough under control ;the wound was reopened during a paroxysm of cough ing and the
eye lost .The nose should be examined part icu larly for the presence of
ozena and sinus suppuration , and the patient should be ques
and post-nasal catarrh, o r any irritative condition of the pharynx
o r tonsil s,elongation or edema of the uvula . Then
,too, evidence
o f the existence of lues i s frequently found in the mouth andthroat and we should be constant ly on the lookout for that condition . The pat ient shou ld be questioned and the ears examinedfor puru lent discharge . which condi t ion might be a direct causeof in fection , but which could eas i ly be prevented i f known before
hand .
Oi cou rse . many of the conditions of the nose , throat , etc .,
which I have ment ioned cannot be cured before operat ing ; buti f we take them into account beforehand we may use such loc almeasures as wi ll minimize the danger from these sources . I f ,for example , there is ozena , s inus suppurat ion o r polypi
,the
proper treatmen t of the nose for a t im e w i l l l essen the danger Ofin fect ion from this sou rce , even though a cure may not beeffected ; and the use of proper antisept ic solutions in the mouth ,nose and throat w i l l undoubtedly diminish the danger Of infect ion from that source ; while a suppurat ing ear can usually be
held pract ically inact ive as long as it i s kep t c lean and dry .
The presence of an acute coryza shou ld be an absolute contraindicat ion for operat ing ; so too an attack of hay fever
,for which
we should put off operating unt i l the hay fever season has passed .
The cardio-vascu lar system requ i res part icular attent ion andc are fu l investigat ion in al l cases of senile catarac t . An examinat ion of arterial tension
,shou ld always be made . whether sugges
t ive general symptoms are present or not ; and w here the tensionis high , efforts to correct the condit ion shou l d be made by p rom oting el im inat ion , arranging the diet
,and by the use of the
n itrites. Thi s shou ld be carried on for some t ime,in fac t
,unt i l
the tension is reasonably reduced in order to guard against apossibl e choroidal or retinal hemorrhage . Of this condition therei s much to be said of the various l ines of treatment
,the adminis
t ration of sal icylates,the acetates , bicarbonate and iodide of
potassium , the variou s mineral waters and the j udiciou s use ofdigital is , and many other remedies .
I n this connection it i s wel l to remember that there are three
of the case a fter operation .
I have personal ly had two experiences w ith nervous cas eswhich caused me considerabl e anx iety
,and which have kept me
on the lookout s ince . One,a case in which a history of epi lepsy
was not obtained be fore operation,and in which the corneal
wound was broken open during an epileptic seizure . Had Iknown the facts beforehand the untoward result cou l d in al l probabi l ity have been prevented .
The other case was one ofgastric neuroses in which the apprehension of the operation made the patient so nervous , that shewas seized with a fit Of gastric pain and vomiting as soon as Ibegan the operation . I was therefore only abl e to do the i rideetomy at the first operation and when
,a few w eeks later, I at
tempted the ext rac t ion,the experience was repeated . I then post
poned the operat ion fOr a few days,gave some ful l doses of
oxalate of cerium,which
,act ing directly upon the vomiting center,
quieted the pat ient and I was enabled to proceed .
These experiences have made me cautious about obtaining aclear history as to such condit ions and I find i t is often a betterplan to Obtain this part of the history f rom another member ofthe family than to depend upon the patient ’s statements .We shou l d always inquire closely and examine these pat ients
for lues, and while its presence i s not always a contra-indication ,any posit ive syphil it ic l esion should cause us to put the patientupon full doses o f mercury and iodides ( or perhaps salvarsan )before going ahead .
It i s very important to always inqu i re into the pat i ent’s habitswith regard to the use of alcohol
,drugs
,tobacco and snuff ; for
i t i s a well-known fact that alcohol ic s who are suddenly and completely deprived of thei r accustomed stimulant are l iable todevelop del irium tremens , and for th i s reason it i s p robably betterto give them a smal l quantity ofw ine , brandy , or whisky each dayat regu lar interval s , j ust before and after operating, unless we
w ith their favorite drug, or wil l have to be given a substitute ifthey are to be kept qu iet long enough for heal ing to take place ;i f a cure of the drug habi t i s to be attempted it should b e aecomplished be forehand .
The use of snuff should be absolutely prohibited immediatelybefore
,and for a number of days subsequent to, Operating .
A s the Obstetrician watches and di rects hi s patients for monthsor weeks beforehand, preparing them for the delivery that al lmaybe well at the crit ical t ime, so too shoul d the ophthalmologist manage direct and prepare his cataract patients for to them an
equal ly important del ivery,and above al l things he shou ld not
hurry matters,but take suffic ient time to get his pati ent into the
best poss ibl e condit ion,both mental and physical , be fore oper
ating.
For some time before the day of operating arrives the skinof the l ids
,the l id margins
,the conjunctiva and the lachrymal
drainage apparatus,shou l d be subj ected to a rigi d examination,
searching for abnormal secretion and evidences of inflammation ,crust ing, scal ing, etc . I f the conj unctiva is congested or there isany undue secretion p resent , or i f there is any marginal l idtrouble
,a microscopic examination should be made . In fact , a
microscopic examination of smears f rom the conj unctiva shouldalways be made
,and i f any pathogenic germs are found by either
smears or cultures the eye should be treated unti l they have di s
appeared .
I f the l id margins are inflamed they Should be treated withfive or ten per cent solut ions of nitrate of si lver unti l healed andspast ic entropion should receive our attent ion i f present .I f dacryocystit i s i s present there is only one certain way of
prevent ing in fection,and that is by prel iminary removal of the
tear sac, as l igat ion of the canal icu lus and seal ing of the punctawith the cauteryare not always a success .Lachrymal obstruct ion W ithout sac inflammation and secre
tion may be t reated by previous probing or , better stil l , bylachrymal styles
,which shou l d be removed several days or weeks
before operat ing .
I rit is i s a contra-indication of course , but i f a chronic i riti s i s
are engorged the tonometer shou ld b e used,and i f tens ion is above
normal it shou ld be reduced by either eserine,citrate of soda
inj ec t ions or a prel iminary i ridectomy . Here we should remem
ber that a swollen lens i s frequently the cause of temporaryincreas e of tension
,and there i s no better method than prelim
inary i r idectomy for dealing w ith such cases .The eye shou ld not be bandaged prior to operat ion
,but may
be flushed several t imes daily,for a number Of days , w ith normal
salt , or boric acid solut ion , or twenty-five per cent argy rol solut ion may be f requently instil led .
The day be fore operat ing the pat i ent shou ld have a bath andthe head shou ld be washed .
Immediately be fore the operat ion the brow s,face and eyel ids
Should be thoroughly scrubbed w ith some non-i rritating soap andw ater . The brow may or may not be shaved
,but the lashes for
at least one-hal f or three—fourths of an inch from the externalcanthus should be cl ipped close so as to avoid contact w ith thekni fe . The conj unctiva] sac should now be flushed w ith steri lenormal salt o r boric solution
, or I to bichloride of mercurysolution
,u s ing the Smith method
,holding the l ids away from the
globe with speculum or retractors and thoroughly s tretching out
the folds of the cul-de-sac . Plenty of warmed solution should
always be used w i th either an i rrigator or a large bulbed dropper .The l id margins and lashes shou ld be wiped thoroughly w ith
steril e gauze sponges moistened with I to bichloride solut ion
,and the eye should be covered w ith a moist bichloride pad .
The cocaine inst il lat ion may now be begun and three appl icationsof a 4 per cent solution at four minute intervals i s usually su fficient .
The field of operat ion is next su rrounded w ith a steri le or
bichloride-moistened operating cloth and the patient ’s head isenveloped in a sterile towel .The operator should use the most rigi d asept ic precautions
in the preparat ion Of his hands and those of his assi stants . Theass istants may wear rubber gloves
,but it i s doubtfu l i f i t would
THE . PREPARATION 2 5
be safe for the operator to do the same . In fact, I have neverheard Of an operator attempt ing it as” the sense of touch i s veryimportant in this operat ion, and it is necessary to be very certainof the grasp of the instruments and the amount of resistanceoffered to them . T he operator and assistants should wear ster ilecaps and steri l e gauze coverings for the nose and mouth .
T he Pr eparation of the Inst ruments .
The non-cutting instruments shou ld be scrubbed wel l withbrush and soap and thorough ly wiped to free them of r ust , blood ,etc . They should then be either wrapped in a sterile towel or putin a rack and bo i led in a covered boi ler for fi fteen or twenty minI‘
I tes, using a weak solution of sodium bicarbonate say I to 50 0 orI to 2 50 ; after bo i l ing they should be again care fu lly dried w ithsterile gauze, placed upon a tray or instrument table and coveredwith dry steri le towels .T he cutting instruments should be either boiled for ten min
utes or should be first careful ly washed with; steri l e water and
wiped with moi st cotton Sponges ; then they shou ld be immersedin either pur e lysol , strong formal in solution I to 1 0 0 . or , be ttersti l l , in ninety-five per cent phenol for ten or fi fteen minutes ;after which they are wel l rinsed in alcoho l and then in steri l edist i lled water . Th ey should be again wiped dry with sterilesponges and are then ready for use .There i s st i l l cons iderable difference of opinion as to the
effects of these var ious procedures upon the edges of the knives ,and they are probably all variously favored by differ ent operators .
Discussion byWm . E . Gamble.
To me a mos t i lluminating part of tonight’s program is DoctorFaith
’
s paper . I can recall compl i cations in cataract extraction I have had which might have been avoided i f I had ‘
studied
the patients more c areful ly.
I t i s wel l that the ophthalmic surgeon th inks of the eye upon
whi ch he i s about to operate in terms of surgica l cleanliness andsurgi cal technique . T oo frequently our attention to the patient
himse l f consists in giving him a cathartic the night be fore theoperation , with an enema the follow ing morning,
and examinat ionof the urine for sugar and albumen
,. immediately before the
operation in a seance of two or three minutes’ durat ion
,we
Commonly, the general disorders that compl icate cataractextraction are ones of metabo l i sm ,
i . e .,diabetes
,gout, etc . I
have under observat ion a man operated upon for cataract l astsummer by one ofour confreres , the resu lt being complete occlus ion of the pupil lary space due to inflammatory exudate. The Opc rator was not aware tha t the man had been a sufferer from diabetes for several years before
,the pat ient being very careful not
to tel l him anything abou t it .The more or less recognized “
ru le Of ophthalmic surgeons , thatyou can operate cataract success fu l ly in a diabetic patient whenthe sugar i s be low one per c ent i s not by any means infall ible .The fact i s that one must take into consideration the condit ionof hi s pat i ent more than the amount of sugar in the urine .
The only instanc e of suppuration fol low ing extraction of
cataract that I have had, was in a case of diabetes in an old man
in which at the t ime of the Operation there was les s than one percent of sugar . The patient died in less than two months after theextraction . He was operated at his own request with the understanding that there was not much hopes of Obtaining vi sion .
I am of the opinion that in some of the cases Op erated uponin which the cortex seems to set up a mild grade of i riti s
,thi s
compli cation cou ld be avoided by previously to the operation
admini stering iodide of potass ium and other remedies to furthereliminat ion , or counterac t the gouty tendency .
It goe s w ithout say ing that the Wasserman test shou ld bemade frequent ly
,where there is any cl inical symptom or other
evidence of past syphil it ic infect ion ; and especial ly questionsasked leading to the di scovery of evidence of hyalit i s having beenpresent .The u se of mercurial ointment or potassium iodide, while it
may not influence the healing process , yet might prevent compl icating low grade diseases of the uveal tract.The state ofmind of the pat i ent i s a factor not to be despi sed
by the cataract operator . There i s no operation in sur gery wherethe co-Operat ion of the patient i s so much to be desired as in this .
Within the year I attempted to Operate upon the eye of anold woman having only seen her twice for periods of a fewminutes . She was wheeled into the Operating room , the eye wasprepared by strang ers , and I , a strange doctor, grasped the eyebal l with a fixation forceps
,ready to make incis ion . The psychic
shock was too much . She began to retch as i f to vomit and continued i t w ith every attempt I made to continue the operation .
She was taken back home and never agai n woiI ld make theattempt to recover her sight . The result i s she wil l probably bein darkness to the end of her days .
Other spasmodic symptoms , as coughing,sneezing
,commonly
compl icate this operation . Smal l doses of morphine wil l usual lyprevent either i f given a short time before the operation .
In conclus ion I wish to repeat that the ophthalmologists oftoday especial ly need to keep in closer touch with cl inical medicine . I t i s along these l ines that the surest progress wil l be madenot on ly in medicinal ophthalmology di rectly but indi rectly inOphthalmi c surgery .
"N o better comment can be made as regards the preparationOf the pati ent than to quote fr om W . Gordon M . Byers in Wood
’
s
Ophthalmic Oper ations .
“We str ive at present for the complet edi s in fection of the field of operation and th e prevention o f contamination
, not only from the air ( the poss ibi l ity and importanceofwh ich were overestimated by Li ster ) but from every extraneous source of asepsis . These are our ideal s ; but that we haveso far been unable to rea liz e them
,and that ci rcum stances and
conditions Often compel us to fal l back upon the original idea of
controll ing bact er ial proc esses ( antiseps i s ) , i s only too wel lknown . E special ly i s th i s true of ophthalmology where the loc alanatomica l conditions
,whi ch wi l l be dealt with more in detai l
elsewhere in this section, present obstacles in the way of com
plete asepsi s insurmountabl e by any means that we now have athand. Sti l l , the goal i s apparent ; but undoubtedly advance wouldbe more rapid i f the spiri t of progressiveness in thi s direc t ionwere more pronounced among ophthalmo logists . I say thisadvi sedly , because
"I am pe rsuaded from wide Observation that
secure a thorough grounding in thi s importan t department ofthei r work. On the other hand, a know ledge of the practi calimposs ibi l ity of completely steri l iz ing certain parts of the fieldof operation
,and of the relatively great resi sting powers which
the oc ular ti ssues po ssess,breeds a laxness that readily passes
into actual uncleanl iness . Sti ll,the facts of asepsi s are so well
etab lished and are so often brought to the attent ion of the surgeon, both as undergraduate and practitioner , that there is no
excuse for negl igence or for part ial measures,which are not only
i l logical , but because of our imper fec t know l edge of infection , aptto be dangerou s . We shou ld rather
,as Czermak and E lschnig point.
out,accept the favorable local conditions which Nature has p ro
vided, not as an excuse for greater laxity, but as a s timulus toachieve a fu l l er measure of suc cess in ou r work ; and unquest ionably the practic e Of Ophthalmology w i l l be most rapidly advancedby a spirit of open-mindedness
,which speedily ad
'
opts everysound procedure indicated by our developing science .
” —E D . ]
embrace at least hal f or more of the corneal circumference andin such there i s great er danger of gaping of the wound .
It was also observed before the days of aseptic surgery thatsuch large corneal flaps were more l iable to slough
,a danger that
i s not , how ever, so great, i f strict asepsis obtains . However,it
i s generally bel ieved that corneal wounds in the l imbus are les sprone to infection and heal more readily
,probably becau se Of
greater vascu l arity of this part .
E xcept when special ly indicated , the sect ion shou ld be in theupper part of the cornea,
for in this s ituat ion the l ips of the
wound are hel d together better by the natural pressure of the
uppe r l id , and even i f the eyel ids shou ld be opened under thebandage , there i s les s l ikel ihood of infection of the wound becau seit i s better covered. by the l id
‘
than i f it were lateral ly or down
wardly placed .
Furt hermore, i f the combined operat ion i s done the colobomaOf the i ri s i s nearly covered by the upper lid
,and hence there fol
lows l ess disturbance of vi sion from“ dazz l ing” than i f the col
Obome is below or at any point exposed in the palpebral fissure .
The sc lero—corneal inc ision enab l es us to meet the terms of thethi rd and fourth requ i rem ents that have been given
,in that with
such a sec t ion i t is possible to make a conj unct ival flap . The
advantages of such a flap covering a good portion of the cornealwound are obvious . When it i s smoothly placed at the end ofthe operat ion , i t heal s qu ickly thus seal ing the wound and preven t ing the later entranc e of in fec tion
,and al so furni shing a l igh t
suppor t so that there i s less danger Of gaping .
This i s part icularly des irable in s impl e extract ion , for with aslight degree of i rregular pressure On the eyeball , as from a mis
placed bandage, or a sudden movement of the eye , there may fol
low a momentary gaping of part of the wound and an almos tinevitabl e engagement of the i ris in it
,or pos sibly a prolapse .
Among the di sadvantages of the conj unctival flap i s that incutt ing it there i s apt to be more or les s hemorrhage , and theblood may get into th e anterior chamber and so obscu re the field
remain
fficulties of a
subsequent disci ss ion of the capsu l e . But this obj ection of the
conjunctival flapmay be sati s factori ly met in most cases by theuse of some preparation of suprarenahn Immediately be fore the
Operation . This so blanches the conj unct iva that there is littlel ikel ihood of enough hemorrhage to obscure the field .
Another disadvantage i s that the flap of conj unct iva is apt toget in the way of instruments used for the i ridectomy and thecapsulotomy. Thi s can be met by carefu l ly folding the l itt leflap back over the cornea with the back o-f the kni fe as soon as
the incis ion i s completed . The obj ection that the flap may getin between the l ip-s of the wound, and so prevent rapid heal ing, i smet by care ful ly replacing the l ittl e flap w ith forceps and spatulaat the end o f th e Operation .
After a l l i s said. the advantages of the conj unct ival flap incataract extraction considerably outweigh its disadvantages , andone feels much more comfortabl e when he know s that the cornealwound is neat ly covered by a w ell-m ade flap .
In a paper of this length it would be imposs ible to describeor even to mention the various incis ions and modifications tha thave been pract i sed and advocated by different dist ingu i shedOperators whose work has contributed to the evolut ion of the
modern section . To study and apprec iate th i s phase of the subj ect one shou ld consult the excellent E ncyclopedic Francoised’
Ophtalmologie, Czermak’
s A wgenéir tzliche Operationen,and the
more recent works,Beard’s Ophthalmic Sur gery and Wood
’
s
Sys tem of Ophthalmic Operations .
A brief consideration of a few that have influenced the development of the modern section may not be out Ofp lace .
To Jean Jacques Daviel we owe the honor of being the first
to practise and teach the method of treatment of cataract by extraction of the Opaque lens . Prior to 1 75 2 ,
when Daviel first pre
sented the result of his early work to the Academy of Surgeryof Pari s , i t was the practi se of surgeons to treat cataract by amethod known as “couching
”or pushing the lens . back into the
Finding this method unsuccessful in a certain case , Davielwas inspi red
‘
to make an opening into the lower part of the cornea
a narrow keratome,and enlarging to right and left in the l ine of
the l imbus wi th» sci s sors or w i th a blunt -pointed knife until thes ect ion included ha l f the ci rcum ference of the corneal base .Through thi s wound. the capsule was opened , and the lens expressed by pressu re upon the l ids or by the means of scoops .
I t i s interest ing to note that with the difference of its beingmade downward
,this i s the incis ion Of the flap operat ion of to
day. But it had to go through a great many changes and modifications before i t was l earned that , after al l , Daviel’s inci sion inth e l imbu s was the correc t one .
Surgeons took up w ith the idea of extract ion , and modificat ions and improvements Of technic w ere rapidly forthcom ing .
Sam ue l Sharp devised a kni fe fo r making the inci sion wi th onecut , and he was followed prompt ly by De L aFay,
who had a sim
ilar improvement . These operators made a puncture and counterpuncture and form ed the flap by an incision downward .
W'
ith few except ions the operators Of the latter half of the1 8th century made the flap downward
,but about 1 80 0 De Wenzel
was a strong advocate for the incis ion upward . Beer made the
flap inc i s ion downward and devised the famous triangu lar kni fefo r this pu rpos e .
Then followed other operators,Pelluci, Santerel l i , Travers
and Friederich Jaeger , who bel i eved in making a sma ll er sec
t ion,termed by Jaeger the l inear inc is ion
,thinking thu s to escape
the danger of s loughing of the larger flap .
V on Graefe , 1 860 ,recognized the dangers ( in those days ) of
the large flap incision and the disadvantage of the smaller l inearinc i s ion for extrac t ion of hard
,sclerosed l enses . He therefore
introduced wha t he termed the modified l inear incision which hemade w ith a narrow Graefe kni fe . To insure better coaptationof the wound and more rapid heal ing, he made the inci sion en
tir ely in the scl era , entering the po int of the kni fe about 2 mm .
behind th e scl ero-corneal j unction , making the counter-punctureat a corresponding point opposite and t erminating the cut in the
THE INCI SION 33
l imbus above, the whole incis ion be ing about 1 0 mm . long . Aniridectomy was made to avoid prolapse of the i ri s .But whi le this sect ion healed rapidly, it was observed that
with it there was greater danger of irit i s , glaucoma and even
sympathetic Ophthalmia, probably b ecause Of wounding of thecil iary processes .Jacobson, in 1 864, advocated a return to the old Daviel in
cision downward, which he made in the sclero-corneal j unction ,including about hal f of the corneal c i rcum ference, and combinedwith a large i ridectomy .
De Wecker, in 1 875 , b rought back the pure corneal flap, making the inci sion in the upper l imbus to include one-third the circumference of the cornea .
Maj or Smith in the so-cal l ed Indian intracapsular extraction,enters the po int of the Graefe knife in the sc lero-corneal j unction
,and makes the counter-puncture through the sclero-cornea
of the opposite side, at such points as to have the incision em
brace hal f or nearly hal f of the corneal base . The incision i s
made upward and instead of terminating in the l imbus,as doe s
the ordinary flap section,the kni fe is b rought out in the cl ear
cornea 1 mm . or 2 mm . from the sclero—cornea,and in finishing
the cut the kni fe sweeps forward. s l ightly so that the wound in the
clear cornea may be as nearly as possible at right angles to thesurface of it .Th ere i s thus lost the advantage Of the conj unct ival flap , and
one might suppos e, owing to the large s ize of the wound and themanner of terminating it at right angles to the cornea l surface ,that the danger of gaping would be increased . Smith and his
followers claim,however, that this does not occur, and that there
i s less danger of over-ri ding of the edges of the wound than i fthey are obl iquely cut , and hence unnecessary astigmatism isavoided.
Assuming then that the sclero—corneal flap incision ,as prae
tised in modern times,i s to be fol lowed
,let us consider some of
the points in the technic of its execution .
Fi rst as to the instruments .
The speculum,i f used , should be of such a patt ern that it can
be as readi ly and quickly withdrawn as i t i s inserted, and i ts
spring shoul d not be too strong . I prefer a l ight,Mel l inger
,sel f
ret'
aining speculum with a weak spring .
that the catch can be turned back .
The kni fe shou ld be of the u sual Graefe pattern with. an edge
straight up to w ithin 4 mm . Of the point . Personally , I shou lds elect one of medium w idth rather than a w ide one . The pointand edge should , of cou rse , be accurately tested before use .
The pat ient previously prepared l ies on a tabl e Of a heightconvenient for the operator . In the preparat ion of the eye forthe operat ion I like to c losely c l ip the eyelashes Of the tempo ralthird of the upper l id border
,for these are so apt to touch the
edge of the kni fe as it enters the eye and thus soi l it . I t ishardly nec essary to c l ip al l the l ashes
,and i f some are left they
fu rnish a good m eans of taking hold of the l id in case of neces
sity. The lid marg ins of course shoul d be careful ly c leansed in
the preparat ion . A solut ion Of fou r per cent . cocain should be
dropped into the eye four t im es at intervals of three m inutes,and w ith the last inst i llat ion a couple ofdrops of I to 1 0 0 0 adren
al in chloride solut ion may be used .
The Operator stands either in front of or behind the pat ient ,according to his own preference of cutt ing away from or toward
him sel f .
The specu lum is then gent ly inserted , and care is taken not to
separate the l ids so forc ibly o r w idely as to cause the pat ient discomfort
,and. he shou ld be gent ly told. not to resist the pressure
of the Specu lum and to keep both eyes w ide open . Indeed iti s a good plan to insert and remove the specu lum once o r tw icebe forehand to give him a l i tt le dril l on this sub j ect .
In taking hold of the eyebal l w ith the fixat ion forceps I m uchprefer to select a point c lose to the cornea in l ine w ith its ver
t i cal meridian,the l ine of the blades being paral lel w ith this me
r idian,rather than a point opposite the in ferior-nasal quadrant .
When fix ing the eyebal l at the nasal s ide there is too much l iability of a fold of the conj unc t iva being drawn over the l imbusat the point where one wants to make the counter-puncture . H ow
ever , thi s procedu re may be varied ac cording to c ircumstanc es .
This much is impo rtant,to place the closed forceps against the
conjunct iva at the point to be grasped,then to allow the blades
to spread 4 mm . or 5 mm . so as to stretch the membrane at thispoin t , then to press the blades a l it tl e more fi rmly against the eye
l tissue . This gives athe conj unct iva nor to
T he hand holding the forc eps shou ld rest gently on the pa
tient’
s nose,and care shou ld be taken not to pres s upon nor drag
on the eye w ith the instrument . The pat ient i s asked to look
slight ly downward and the eye is held in this posit ion .
Holding the kni fe firm ly but l ight ly, and making sure that thecutting edge i s in the right di rection
,the operator
,rest ing the
l itt le finger on the side of the head , may begin the inc ision . Be
fore making the punctu re , it i s not a bad. prac t ice to place theblade acros s the cornea in the posit ion it i s desi red to have i twhen the counter—puncture is made, to mark out , so to speak , the
course it i s about to take .
Then inserting the point of the kni fe exac t ly in the sclero
corneal j unct ion at the selected spot,a l itt le above the horizontal
corneal meridian , the blade is pu shed into the anterior chamber
toward the center of the pupil,but as soon as the t ip of the blade
i s seen in the chambe r its di rect ion is s l ight ly changed and it iscarried st raight ac ross to the point of counter-puncture exactlyopposite .
Bec ause of the ref ract ion of the cornea,the beginner i s apt
to make the counter—puncture too far back , and should rememberthat i f the point engages in the c l ear cornea about I mm . f rom
the l imbu s it w i ll emerge a t the right spot in the scl ero corneal
j unction . A s soon as the counter-puncture is made the cuttingshould begin by pu shing the blade on and keeping the edge exactly in the l ine of the l imbus .There shou l d be no hes itat ion at this stage
,and w ith the for
ward thrust the corneal section shoul d b e at least hal f completed .
By carefu l attention to this point there is les s danger of the iri sgetting onto the edge Of the kni fe and being “scalped” as the cut
i s made . Some operators endeavor to comp lete the inc ision w iththe forward thr ust
,but unless the kni fe i s extremely keen
,this
is very difl‘icult .
Then by steady withdrawal,cutting al l the t ime
,and
,i f neces
sary , another thrust , the incision w i l l be completed. At thetermination of the sect ion somewhat more del iberation i s necessary to avo id bringing the kni fe out w i th a j um p, which mightcause the patient to Start or to squeeze the eye and force out i ri s ,
flap , i f des ired , about 3 mm . or 4 mm . in width . The edge isthen rotated forward to divide the flap . The l ittle flap shou ld beplaced forward on the cornea w ith the back Of the knife , beforeproceeding to the next step of the operation .
Throughout the whole incision,there Should be no hesitation
whatsoever, but at the same time no hurry . The kni fe should
not sto p moving f rom the t ime the puncture i s made unti l theend , or at leas t unt i l the cornea i s nearly divided and the con
junctival flap is to be fashioned . At the same time the operatorshou l d not forget the hand that holds the forceps
,and shou ld
avoid m ak ing pres sure or pu l l ing on the eyebal l .
But “ i f to do were as easy as to know what ’twere good todo al l ofus cou ld make beauti fu l corneal sections all the time .
Care must of course be taken in the forward thru st that thepoint of the kni fe does not come into contact w ith the s ide of thenose or the eyel id
,cau s ing the patient to start and also soi l ing
the kni fe . By directing the eyeball sl ightly outward as w el l asdownward this may be avoided .
E yes that are deeply placed in shrunken orbits,and those w ith
contract ed palpebral fissu res,are difficu l t to operate on , but in
such cases I shou l d not hesitate to make a free preliminarycanthoplasty , which can be eas ily done under infilt ration. anesthesia.
I f the poin t of the kni fe enters the cornea too obl iquely thereis danger ofspl itt ing i t for a considerable distance and thu s shortening the wound canal too much . This may be avoided by hold
ing the blade across the cornea for an instant be fore beginning ,
to mark out the line of incision,and then draw ing back the kni f e
in the same plane and beginning the puncture . I f the iri s fal l s onthe edge of the kni fe after a wel l-placed counter-punc tu re , it i susually be st to proceed w ith the cut and take away the port ion ofthe iri s that has engaged . I t u sual ly makes a rather poor colob oma , but the subsequent i ridectomy may remedy this .
I f,however
,the counter-puncture shou ld be made so far back
as to t ransfix the i r i s at the root , it would be b etter to gent lyw ithdraw the kni fe enti rely and either wait for the chambe r to
of i t . With this there is les s danger of the i ri s fal l ing in frontof the kni fe before the inc i s ion is completed
,and a smoother in
cision can: be made than w ith a narrow er one .
In order to keep the punc tur e and counter-punc ture at thesam e level it is wel l to lay the kni fe on the cornea so as to get iton a plane w ith the i ris , then , i f its direc t ion is not changed , ther ew i l l be no danger of making the counter-puncture either too farforward in the cornea or too far back in the scleral t i ssue . The
inc ision shou l d be made w i th as l ittle saw ing mot ion as poss ible ,
pushing the kni fe through on an even plane unt i l the conj unc t ivalflap is reached.
T he point at which the punc ture and counter-punc ture shou ldbe made w i l l vary according to the prob able size of the l ens , as
wel l as its relation to the size of the cornea .
T he sc lero sed lens of a person of 70 w i l l need a much largeropening than that of a person of 50 or 60 w ith more or less softcortex .
The most disastrous m i stake which can be made is in mak
ing the inc is ion too small , necess i tat ing pressure on the eyeballin the removal of the l ens
,and in that way bringing about pos
s ibl e vitreous prolapse and inj ury of the i r is i f it shou ld becom eengaged betw een the edges of the inc i s ion .
A s my preference is to do s imple ext rac t ion in all uncompli
cated cases , I always endeavor to make a smal l conj unc t ival flap .
This shou ld be 2 or 3 mm . w i de,for
,as Czermak has demon
st rated,this gives a better resu l t than a w ider flap and a more
rapid c losure of the wound,thus prevent ing i ris prolaps e .
When the combined extraction is done , there is danger of p rolapse of the vitreous i f the inc is ion is made near the periphery .
In order to avoid' this,many operators have brought the inc is ion
down in the cornea so as to end it 2 or 3 mm . f rom the upperbo rder .
T o make a suffic ient ly large incis ion , i t i s necessary to starti t at a much lower po int in the cornea or much farther back inthe sc leral t issue . While this reduces the ri sk of vitreous pro
extremit ies o-f the incision come so close to the i ri s that adhesionsof i t to the inner side of the wound , or s light prolapses , are veryfrequent . Should these difficu lt ies occur
,the iri s , instead of b eing
drawn towards the upper border of the cornea, i s pu l led forwardso as to obl iter ate the filtrat ion angle over a large area . It i s
for thi s reason that glaucoma i s l ikely to follow thi s incision . I
have recent ly had under care th ree pat ient s with glaucoma following cataract extraction where the iri s was drawn forward inthe manner j ust described . One of them was operated by the
intracapsular method and two with capsulotomy . In one patient
both eyes were glaucomatous w ith complete loss of sight in oneeye . While adhesion to the wound or sl ight i ris prolapse wil lcau se drawing up of the pupil
,with interference of vision , the
danger ofglaucoma seems much less when the incision i s made atthe sclero—corneal j unct ion .
Another reason why I prefer the sclero—corneal section i s thatthe amount of astigmat ism fol low ing operat ion i s less than withthe corneal incis ion . In two extract ions by the intracap su larmethod with the l inear inci sion which I have seen the cornealastigm a t i sm in one case was 1 0 dio-pter s and in other I3 diopters ,making it imposs ible to get anything l ike perfect v i s ion althoughthe media were cl ear . While i t i s impo ssible to prevent a certainamount of astigmat i sm
,the farther the incision i s brought into
the co-rnea the greater the chance of the over-riding of the edgesand a subsequent i rregularity of the cornea l ikely to be p roduced .
"Failure of the experienced operator to make the incis ion asdesired depends as a rule upon two conditions . Improper be‘
havior of “the patient and insecure hold upon the conj unctiva orloss o-f a secu re hold through friabi l ity of this membrane . Dr .
Beard makes the following suggest ion in’ his Oph thalmic Surgery :“The best point at which to take hold with the fixation forceps
in upward extract ion is a matter of no mean importance . Thepoint in quest ion i s at or near the center of the in feronasal fourthof the corneal l imbus ; in other words , j ust b eneath the inner ext remity of the horizontal diameter of the cornea . To grasp thetissues h ere affords a much more sati s factory means of control.l ing the eyebal l than does the more general ly chosen one of seiz
smoothed out or put l ightly on the stretch,the obj ect be ing to
obviate pick ing up too much of the conj unctiva, thereby causing
it to overlap the cornea along the s ite of the proposed inci s ion .
The instrument is then pressed more firmly, and a good big bi tei s taken , and as deep a one as can be obtained. The fold composing this bi te should stand perpendicu lar to the tangent of thel imbus . I f the conj unctiva proves too friable to insure a sufhci ent hold
,try lower down or even beneath the cornea . The for
ceps referred to here are w ithout a catch or lock and have broadj aws . I f , whil e the kni fe i s engaged in the section , the fixationbecomes insecure because of a purely conj unctival bite
,twisting
of the forceps on its long axi s wil l tighten the hold . The second
finger rests upon the patient’s nose,the third and fourth upon
the oppo s ite cheek , and the hol d i s steadily maintained, meanwhile scrupulously avoiding either to press or to pul l upon theeyeball .”— E D . ]
C H A PT E R I I I .
lRlDECTOMY AS A PART OFTHE OPERATION
OFCATARACT E"TRACTION .
BY CASEY A . WOOD,M . CHICAGO .
T he most important purpose of the iridectomy in cataract removal is to prevent prolapse of the iri dic and other ti ssues andtheir incarceration between the lips Of the corneal or sclerO-cornealinci sion . It also faci l itates the extrus ion of the lens , and insome instances diminishes the chances of infect ion whi le it favorsultimate improvement in vis ion .
I t probably lessens the danger of prolapse by allowing thebirth of the lens without stret ching and weakening the sphincterpapilla and by furni shing a means of escape for the flu id, semifluid and sol id dé bris resu lting from the Operation as a whole .
E xci sion of a portion of the iri s as a part of the operation forthe removal of cataract may be performed some t ime before , atthe same time as , or at a period subsequent to the extraction of
the lens .I have assumed that the performance of a smal l i ridic ex
cision for op tical purposes in central cataract ( anterior-po lar, pos tpo lar, certain forms ofnuc lear opacity, etc . ) as wel l as an irideetomy in any form or stage of juveni le cataract , does not form apart of this sympos ium .
Preliminary Iridec tomy.
A few surgeons , Mooren for example, advoc ate an early iridectomy in every form of seni le cataract— mature or immature,compl icated or normal— in which an exci s ion of the i ris is cal ledfor. There seems no reason for its per formance in favorablecases . I t is an open secr et that about forty per cent . of catarac textractions t erm inate equal ly wel l under any form of Operation ,even at the hands of the inexperi enc ed . Given a hard , properlymatured, opaque lens easi ly separable from its capsules , occurr ing
add unnecessari ly to the ri sks,los s of t ime
,expense and anxiety
of the pat ient by ins i sting upon two separate operative seancesin cases where one i s sufficient? In other words , in. this discussionthere ought to b e fo rmu lated , as nearly as pos sible, reasons fo rthe per formance of a prel iminary i ridectomy .
V on Grae fe first prac t i sed the prel iminary operation and ad
vised that it be per formed a few weeks prior to the extraction .
I n the pre-asept ic era he found the double operation to reduce thenumber of in fect ions , incarcerations and pro lapses .The succeeding extraction was found to be les s dangerous
than the ordinary combined operat ion , ow ing to a smaller area ofposs ible infect ion , the absence or smal ler amount Of bleeding ,
the avoidance of anterior synechiae,and the lessened risk of the
iris fal l ing over the knife edge while making the corneal section .
Moreover , the primary and less serious intervent ion undoubtedlyhas a good effect upon both: surgeon and pat ient ; they come toknow one another better ; some l ight is thrown upon the probabl e behavior of the pat ient when the t ime for the lenticu lar ext ract ion arrives ; the latter Often finds that the ordeal i s not so
dreadfu l as he expected ; greater confidence in the surgeon i s eugendered whil e qu iete r and more favorable condit ions for theheal ing ofthe extraction wound are the resu lt .
T he surgeon somet imes Obtains valuable informat ion aboutthe condi t ion Of the lens periphery, and even as to the contents ofthe posterior chamber , a fter a prel im inary exci sion of a po rtion
of the i ri s .
I have on several occasions noted the value of the early i ridec tomy in determining the character of the globar contents .
I general ly m ake my inci sion w i th a keratome two or three mm .
from the sclero—corneal j unction and carry the point of the in
strum ent forward very close to the anterior sur face of the i ris .
I t i s w el l to remember that the keratome is not a spear whosehead is to be plunged through the eye coats for the pu rpose ofmaking an opening in the eyeball .For mysel f I prefer to stand behind the pat ient with the eye
rotated and held downwards . The handle of the instrument i s
chamber close to the root ofssed and the opening enlarged
by cutting a path w ith one edge Of the blade unti l the point appears at the pupil . The handle of the inst rument i s then moveda l itt le to one side and the second edge of the blade cuts its wayout so as to make the second wound margin paral l el to the first .An advantage Of such a peripheral wound is that when the
vitreous i s flu id it is very l ikely to present and to warn the surgeonto be on his guard when the extract ion i s made .
I bel ieve that in MO-rganian catarac'
t , or where milky or
sim i larly degenerated lenses are present,a prel iminary i ridec tomy
shou ld always be made ( especial ly i f the cystotome is employed ) ,
because the in fection of the iridic wound from the “milk” or otheri rritant
,intra-capsu lar contents i s les s l ikely to occur .
Another point . The ' healthy i ri s bleeds l it t le or not at allwhen a portion of it i s excis ed ; hemorrhage therefore is almostinvariably an indication that i t or some other part of the uvea ltract has beenthe site of a previous inflammat ion
,a fact of great
importance to the surgeon who i s later on .to do the extraction .
H i rschberg""bel ieved the prel iminary Operation to be of advantage in catarac t compl icated w ith annu lar or mu lt ipl e poster iorsynechiae, in pat ients w ith only one eye
,in condit ion s that pre
c rude post -operat ive rest or sleep,in all cases of inc reased intra
ocular tension and in immature cataract where iridectomy migh tbe employed (as in Bettman
’
s orFOr ster ’s intervent ion ) for thepu rpose of ripening” the cataract .
C ritchett advised i t when there is evident ly soft cortex,whi le
Kuhnt does the preparatory Operation in gout , diabetes andchronic rheumat i sm ; in nervous or over-anxious pat ients ; in eyesaffected by posterior synechiae , cycl it i s , or anesthesia of the
cornea ; and in suspected glaucoma .
Personal ly , I am in favor of and have done a preparatoryi ridectomy in about hal f of my cataract extractions during thepast twenty years and
,weighing the advantages and disadvantages
of the procedure , I am inclined to beli eve that this proportion corresponds in my practice closely to what might be termed “
ab
normal” senile cataract .*Deut§ch . Zez
'
ts chr ift f. plat . Med. 1874, p . 31 .
pupi l reaction to light or accommodat ion,when the pat i ent is
under s ixty years of age and in the presence of any form of conjunctivitis, lach rymal insufficiency or nasal di sease .
An interval , usually about a month , should be allowed to intervene be fore the extraction . In most instances , the iridectomv
wound clos es in a few hou rs and uni formly heal s firmly in a fewdays . I t thus happens that this divis ion of the cataract oper ationinto two sittings does not material lylengthen the stay of the patient in the hospital
,while the lessened risk in many cases and
the better vis ion in others,undoubtedly form an unanswerable
argument for the Operation in the class of cases I have detailed .
C atarac t E x trac t ion w ith I ridec tomy in One Sit t ing .
Although this may not be the place to discuss the merits ofthe simple ver sus the combined cataract operat ion i t w i l l readi lybe seen that one can hardly consider the i ridectomy at this stageof the procedure without saying som ething about it . I may , perhaps , be pardoned for quoting from my own chapter in A Sys temofOphthalmic Operations ( pages 1 1 98 and 1 1 99 ) those views on
the subj ect that I have long held : It woul d requi re many pagesto discuss the merits and defects of the two principal methodsof extract ing senile cataract . Probably the proper form of in
qu i ry should relate not so much to a decis ion as to which i s thebetter method
,but to an attempt to decide the cases in which
one operation ought to be performed in pre ference to the other .In other words
,a selection of cases i s called for becaus e it is
undoubtedly true that an operator may employ the s imple methodtoo much .
The ch ie f complication and,i t might be added , the chief obj ec
tion to the operation without iridectomy i s the more frequent occurrence in i t of i ris prolapse and the difficulties in deal ing withcortical matter . Both these drawbacks are assoc iated with theirattendant evi ls
,uveiti s
,astigmatism
,ir regular pupi l
,secondary
cataract,etc .
,and it i s a question whether the simp le operation
should be done in every instance by one who has not had con
wound,and of their sequels ( cystoid scar , smal l staphyloma
'ta ,i r it is
,i rido—cyc l it is and sympathet ic ophthalm ia ) ; sl ight incar
cerat ion of the capsule ; in ferior visual acu ity , dim inut ion of
peripheral s igh t and,in consequence
,defec t ive orientat ion greater
l iabi l ity to pos t-o perat ive glaucoma on account of i ridic and cap
su lar h ernia .
However,the dic tum ofTerrien ( C hir iirgie de l
'
Oeil,p . 1 49 )
that the s imple operat ion is the procedure of choice and the com
b ined one of necessity or selec tion ( operation d’
ex ception) i s
prob ab ly true . I n any event,it is better to do an iridec tomy in
rigid i rides,or thos e that are not qu ickly affec ted by mydriat ic s ;
in unripe cata racts : in diabet ic c ases,and whenever there is any
suspic ion of pos terior synechiae. To this category m ight al sobe added hard catarac t oc curring in high myopes or in pat i entshaving any of the undes i rable compl icat ions elsewhere ment ioned .
The iridec tomy thus made is one rather of prevent ion and prudence ; th e unmut i lated iris and the round pupi l shou ld be r e
tained i f poss ible .
T he T echn ique of I r i dec tomy in th e C omb ined Operat ion .
The only point in which I differ from the ma j ority ofsurgeonsis in my decided preference for smal l sci ssors ( sem i—cu rved on
the flat ) instead of the de Wecker , Noyes o r other form ofpinceciseaux
,in excis ing the iris . But this
,of course
,is me rely a per
sonal affair,and is of l itt le importance .
I pre fer the Noyes’ i ri s forceps because it is an instrum enteasi ly handled , small enough to be retained between the thumband index finger and more readi ly manipulated than long-handl edforceps .
I have never been able to discover any use fu l purpose in eitherlong-handled sc i ssors , long handled ophthalmostats o r long
handled iri s forceps . The personal equation doubt les s determinesthe choice of all the instrument s in this operat ion ; in any event
it i s not so much ‘
a quest ion of what instruments as to how theyare emp loyed that interests us . E ach operator shou ld hold andcut Off or out the small piece of i r is w ith whatever forceps andsc i s sors he can handle most deftly and with the least discomfortto the pat ient .Imm ediately b efore proceeding to this manipu lat ion it i s w el l
to noti fy the pat ient that he may experience a l itt l e discomfortbut that he must under no c i rcum stances “
squeeze up” his eyes butbear w ith a l itt le mo mentary pain . T he surgeon shou ld again askhim ( always in a very qu iet and. low voice ) to look down and
Fig . 1 .
E xtrac t ion of Senile C ataractSome of the I r i dectom ies and I r idotom ies Made in V ar ious C omb ined
Methods . "Wood ]
keep both eyes , hands and mouth open . Th en,holding the iri
dectomy scissors c los ed,w ith the right thumb and middle finger ,
and a pai r of smal l i r is forceps ( also closed) w ith the le ft handI introduce the forceps into the anterior chamber . "V hen thepoint of the forceps reaches the margin of the i r is, the j aw s of
the instrument shou ld be opened and the iris grasped at this point .
T‘
h-en , b y gentl e t rac t ion , the forceps are w ithdrawn unt i l thepupi l lary edge of the ir i s appears w ell outs ide the corneal in
c ision . At this moment the folded iris tissue is cut through w i thone snip of the scissors held exac t ly in the vert i cal mer idian of
the cornea . I f thi s step is properly carried out the margins ofthe coloboma thus formed w i l l recede w ithin the anterior chamber . I f , a fter waiting a few moments , there i s no disposi t ion on
Modificat ions of the O rdinary Ir idec tomy in C atarac t E xtr action.
As set forth in my Sys tem of Ophthalmic Operations, (pp .
1 2 0 0 -1 2 03) several operators have devis ed modifications of theusual operation . V erhoefi makes the corneal incis ion in the usualmanner . The iri s i s then grasped with the forceps as near itsroot as po ssible and a small bit of tissue exc i s ed with sci ssors soas to l eave a small hole in it . ( See figure The iri s w i l l im
2
Fig . 2 .
V erhoeff ’s Modified I r idoec tomy as C ompared w ith the Usual Ir idectomy.
mediately retu rn to the anterior chamber of it s own accord . de
Wecker’s small i ri s scis sors,preferably w i th blunt—pointed blades
(Noyes’ scissors w i l l probably serve as well ) , are then introducedthrough the corneal inci sion
,gently opened
,and one blade passed
downw ard through the “hole in the iris unt i l i t proj ects b elow thepupil lary margin . The blades are then qu ickly c losed , thus making a cl ean cut through the iri s to the pupi l .
Ow ing to the mlydriasis produced by the cocain,the edges of
the inci sion wil l separate,usually at once
,as widely as a fter an
o rdinary i ridectomy . ( See the figure . ) I f , how ever , the i ri s i s
pres sed against the cornea by the lens,this may not happen unt i l
a fter the len s has been extracted . The lens capsu le may nowbe opened w ith the cystotome or capsule forceps and the l ens expressed in the usual way
,or the l atter may be extracted in its
capsul e . In making the toil ette of the wound , care should betaken,
as after iridectomy,to f ree the pil lars of the coloboma
IRIDECTOMY A PART OFCATARACT EXTRACTION 49
f rom the incision . It is probably best to instil atropine immedi
ately a ft er the operation since thi s enlarges the coloboma and thuslessens the danger of i ris prolap se.
Thi s operation offers the advantages of both the simple and
c ombined operations without their disadvantages . The lens i sremoved with the same ease as in the combined ope ration , thedanger of i ri s prolapse i s
'
minimized , and cort ical matter can beexpres sed with even greater faci l ity than a fter an i ridectomy .
Moreover,the modified iridectomy requires no such rough han
dling of the iris and causes no such pain as i ridectomy, whi le i ti s superior to the latter in its cosmetic and Opti cal results . Theexci sion of i ri s t i ssue i s made where it wi l l be most effective inp reventing i ri s prolapse and at the sam e time do the least damagefrom an optical standpoint .
I n the case of i ridectomy,a large section of the sphinct er
muscle i s alwavs removed so that the reaction of the pupi l to l ightis necessarily much impaired ; the claim in this operation i s thatthe sphincter muscle is s imply incised and the pupi llary react ionsless interfered w ith . For thi s reason , as well as on account of thenarrow co loboma final ly Obtained
,the dazzl ing on exposure to
bright l ight O ften complained of after iridectomy is,after thi s
method,notably absent . The Optical resu lts are , in fact , practi
cal ly as good as after the simple extraction o r the Chandler button-hol e operation .
Chandler,to prevent pro lapse of the iris
,makes a smal l per
ipheral button-hole opening in that membrane a fter the del iveryof the cataract . At first he simply perforated the i ri s with hiskni fe, but he now removes a piece Of tis sue 1 mm . in diameter,making the round opening as near the root of the iri s as possible .
The obj ec t Of th i s smal l, circular opening is that it not only al
lows drainage of the intraocular fluids but the cort ical matterthat collects above and under the iris can be pressed through theopening Moreover
,in washing out the anterior chamber the
fliiid flows backwards through the opening and carr ies with itall the corti cal dé bri s . In perform ing the operation Chandler tri esto make b ise nt exactly at the scleral-corneal j unction . After thelens has been del ivered , he al lows the iri s to prolapse for a fewmoments , knowing that he can remove cortical matter throughthe perforation in it .As a result of thi s me thod he has had only three cases of
the teeth at the tip and scissors whose blades are very thin ; otherwi se the Opening i s made too large and farther down than itshou ld be . The opening i s made after the expres sion of the lens ,as it seems that the smal l amount of aqueous under the i ri s actsas a buffer and faci litates it s extraction .
Iridec t omy in th e R emoval of C atarac t in it s C apsule .
D . W . Greene (Wood’s Sys tem of Ophthalmic Operations ,
p . 1 2 8 1 ) expresses the following opinions of this procedure in theSmith Operation , and in hi s own modification O f it — “TheJu l lundur method is as follows : One blade Of the i ri s forceps
held in the l e ft hand was held on the pos terior l ip of the woundand the other on its anterior lip . By pressure dow nwards (moreon the ant erior than the posterior lip ) the iri s was made to prolapse
,was caught as the forceps closed , and cut in the di rection o f
the section by the scissors held in the right hand. An advantageof such an iridectomy i s that no instrument enters the anteriorchambe r .”
“While in Ju l lundu r I was permitted,at my request
,to make
the i ridectomy as I had made it for many years,viz . : by passing
the points of the forceps wel l inside the sec t ion ( i f necessary )and catching a smal l bit of i ri s , draw ing i t out and cutt ing it offfrom below upward. By pres sing the sc i s sors downward acrossthe sect ion a more peripheral ( the important thing ) i r idectomycan be made .
”
Greene expresses the further Opinion That any cataract operation wil l be safer i f the iridectomy is performed from two to four
weeks (or longer ) be fore the extraction . I have proved this content ion to my own sat i s fact ion in making a test of the value ofa small prel iminary iridectomy w ith the inci sion back in the l imbusin 1 0 0 cases .
”
He also th inks that There i s in intra-capsu lar extract ion atendency to draw ing up of the pupi l which I am convinced wouldbe best counteracted by a prel iminary operat ion ; otherw ise by asmall i ridec tomy m ade as peripheral as possibl e at the time of thecorneal sect ion .
”
During the operation even a careful ope rator, in hi s anxietyto remove as smal l a port ion of the i ri s as poss ible, may find afterthe use of the scissors that he has made a “button-hole opening
in that membrane . This generally follows the seizure of the i ri stoo near its base .
T he i ridectomy can stil l be carried out by passing in a Tyrrell’
s
hook, drawing out the l ittle band Of uncut tis sue and snipping itw ith the scissors . Herbert ( C atarac t E x trac tion,
p . 97) advises
that —“The narrow strip of ti ssue may be readily hooked up
wards by the cystotome ( held in the right hand ) after the capsuloto-my has been done . I f very narrow it tears readi ly ; otherwise the loop is released
,and the forceps and scissors are again
taken up . The forceps are used so that one blade passes downin front, and the other , generally more or less embedded in softlens matter, behind the band . This w i l l sti l l be found lying nearthe wound
,retraction being interfered with by the sticky lens sub
stance . The points of the forceps being closed beyond the band ,the latter may then be readi ly hooked up and cut away . Or i f
the eye be very unsteady the forceps may be dispensed with . Thele ft hand may be usefu l ly employed with the curette or expressing hook . Pressure is appl i ed at the lower edge of the cornea,as for expulsion of the lens . The wound i s thus forced open
,and
the l ittle band of i ri s stretched and carried forward on the presenting lens
,either into the wound or near it , so that it may be
eas i ly cut w i th scissors . Usually the strip of i ri s may be madeto present sufficiently wel l for the sci ssor blades to be appl i ed
t ransversely,snipping off lens subs tance together with the i ri s .
Shou ld by chance a long tag be le ft attached to one angle of thecoloboma , this shrinks afterwards
,but forms a posterior
synechia .
”
Besides thi s complicat ion one may have a free and embar
rassing hemor rhage into the anter ior chamber which may renderquite difficult the subsequent capsulotomy and removal of corticalmatter .
Detachment of the ir is or an i rregu lar rent or wide tear may
also occur, generally a result sudden and unlooked for. A lthoughevery operator knows that he shoul d never relax his
”
vigi lancefor
'
one instant and expect every untoward incident during all the
lat ion into the anterior chambe r immediately after the cornealincis ion . When either of them does happen a clean incis ion of
the strands or shreds of the iri s shou ld be made and great careexerc i sed that no tags remain in the corneal wound .
I ridec tomy after the r emoval of the lens and be fore the complete healing of the bu lbar inc i s ion i s general ly done because ofthreatened or ac tual prolapse in case of s imple extraction or in
those combined instances where at the angle of the corneal woundan incarceration has occu rred.
In the fi rst compl ication the wound is opened i f neces sary,the
i ris care fu l ly drawn out O-f the wound and exc i sed in the usualmanner . The repositor is now brought into play and a firm bandage appl ied . Some surgeons also keep the eye under the influence Of eserin but I have never been able to see that th is , or anyother agent
,does any part icu lar good in such cases .
A s Knapp pointed out , a w ide and peripheral i ridectomy i sa prompt and effec t ive remedy for the gl aucoma that occas ional lyattacks eyes from which a cataract has been extrac ted by thes imple method .
Of the i ridec tomy employed in treating massive exudates , anterior synechiae, etc .
,compl icat ing and fol low ing cataract extrac
t ions i t is not necessary to speak,especially as there is nothing
in the proc edure i tsel f of spec ial importance .
I may add to the foregoing that although my observat ions andconclu sions are based upon a comparat ively small number ofcataract extrac t ion s
,i . e . ,
1 1 60 publ ic and private cases during thepas t twenty-two years , yet most of them have be en in privatepatients whose subsequent fate I have been able to follow w itha fai r degree of accuracy .
D iscussion by l/Villis O . N ance .
D r . VVOOd,in hi s usual mas terfu l style , has so fu l ly covered
th e e ssent ia l points of this subj ect that there remains l i ttle ofimportance to be added.
Iridec tomy when per formed as a part of the Operat ion for
theext raction of cataract is by no meaans one of the least im
T he question of simple versus combined extract ion i s oneover whic h I have never lost much rest . D r . Wood bel i eves
with Terrien that the s imple operation is the procedure of choice .
I do not disagree w ith either of these distingu i shed surgeons . Theappearance of an aphakic eye with a perfect ly round pupi l , w ithno visibl e evidence of operat ive interferenc e is one of the mos tbeaut i fu l and conspicuous accomplishments of ophthalmic surge ry . And yet I seldom do the s imple operation . I bel ieve thecombined operation appl icable to pract ically all cases
,safer from
the standpoint of bo th operator’s and pat ient ’s interests . E s
pecially to the su rgeon who has an operative reputat ion to make ,I recommend the combined Operation .
The quest ion as to s ize and location of the coloboma hasbeen considered . I have found by experience that it is not alw ays poss ible to regu late the exact amount of i ri s to be exc i sed .
I u sually endeavor to c reate a rather narrow “key-hole” Open
ing . In a number of cases I have “button-holed” the iri s andhave extracted the lens w ithout difficu lty or subsequent i l l effeets . In a case Ope rated qu ite recently a bridge of i ri s whi ch
remained int erfered momentari ly w ith the bi rth of the lens .
With a Tyrrel l’
s hook the “bridge” was brought to the woundopening and separated and the lens immediately presented .
T o assist in the creat ion of a narrow coloboma a hook has
been employed by some operators in l ieu of forceps . I have
never used this instrument for fear that a sudden movement onthe part of the patient migh t render difficu lt instant release of theiri s from its hold .
I ridectomy after extrac t ion Of the lens i s a procedu re thatI have seldom employed and as I comparat ively infrequently dothe “ simple” operat ion it concerns me l ittle .
In conclusion,permint me to suggest , as the resu lt of pe r
sonal experience , two o r three essent ial s to the performance ofa sati s factory i ridectomy : sufficient i l lumination of theeye ; complete anes thesia ; intel l igent control of thepatient .
scissors of De Wecker, used as described by Friedenberg( Claiborne, C ataract E x trac tion) . The iri s is cut Offas closeas possible to the cornea by means o f De Wecker’s sc is
sors or an ordinary curved iri s sci ssors, s l ight pres sure beingmade against the l ips of the section with the scissors
,and the
ir i s cut through in two strokes . It is well to draw the i ris a
l ittle away from the angles of the wound as the cuts are made,in order to free it as much as poss ible and to aid complete repositiou. De Wecker’s scissors may be held at right angles or
paral lel to the corneal sect ion and the i ridectomy done with one
snip . I n the former case the coloboma i s narrow w ith parallelor s l ightly converging margins . When the scissors are heldparallel to the corneal section , the iridectomy i s broader and themargins diverge
,the amount of thi s divergence depending on
the amount of tissue cut away near the ci l iary attachment . Thisvaries direct ly and in proport ion to the pressure on the woundwith the scis sors , i . e . , the length of the cut, and with the amountof i ris drawn out with the forceps . -E d. ]
C H A PT E R I V .
THE CAPSULOTOMY.
W. A . FISHER,M . D. ,
CHICAGO .
The lens may be removed: in its capsule, the so-called intracapsular operation the anterior capsule Of the lens may be cutin various ways , or a portion of the anterior capsule may be removed and the lens extracted, leaving the remainder of the capsule in the eye . Advantages and disadvantages are claimed foreach of these methods .
I f the lens i s removed in its capsule,without accident during
the extraction , good vision and rapid recovery can be expected ,since there i s no capsule or cort ical dé bri s le ft in the eye to causeinflammat ion with consequent los s of vis ion ; and noth ing to oh
struct the vi sion when the eye has recovered from the operat ion ;an obviou s advantage being that it i s never tnecessary to perform a
secondary operation . The greates t number Of obj ections to theinfra-capsular method come from those Operators who are leastfami l iar with this operat ion .
Many operators prefer a capsu lotomy and contend that ithas superior advantages . The principal claim advanced fo r it is
that the lens i s mo re easily extracted after the capsule has been
T he ob j ections to capsu lotomy are many,the chief one be ing
that th e m psule i s le ft in the eye, and u sual ly some Of the cor
tical matter . These may cause total loss of vision from irr itationand inflammation , or par t ia l loss of vis ion from thickening ofthe capsule
,the reby necessitating a secondary operation . Fur
thermore, the opening in the capsule may close , rendering an
other Operation necessary .
Ob jec t of C apsulotomy .
The lens capsu le i s Opened in de ference to the prevalent ideathat it permits the lens to escape more readily than it would
Should C ap sulotomy b e Performed?I f the average operator can remove the lens in its capsule
without subj ecting the patient to increased danger during the
Operation , other than he would by the capsulotomy method, i t
Fig . 3.
C ystotome in pos ition ; patient looking down.
wou ld seem that capsulotomy should not be the method of choice ,for the reason that post-Operative dangers are greater when cap
sulotomy has been per form ed . He is a wise man who seeks toavoid an added ri sk .
C apsulo tomy Meth ods .
There are fou r methods of opening the capsul e . In whatevermanner capsulotomy is per formed, the obj ect i s to make a permanent opening in the anterior capsule
,thus reducing the neces
sity of a secondary operation .
First . By Opening the capsule with the point Of the catarac tkni fe in trans it when the incis ion i s being made . Thi s methodis used at present by only a very few operators .Second . The capsule i s Opened six hours before the opera
tion for extraction of the lens . The author has had no experi encew i th th i s method .
Th ird . The method usual ly employed,and the most popular
one, i s made with the cystotome (Figure The Opening is
made in the capsule in various ways,some making a circular
When the instrumen t i s sufficiently advancedrotated one-fourth on its long axis in order to bring
C apsule forceps in pos ition ; patient looking down.
Fig. 5 .
T ooke capsule forceps in pos ition ; patient looking down.
the cut ting edge di rectly in contact with the lens . A fter the capsulotomy i s finished, the cystitome should be turned one-fourthover, in order to remove the instrument with the back coming outfirst . Manipulated in thi s manner
,there i s no danger of gett ing
the instrum ent entangled in either the cornea or 1 1 18 .
T he fourth method , and the one that appeal s to most operators , i s the removal Of a sect ion Of the capsule with the capsuleforceps . I do not deem it necessary either to mention or
describe t he var ious forceps that have been devised for th isoperation . With any of them a skill ed Operator can removea piece of the capsule . Wh il e most operators acknowledge
to introduce the forceps . E very t ime a patient looks down duringthe extraction Of cataract
,a fter the incision has been made . he
Fig . 6.
A uthor’
s capsule for ceps .
increases the danger of loss of vi treous and with it o ther com
pl ications .The second danger i s tha t if he looks up whi le the forceps are
in the eye , unless the eye i s held by fixat ion forceps,there i s
exceedingly great risk of comp l icat ions , such as dislocating thelens , los s of vitreous
,and cons iderable trouble in removing the
forceps . Fo r these reasons many operators have rel ied uponcutt ing the capsu le w ith the cystotome
,in order to let the l ens
escape,rather than take the risks Of forceps complications .
Most operators,
I am convinced,wou ld pre fe r to remove a
port ion Of the anterior capsul e w i th the capsu le forceps i f theyknew i t cou ld be done w ithout danger . For this reason I wantto call attention to a capsu le forceps which I have devised ( Fig
u res 6 . 7 and I I ) , which can be u sed while the pat ien t is looking up , thus prac t ically el iminat ing all the danger usual ly attendant upon the introduc t ion Of the ordinary forceps .In using my forceps there is no danger of dis loca t ing the
lens . because the patient i s looking straight up at the cei l ing whenthe forc eps are int roduced . I f the pat ient should suddenly lookdown , the eye wou ld draw itsel f away from the forceps w ithoutany effort on the part Of the Operator
,and they cou ld be rein
t roduced at once w i thout endanger ing the eye in the least .
while to do an i ridectomy at the t ime the lens i s removed , thepatient must look down .
A prel iminary iridectomy i s so trivial an affair that i t i s hardlyto be classed as an Operation . The opening in the cornea withthe keratome i s so small that there i s no danger of the lens escaping, and with modern antiseptic p recautions there is l ittl e if anydanger of in fection . The patient can look down while the iridectomy is being done wi thout any risk , but after the incis ion hasb een made for the removal of the lens , the patient should neverbe told to look down as looking down always invites ri sk . Thedirection in which the patient should look , after the inci sion forcataract Operation has been made , i s straight up at the ceil ing , no
T H r: CA PSULOTOM‘Y 63‘
I n the per formance of a cataract Operation, a good l ight i svery essent ial . In do ing a capsulotomy with the patient lookingup
,i t i s preferable to have a smal l l ight which wi ll throw the
illumination not only on the eye, but up and under the upper l id .
It i s very essential that the patient look up when operating withmy capsule forceps , and have the field i lluminated with a l ight Ofthis description (Figure
Fig . 9.
A uthor ’s l id r et ractor .
Posit ion Of Surgeon and A ss istantTo remove a portion of the capsule with. the author’s capsule
forceps , the assi stant should stand on the left s ide and in frontOf the pat ient, when operating on either eye . He should hold theupper l id up and away from the eye-bal l with my lid retractor inhis right hand (Figure and with his l eft index finger or
thumb pul l the lower l i d downw ard , j ust making sufiicient trac
tion to hold the l ids open and away from the eye-ball (FigureIn this position the ass istant secures the most comfortable
pos it ion for the patient , i s not in the way of the surg eon , and doesnot obstruct the l igh t ; at the same t ime he can observe the fieldof operation . This i s imperat ive
,as the role of the assistant i s
nearly i f not qu ite as important as that of the surgeon . Theas sistant doe s not change hi s position unti l the operation is finished. The lid retractor is not removed unti l after the Operationis finished and the eye closed . After the inci sion has been made ,the surgeon shou ld finish the operation by standing on the rightside and in front of the patient when operating on either eye .Dr . Vail wil l ably describe the methods of removing the lens ,
but I would l ike to say at thi s time that be fore the capsule i sopened, emphasizing E lschnig’s rule , the operator can make an
64 THE CAPSULOTOMY
effort at removal Of the lens according to the Smith method.
With a so-cal led strabismus hook he can make sl ight pressurenear the inferior corneal margin , backward toward the Opticnerve
,whil e the patient i s looking up . He may be rewarded by
Fig . 10 .
E xpulsion of the lens ; fir st step in Sm i th method . A uthor ’s l i d re
t rac tor and Sm ith hook .
seeing the lens appear in the opening and with s l ight manipulation he can remove it in i ts capsule ( Figure I f the lens doesno t appear in the wound after sl ight manipul at ion Of the hook ,
no harm w i l l have come to the pat ient and a capsu lotomy can then
be done in any manner wh ich seems best to the Operator .
Method of Us ing the C apsule Forc eps .
With the ass istant in the posit ion and holding the lids awayfrom the eye-bal l as be fore described
,the operator takes the cap
D raw ings were made by D r . A . C . Seely, former ly a student of theC h icago E ye, E ar , N ose and T h roat C ollege ,
now Of R oseburg, Oregon.
inc ision,while the
grasps and removes a piece ofthe capsul e (Figure The Operation is now finished by following the Smith technique , the same
as i f an intra-capsular operation was to be performed . This willb e fully described by Dr . Vai l in the del ivery of the lens in it sc apsule . I prefer to have the assi stant hold the upper l id up and
Fig. 1 1 .
A uthor ’s cap sule forcep s in pos i t ion ; pat ient looking at cei l ing .
away from the eye with my l id retractor rather than with theSmith hook (Figure It seems to me to be much les s dithcult to do, there be ing no further need O f changing instru
ments from the time the operation i s begun ti l l it i s finish-ed.
T his is very impor tant ifthe patient is nervous . The patient continnes to look up at the cei l ing after the lens i s expel led
,and the
cortical dé bri s can be removed in this pos ition,the toi let completed
w ith l ess danger than in any other posit ion , and the lid retractorremoved without the patient being conscious of it after the operat ion has been finished and the eye closed .
Fuchs says : “An important improvement has been the introduction of the capsul e forceps for opening the capsule . With thi sthe anterior capsule is
.
not only split , but also has a piece taken out
of i t . Thus , the capsular wound is prevented from closing
quickly again, and in this way from resorption of the fragmentsof the lens that remain . Since the employment of the capsulefonceps, secondary cataract has become much less frequent ,
T o summarize ( I ) The lens may be removed w ithout capsulotomy, whi ch procedu re, i f successfu l , yields more rapid and
better vi sual resu lts .
( 2 ) Many operators st i l l pre fer capsu lotomy , which may beperformed w ith cystotome or capsu le forceps .
Fig . 12 .
A uthor’
s l i d r et rac tor in posi t ion.
(3) Capsulotomy w i th forceps is attended by the danger Of asudden upward movement of the patient’s eye, but thi s danger isremoved by the u se Of the author ’s forceps .(4 ) Caps u lotomy is easier to per form and attended w ith less
danger i f prec eded by a prel iminary iridectomy.
( 5 ) T he po s it ion of the operator, his ass i stant , the method of
holding the lids away from the eye-ball,and the posit ion and
character of the l ight used , are Of great impo rtance .
Discussion by H ar r y S . C radle.
Cataract has b een Operated upon in one manner o r anotherever since the early E gypt ian periods
,although its nature and
location was not recognized unt i l the mediaeval ages . Our pres
ent operative methods date from Daviel who Operatedboth w ith and w i thout capsulotomy . He used a fine lancet andi f the capsu le w ere thickened
,made a c i rcu lar inc i sion , removing
uc cr
used the point of hi s cataract kni fe to open the capsu l e and. his
example was fol lowed by the maj ority of operators unt i l themiddle of the nineteenth century . The sharp hook cystotome waspopu la rized by v . Graefe and v . Arlt , but both Of these men u seda forceps fo r thickened anterior capsu le s . The u se of capsu leforceps in non-thickened capsu les was introduced by Forster .E xtract ion of catarac t w ithin the capsu l e ( Smith operat ion )
also dates from Daviel , and de la Faye who operated six cases
by thi s method in 1 753, and it was performed intermittently bymany operators
,including Sharp
,Ri chter
,Beer, etc . C hritiaen in
1 845 again brought the intra—capsu lar expression to l i fe and simplified it by removing the lens under pressure alone . The indica
tions for thi s operat ion were first definitely stated by Pagenstecher in 1 866 . But as H i rschberg said
,I t i s impossible to
separate the name of Smith from this operat ion becau se of the
enormous experience that he has had .
”Y et H i rsc hberg does not
give Smith enough c redit,for the Indian surgeon introduced the
refinement s that added so to the safety of the operat ion . The l id
hook was hi s idea , but more important w erehis di rections to thepatients in regard to looking upward .
As not al l of us have had the opportunity of studying Smith ’soperation at first hand and therefore have not the necessary exper ience in regard to the cl inical and pract ical detai ls , I be l ieve weshou ld follow the cours e emphasized by E l schnig
,
“Continue theexpress ion only when the edge of the lens appears in the woundupon l ight pressure .
” I do not think that the expressio lent i s i sso universal ly appl icable in thi s country as in India
, b ecause of
racial differences . There mu st be a difference in the adhesion ofthe posterior lens capsu l e and the hyaloid membrane and it standsto reason that the zonu l e fibres are more pl iable in younger people .
In consequence , we who operate upon the Caucas ian race shou l dsel ect our method of operating w ith due regard to the patient’sage, degree of sclerosi s , etc . ,
and that “the capsu lotomy should notbe entirely neglected in our operative teachings .
The capsule forceps advocated by Dr . Fisher certainly are a
valuable addition to our armentarium,for we all know the danger
of sudden movements upwards by the pat i ents and when this can
i s first
pen . The le ft hand is laid l ightly the pat ient’s face and the
Fig . 13.
Show ing the cor r ect pose for the ass istant.
to assume in expos ing theeyeball for del ivery of the lens and also showmg the natural po s i t ion the
eye of the patient assumes . T h is I s the most favorab le position of the eye.
end of the lens-spoon is held in c lose prox im ity to the wound forem ergency use . The lens-hook held in the right hand
,i s used to
express the catarac tous mass (Fig . He w i l l apply the elbow( greatest convexi ty ) of the lens-hook to the cornea j ust abovei ts lower margin
,at the point or l ine corresponding to the cir
cumlental space, and make deep enough pressure toward thedepths of the eye to caus e the lens to start from i ts bed . Thi s
wil l cause the wound to gape by virtue of two forces ; first , thedepression in the eye-ball w ith the lens-hook causes the corneal
to ensue
Fig . 14.
Show ing the lens-nuc leus ( and cor tex ) escaping through the woundas the result of proper pressure w ith the elbow Of the lens-hook.
by the escape of the lens . This interval of momentary rest canbe uti lized to good advantage in an endeavor to engage as muchof the lens mush around the nucleu s as possible , so that a goodevacuat ion Of the cataractous mass may be effected .
The same depth of pressure i s maintained , but the di rection i snow shi fted upward toward the wound to drive the lens and cor
tex on out . The upward sweep of the elbow of the l ens-hook i s
not completed unt i l the inci sion itsel f is reached . The lines of
pressure from start to finish represent the tal l letter L,lying,
we will say, with its vertical arm horizontal ly, e . g .,l The
short.
arm of the l etter, which now stands vertical ly, represents
the first pressure made against the so ft eye-bal l at the po int designated abov e , and the long arm of the letter represents the l ine
toward the summit of the incision from below upward in th e vertical meridian of the cornea (Fig.
Fig . 15 .
Side v iew to i llust rate the sam e points shown in Fig .. 14.
In pursu ing this technic,one should have his own eye and
hand so well t rained that he at no time w i l l exceed the amountof pressure requ i red to accomplish each s tep in its turn ; in otherwords
,he w i l l use enough pressure to accomplish the result and
no more . It wil l natu ral ly follow that after the greatest convexityof the lens passes through the parturient opening in the eye-bal lthe actual pressure wil l be lessened to meet the fading requi rement to effect the balance of del ivery, although the same dep thof pressure is maintained .
The lens,or
,more prop erly speaking,
the nucleus and moreor l ess O f the cortex , now l i es outs ide the incision and here i swhere the angle of the lens-hook becomes usefu l . The operatorw i ll engage the nucleus and as much of the soft lens matter as wil lnatural ly cl ing to it in the hollow of the lens-hook and gently
draw it away from the inci s ion along the l ine of its di rect ion , at
the pupil . Inspection wil l at once dec ide whether another sweepi s needed to aqueous chamber Of lens
Fig .
Show ing how convenient i t is to r emove the lens from the woundafter del ivery by using the same lens-hook that effected ltS del ivery.
I f soft cortical matter remain s in the eye after the nucleus i sdel ivered
,it may be, at least in part , forced out by repeating the
pressure from the lower margin of the cornea upward to i ts summit two or three times , to effect , i f po ss ible, it s del ivery f rom theaqueous ch amber and yield a nice
,black pupil . Or
,i f it be pre
ferred,no attempt to del iver this Obj ec tionable soft lens matter
with the lens-hook need be undertaken,but the aqueous chamber
i rr igator may be used .
I n accompli shing delivery of the l ens by the technic above
desc ribed, the operator must bear in mind that he cannot command a view of the field of operation (meaning the incis ion and
directing hi s vi sual axes upward,but to do so he must ti lt hi s
own head sl ightly to hi s right shoulder and peer obliquely upunder the upper eyel id
,which
,as stated
,i s being ‘he ld away from
the eye-bal l by the assi stant ( see Fig . This i s important toremember .
In describing this technic , I am ful ly aware that I am not
describing the method in vogue in America or E urope . There arediverse methods practi sed in various countries and by differ entschools . In fact , no two operators seem to pursue exactly thesame m ethods . Some requ i re the patient to l ie flat on his back
w ith or without a pi l low under his head . Some requ i re the halfrecumbent posture in a reclining chai r, and some prefer the sittingpostu re the operator fac ing his patient during the operat ion ;how ever
,they al l pract i se one point in common and that i s that
j u st before del ivering the lens,they di rect the patient to look
down .
” Th ere are often vexatiou s Obj ect ions to thi s,for
,as
ridiculous as it may seem,many pat ients cannot
,or will not , “ look
down,
” and the operator being naturally tuned to the concertpit-ch ,
w i l l be apt to lose his temper and begin to abuse him . I
have heard. strong language used on these occasions and have evenseen the operat soundly cuff hi s patient for not “ looking down”
when told to do so . Such scenes are disconcerting to al l concerned and are disgraceful , being ent i rely uncal led for . I f theoperator had emp loyed the technic desc ribed herein , he would nothave had to direct the patient to “ look down at any stage of theoperat ion . The fac t of the matter i s , t hat pat i ents , almo st w ithout exception , w i l l look straight ahead or sl ight ly up during thecataract operation
,for that seems natu ral
,and consequent ly i f the
above technic i s u sed not a word need be said about where tolook . In th is case the operator i s master of the si tuation and hisbehavior i s in keeping with the part he assumes when he attemptsso grave an operation as removing cataract .There i s another argument
, which , wh i le I personal ly am not
convinced contains much i f any force , i s considered to be a v ery
the lens or after . The argument made is that the inferior rectusdragging the eyedownward tends to cause the wound to gape .
This,i t is argu ed , i s because Of the nature and position of the
wound ( being a sharp curve upward ) , which i s a flap-l ike valve
opening in the eye-bal l , the summit of which is not a great wayfrom the insertionof the superior rectus tendon . Thus , it i sclaimed
,in the eye-bal l made soft by the inci sion, aided by the
withdrawal of the aqueous, there i s apt to occur an unexpectedspontaneous del ivery or forcible extrusion of the lens and moreor less vitreous
,i f the patient “ looks down” too suddenly or too
far .
I cannot deny the apparent force Of thi s argument, especiallyas it seems to be sustained by actual fact, but I have deliveredhundreds '
Of lenses and have no fear of disaster occurring to thepati ent who “ looks down” so long as the lower lid
' is proper lyheld under contr ol.
The combined contraction of the orbi culari s pa lpebrarum andlevator angu l i oris et aliquae nasi i s what causes di saster when apatient “ looks down” and th i s contraction i s eas i ly frustrated bythe ope rator who knows this fac t and keepsthe lower l id depressedagainst the bone at al l t imes during the cataract Operation.
A side from the great advantage of del ivering the cont ents ofthe capsu l e by the method above described
,viz . , that the co-opera
tion of the patient is not asked for at any s tage, there is sti l l a
greater advantage,and that l i es in the fact that the operator may,
by em ploying this or s imilar technic befor e capsulotomy, succeedin delivering the lens in its capsule and that , too ,
by the employment of very safe and moderate pressure , thus at once avoidingall the manipulat ions , massagings , instrumentations , i rrigations ,etc .
, incident to opening the capsu l e and extracting piece-meal .I f this can be safely done we at once avoid the vexatious and
di sappointments that follow to both operator and pati ent wher eafter—Cataract , membranous cataract or capsular rema ins haveto be watched , treated , explained and Operated on sooner or later .The operator wil l find , however, that in attempting intra-c-apsularextract ion , he can make better headway by using the bulbous end
don the attempt and proceed with Fisher’s forceps to secure theanterior lea f of the capsule by merely dropping the lens-hook andus ing them . These forceps are admirably adapted for seizing theanterior capsule while the patient i s looking straight ahead orupward . A fter their use the lens-hook is again used to expres sthe nucleus and cortex without requesting the patient to changethe di rection of his eye .
Difficult ies t hat may A r ise.
I f al l cataract s were nice and ripe at the time of operat ion ,there would not be such volumes written on the subj ect . But
unfortunately al l are not so,in. fact , l ess than half Of them are
ideal from an operat ive standpoint . Many cataracts never becomemature in the sense that we have a medium-s ized nuc leus
,a mod
c rate amount of recent ly dis integrated cortical substance and athin smooth capsule . It i s not my privilege here to di scuss thekinds of cataract that we are called upon to remove that are noti deal . N o operator of experience wi ll deny that capsu lotomy isdifficult or impossibl e to perform in many instances
,ow ing to
thick,wrinkled capsu l es , normal capsu l es closely adherent to l ive
lens fibers surrounding a cataractous nucleus,capsules covering
shrunken , discoid lenses and large, hard cataracts apparently al lnucleus , not to speak of luxated or subluxated lenses or calcarcous cataract and the various forms of capsu lar cataract
,dense
post-polar cataract,etc . In any and al l O f these
,we may find
every evidence of the existence of a normal fundu s and we arecalled upon to operate under these condit ions , be they what theymay. I have studied this subj ect deeply and am firmly convinced
that in these cases,as w el l as in the cases of immature cataract ,
which make up the maj ority of the cataract patients who come
to consu l t u s,the capsulotomy operation should not be even
attempted .
But this art icle so far i s an attempt at instructing the operatorhow to deal with cataract when casulotomy has been success ful ly
I ment ion because I consider i t the best and which , as before
stated , i s throughout every del ivery held in close proximity to thewound
,i s inserted in the vitreous chamber j ust back of the lens
and held steadily there as a back stop or incl ined plane for thelens to be forced out against ( see Fig . Some operators areacc u stomed to u se a wire lens- IOOp or vect i s to rake the lens out ,
using no external p ressure during this act . Others use a barbedw i re Ioop for thi s purpose . Sti l l others use a Tyrrell hook bentat right angles at the point instead of the u sual crook
,which i s
passed below the posterior pole of the lens and made to hook intoits subs tance , thus secu ring it for w ithdrawal ; and st i l l othersagain prefer to use no loops
,spoons o r hooks , but to force the
l ens out regardless ofwhether li tt le or al l of the vitreous escapes .I have tried and seen tried all these methods . I recommend
Smi th ’s method as being the best .And fourth : the pat ient may become incorrigible through fear
or panic,s itt ing bolt upright and fight ing Off all who attempt to
res train him . My method in these rare cases i s to try gent leremonstrance , for I never quarrel w ith a cataract pat ient at anyt im e
,a t the same t ime cast a look to the ass i stant and give a s ide
nod which he understands at once to mean “chloroform .
” While
the anesthet ic i s being prepared, I have a littl e talk w ith thepati ent , which somet imes suffices to qu i et him , but i f he refusesto submi t , I w il l give h im a general anesthet i c and complete theoperat ion . To do this i t is usually necessary to get the consen tOf the member of the family present . I have never had any badresults from this method of procedure
,but fortunately have had
very few such cases . While visit ing Smith’s cl inic at Jullundurin the fal l Of 190 9 , I saw Smith encounter one such cas e and he ,too
, proceeded to finish the operation as I have described .
PART II .
There are several excellent methods of del ivering the lens
a fter capsu lotomy but space wi l l only permit me to discus s one
Ol iver’s “
Sys tem ofDiseas es of the E ye, Vol . I I I ,
Grant ed that we have a quiet patient , the speculum is le ft inplac e. The Operator who stands at the exact head of the patientstoops over so that he can see wel l the field of operation and w ithDaviel ’s spoon or a simi lar spatula held l ike a pen in his righthand for the right eye , or the l eft hand for the le ft eye, he makespressure on the lower edge of the cornea directly toward thedepth of the eye s low ly and pos itively . In h i s le ft hand for theright eye
, or his right hand for the l eft eye, he holds a lens-scoop ,
spoon or vectis , with which he may aid the del ivery Of the lens
by making s light pressure on the sc leral s ide of the wound , butmore Often he merely holds thi s latter instrument with its tipclose to the wound
,but touching nothing, having it in readines s
to apply wherever needed to aid del ivery in case i t should berequired . The deep pressure w ith the D-
aviel’
s spoon on the lower
edge of the cornea is steadily kept up unti l the wound gapes andand the lens is nearly hal f out
,when it i s shi fted to follow up the
lens or drive I t On out of the eye . When the lens i s hal f out , amoment’s time should be uti l ized to gather in the l ine ofmarch asmuc h of the soft cortex as can be gent ly massaged in place belowthe nucleus
,as suggested by Wilder . During al l this the pati ent
mu st look slight ly down toward hi s feet , but when everythingi s in readiness for final delivery
,he is instructed to “ look down
”
sti l l further . A s he does this,the expressing instrument i s held
pe r fectly st i l l and the eye-ball making a downward move wi llcause the cornea to gl ide under i t
,thus effecting de l ivery of the.
nucleus and a pretty thorough evacuat ion of the soft cortex .
The nucleus and lens substance i s wiped aw ay from the woundthe speculum is removed , the eye i s closed by l i fting the upperl id down over the eye-ball by means Of the lash-es and a wet padappl ied .
It i s now wel l to allow three to five m inutes to elapse in orderto permit a reaccumulation of flu id in the aqueous chamber .There i s no more efficacious way of delivering the remnants
of soft cor tex a fter del ivery of the nucleus than to uti l i ze the
Fig . 1 7 .
Show ing Knapp’s method of r idding the pupi l space of so f t cor texafter the nuc leus has been del iver ed .
contact w i th the edge Of the incis ion . I t i s qu ite easy to avoidcontact with the wound by this technic . A second such attempt toevacuate the soft substance sti l l remaining may be tried
, but i f
that fai ls,no further attempt shou ld be made . The assistant then
takes control of the low er l id and the operator has his right handfree to cleanse the wound . This i s done by means of a sma l l
pledget of bo i led cotton which no one has touched since i t camefrom the steri l izer
,and this
,after being squeezed
,i s used to w ipe
the wound free from capsu lar remains , lens dé bris , etc . The i ri s
repos itor i s then used and the eye closed by grasping the lashes(which in the middle o f the upper l id never shou l d be cut ) and
T roub lesome C ases .
I f the patient is restless or unruly , no speculum should beThe operator secures the eye-brow and upper l id with the
Fig. 18.
Side v iew i l lustrating how the nuc leus may b e successful ly del iveredin unruly or untrustwor thy patients .
forefinger or thumb of his le ft hand,which i s w rapped with
gauze,and delivers the lens by u s ing the thumb of his right hand
pressing against the eye-ball through the lower l id (Fig.
The ass istant uses the lens- spoon or wire Ioop to secure thenucleus a fter it has escaped through the wound , or, in case of
difficult delivery,he may assist in turning the lens out of the
wound l ike a cart wheel . Some difficulty i s occasional ly met within unruly patients in having them “look down” and in that cas e
the assi stant must hold the lower lid away from the eye-ball withhis thumb wrapped in gauze, whil e the operator proceeds toexp ress the lens with Daviel
’s spoon, Smith’s lens hook or some
such instrument .
The difficulties which sometimes arise I have already men
tioned in Par t I of th is arti cle . T he same principl es app ly in thismethod as in that .
in any form,detachment Of the retina
,myopi c choroiditis , senile
choroiditi s central is or blood pressure exceeding 2 0 0 mm . mer
cury . We mu st be very sure in our diagnosi s as regards thesecomplications , as they all predispose to expu l s ive hemorrhagefrom the choroid .
Second . The incis ion mu st be unquest ionably large in al lforms Of catarac t exc ept in cases where a deep anterior chamberexists
,in which the incis ion may be moderately s ized , but never
small . The reason for this exception to the large size of the section i s that i n cases where deep anterior chamber ex i sts we may
nearly always exp ec t to find lenses wh ich do not demand the largesect ion . Moreover , the large sec t ion in these cases predi sposesto escape ofvitreous . This is a logical deduct ion . T o err in mak
ing the section too large is always safer and b etter than to errin making it too small . Conj unct ival flaps shou l d be avoided .
Third . An iridectomy is always best . This is not becausethere i s any special difficu lty in del ivery of the lens in its capsulethrough the act ive pupi l where no i ridectomy has been done ; therei s not ; but because the large sec t ion necessari ly invites i ri s prolapse where no i ridectomy has been pe rformed .
Fourth . Any kind ofuncompl icated cataract can be extractedby the infra-capsu lar m ethod , no matter what stage it i s in ,whether imm ature
,mature
,hyperm atu re o r Morgagnian , whether
tumescent,post- tumescent , shrunken or sc lerosed , whether cap
su lar,nuclear
,post-polar , striated
,dotted
,hard o r pigmented
( j uveni le , congenital and traumat ic cataracts excepted ) .
In al l the vari et ies j ust m ent ioned , w ith the except ion of the
nice ripe kind , to cut the capsu le i s difficu lt,to remove the
anterior lea f by m eans of forceps i s often impossible”"and to forcethe nucleus out of the imperfect ly incised caps ul e thr ough a smal lsection i s dangerous . Fur thermore
,in some cases
,after the
* I w ish to m od ify t h i s s tat em ent b y say ing I have r ep eat ed ly , andw i th p er fec t ease
,r em oved the ant er io r cap sule in cases Of imm atur e
catar ac t b y m eans of Fi sh er ’s for c ep s in cases w her e th er e was a
s tubborn r es i s tanc e on the par t Of the lens to m ove in at tem ptingintracapsular extraction.
THE DEL IV ERY OF THE LENS 83
whic h , whi le harmless as long as it was imprisoned.
w ithin the
capsule, b ecomes , i f not washed out by a more or less hazardoustechnic which can only be employed in docil e patients , a dailymcreasmg menace to the integri ty of the del icate infra-ocu lar tissues a fter it admixes wi th the aqueous , or, more properly speaking, the serum ,
albumen,inflammatory lymph and aqueous , and
permeates and blocks the avenues of escape, being thus lockedup within the aqueous chamber of the eye . The a fter-picture issummed up in the one word “ i ridocyclitis .”
I n the intra-capsular operation,the eye i s safeguarded against
iridocycl iti s and dense after-cataract . It i s not a partial extraction, but a radical one.
There are several very different methods of extracting thecataract in its capsule
,e . g . , Pagenstecher
’
s extract ion by meansof a spoon , Wright’s combined upward express ion , Mulroney’scombined lower expr ess ion, Smith
’s “tenotomy hoo expression ,Savage’s detaching and express ing method
,Hulen’s extraction by
means of a vacuum cup ,and other methods mostly experimental
in character .The technic which I shal l describe i s that of Col . Henry Smith ,
I . M . S. , Amritsar, Punj ab , India . I have studi ed th i s methodminutely under the personal direc t ion of Sm ith himsel f in Oc tob erand N ovember , 1 90 9 ,
at Ju l lundur,India
,during which time I
per formed 358 extractions""mysel f and w itnessed upward of 60 0done by Greene
, ofDayton , Clark, of Columbus , Major Birdwood ,ofAgra
,Major E l l iott , of Madras , Li eut . Smith (nephew of Col .
Smith) of Ju l lundur, Li eut . Ross , of Ju llundur D i strict, Dr .
Diwanali ( Smi th’s first assi stant at Jul lundur ) and C O1. Smith
himsel f . The technic i s the result of an evolut ionary growth. thatgradual ly developed under Smith ’s keen eye and trained hand inan experience comprising over cataract operat ions performed on the living human subj ect du ring a period of fifteenyears . Smith told me in 190 9 that he regarded the technic perfected in every detai l and that he had not introduced a single newfeature sinc e two years prior to that time . The history of anyone Operat ion in the archives of surgery does not offer the dupl icate of such steadfast
,pat ient and unt i ring endeavor on the part
0
*See Knapp’
s A r chives Ophthalmology."an 19 12,for detai led sta
txst ical r epor t of these 358 extractions .
presented to the C hicago Ophthalmological Society, N ov . 1 9 , 1 9 1 0 ,
and published in the C incinnati L ancet-C linic, Jan . 7 and I 4, 1 9 1 1 ,for a fu l l and complete account of the ent i re operat ion .
De l ivery of the L ens b y the Sm ith Method .
T he assis tant takes his stand to the left of the patient withh i s le ft hip rest ing against the sol id operating table . With the
large short—shank l id—hook of Smith in his right hand,he proceeds
to expose the field of operation in the follow ing manner : Heholds the l id-hook low down on the shank in such a way that thepalm of his hand i s open toward the pat ient
’s feet and the fingersare straigh tened out so that the t ips ofthe ring and middle fingersare anchor ed j ust under the eye-brow . The brow can thus beel evated on its bony background and maintained in an elevatedpos ition until the close of the operation ( see Fig . The upperlid i s engaged on the hook and gently l i fted off the eye-ball . Thismaneuver , when rightly done , i s not the least di stress ing or pain
ful to the patient and will take the w eight of the t i ssues ent i relyoff the ball , at the same t ime affor d a gable- l ike exposure of thesummit of the eye—b al l and the upper fornix . In carrying outthese ideas he shou ld hold his elbow high in order to allow roomfor the operator to approach the eye on both sides of the forearmand wrist . With the thumb of his left hand he depresses thelower eye—l id . In rare instances , as when the lower l id i s wet andsl ippery , he uses a very sm all p iece of dry cotton under the bal lof hi s thumb . The thumb is sl ight ly flexed and the fingers areextended over the pat ient ’s right cheek, the t ip s grasping thelower j aw to steady the patient’s face in case ofmovem ent .The above described pose Of the assistant i s kep t up unaltered
unti l the operat ion i s finished unless vitreous presents . I f at any
stage of del ivery vitreou s does present,he sl ightly t i lts the handle
of the hook toward the pat i ent ’s feet in order to put on thestretch al l the loose ti s sues of the fornix , thus hal f closing the
eye, at the same time rai sin-
g the supra-tarsal soft t i ssues on thetip of the blunt l id-hook in a tent-l ike fashion . He w i l l in th i scase straighten out the thumb
,which i s holding down the low er
other words,so that the end of the bulbous tip i s about 3mm .
above the lower corneal margin (Fig . Thi s point co rresponds to the lower edge of the lens and the circumlental spaceadj oining ( see Fig . 2 1 A ) . The handle of the hook i s now turned
Fig . 20.
I llust rat ing deep p r essure b eing applied b elow the lens and towardthe depth of the eye to cause upr igh t delivery . T he lens is mov ing up in
the wound and soon the p r essure w ill b e sh i fted to tuck the corneal flapbeh ind the lens .
about one—eighth , so that the bu lbous t ip of the hook w i l l indentthe cornea at the po int above desc ribed and pressure is now madewithout vac i l lation straight back toward the pos terior pole of theeye . T he t ip of the hook thu s t i lts the lens on its vertical plane( see Fig . so that the upper edge presents in the gapingwound and as the pressure i s made a litt le deeper , the zonu larfibers let go and the lens begins to gl ide on out (Fig . I f
thi s be the case,for there are several varieties to consider
,the
deep pres sure i s only maintained ( nei ther increased nor l es sened )and the end of the hook is made to follow up the lens ( see Fig .
2 1 C ) . The idea which prevai l s throughout this performance i s
87
Fig . 2 1 .
A — i l lustrates the point where p r essure is fir st app l ied . B— for c ingthe lens on out . C — tucking the cornea b eh ind it . D— del ivery comp letedand the hook is now to b e r emoved f rom under the lens and used to rakei t away from the wound along the line of inc is ion .
pleted only when the corneal flap is tucked behind the lens ( Fig .
2 I D The lens at this stage may be entirely outside the eye
Fig . 22 .
A — i llust rating trac t ion b eing made away f rom the wound in the case
of ver s ion-delivery w ith the end of the hook engaged on the c i l iary r idge .
B— the cornea is now being tucked b eh ind the lens wh ich w i l l in th is case
b e del iver ed lower edge fir st . C — the cornea tucked “home
” thus com
p leting del ivery of the lens by ver sion. N ote that the suspensory l igament
is st i ll attached above. T he hook must now be r emoved f rom b eh ind thelens and used to roll it away f rom its attachments as shown in Fig . 16.
out of the eye ( see Fig . When the l ens has ascended
st raight up from i ts bed and l ies qu ite outs ide the eye-bal l , thehook i s natural ly used in the right way to complete i ts del iverance from the region of the wound , but i f i t stands apparentlyonly two-thirds of the way out and: vert ical ly to the wound, it willrequire some special instruct ion to know how to effect i ts entiredel ivery . In thi s case the hollow of the hook i s placed to the le ftof the lens
,the point of the hook directed obl iquely upward away
from the wound and the convex side of the elbow of the hookpressed toward the depth of the eye , thu s pressmg backward boththe corneal and scleral s ides of the wound . By thi s maneuverthe wound is forced shut as both scleral and corneal l ips are leveland approximated. This secures the l ens beyond peradventure
and i t i s s imply rolled out of i ts posit ion and secu red .
A l l that remains now to the ope ration i s to disengage the irisentanglements from the wound and close and dress both eyes .Approximately seventy-five per cent of the smooth cases wil l bel ike the above descript ion . In about twenty-five per cent ofsmooth cases the lens w i l l turn and come out lower edge first .
V evasion Delivery : I t is w rong to say that the lens turns overwithin the eye and is born w ith its posterior surface next to theinner sur face of the cornea and the lower margin next to thewound . True I have seen this occur
,but only in rare instances .
The behavior of “ tumblers ,” as C ol. Smi th cal l s these cases ,may be described as follow s : The suspensory ligament first ruptures under the tip of the lens—hook and the hook descending moredeeply toward the opt ical center of the eye-bal l , causes the loweredge of the lens to present forward against the cornea and theupper edge to dip backward behind the sc leral shel f of the wound .
Th is,in fact
,constitutes only a one-eighth turn o f the lens and
there it usual ly remains unt i l the tip of the hook,which li es over
the summit of the corona ciliar i'
s,or what in plain E ngl i sh i s
90 THE DEL IV ER Y or THE L ENS
cal led the ci liary ridge,i s made to drag the eye downward
toward“ the patient’s feet ; or in other words , unti l distinct traction i s made away from the wound by means of the tip of thehook caught on the ci l iary ridge . ( Fig . 2 2 A . Note the directionindicated by the arrow . ) Thi s tends to invite forward movem entof the vitreou s through the gap made by the ruptured zonulebelow the lens
,which become s the l ine of l east resi stance and the
lower edge of the lens i s thu s forced upward . When the lens i s
turned one-fourth by these dynamic forces so that it l ies at rightangles to its normal pos it ion
,the downward trac tion i s abandoned
and changed to the exact opposite direction (Fig . viz . ,
upward toward the incision in order to tuck the cornea under theforward edge of the lens
,and behind it in. order to not only effect
the birth of the lens , but also to head off the forward push of the
Vitreou s . The lens is del ivered outs ide the eye-bal l by simp lytucking the flap of the cornea behind it (Fig . 2 ZG) . T he l ens
now hangs by a hinge—l ike attachment at its upper edge , which i sthe unruptured suspensory l igament above it . A fter the lens i soutside the eye-ball and the cornea tucked hom e
,i t only remains
to effect complete detachment and del ivery by means of the hollow elbow of the hook u sed in the manner descr ibed . The idea
involved in this “ feet fi rst"del ivery of the lens is to get thecornea behind the lens . The gap which form s f rom ruptu re of
the suspensory ligament below the lens furnishes an opportunityon the p-art of the eye for us to tuck the cornea behind the lens ,which is best done in the manner j ust described
,viz .
,tract ion
away from the wound to w iden the gap and under- tucking of the
corneal flap by upward movement . Indeed the process has beenlikened by Birdwood , Greene and others to peel ing a t ight prepuceand exposing the gl ans peni s in an infant .
The del ivery by version is pract ically l im ited to nearly al lcases of tumescent catarac t and to many cases of Morgagn ian(bag- l ike ) catarac t . I f the incis ion is large
,i t affords the most
sat i s fac tory kind of delivery to encounter ; but one must be c arefu l in roll ing the lens away f rom its final attachments after i t i sdel ivered
,as the cap su le is very fragi le in the case of tumescent
cataract and w i l l not tol erate anv thing but the gent lest treatmentwithout rupturing .
C ombined Delivery : It now remains to describe what to do
I l lustrating comb ined p ressur e in case the lens does not gl ide upwar dsout of the wound
, but the pressur e w i th the spoon above must be l ightlyapp l ied as v itreous may otherw i se w el l up and not the lens .
that i t shou ld be enlarged w ith a pair of scissors . Or it may bethat the lens has sl id upward and the upper edge is caught behindthe scleral shel f of the wound instead of present ing through theOpening . This call s for a new start . Possibly the sc leral lip of
the wound should be gent ly depressed to enable the edge of theoncoming l ens to ride forward and out of the wound (Fig .
Or , again , the su spensory l igament may be abnormally tough , asi s the case with old cataracts ( longer than two years ’ duration )in comparatively young adu lt s ( in fac t , j uvenile cat aracts ) , in
which be fore operating we note deep anterior chambers . In
event of thi s stubborn resistance of the lens to move by the
to plunge the hoo-k deeper and deeper into the eye , brute
Fig .
I l lustrating the lens-spoon introduced a shor t d istance b eh ind the lensto affor d a backgr ound for pr essur e thus taking the strain off the V itreouswh ich has either “p resented” or shown thr eatening s igns of presenting .
force . I wou ld rather give up the attempt at del ivery in the capsule at this stage and in this event and resort to the capsulotomyoperation , as Fisher described in h is paper before the A merican
A cademy ofOphthalmology and Oto—L aryngology, at C incinnatiin 1 9 1 0 ( see T ransac tions ) , than to go doggedly on plunging
deeper and deeper into an eye that has signaled by unmistakablesigns that the lens cannot be del ivered w ithout dangerou s pressure . In fact , this i s what I do recommend in many cases andFish er has my hearty endorsement on that point .There are cases
,however
,in which i t i s sti l l better to intro
duce the spoon bo ldly behind the lens and del iver in its capsule asdescribed rather than to open the dense capsul e and leave it,together with more or less lens substance
,behind to result in a
of all cases .
Discussion by R ichard T ivnen.
The two methods for the del ivery or expression of the lens
presented by the es sayist,D
'
r . Vai l,for our consideration thi s
evening are known as,first
,the “capsu lotomy” method ; second ,
the “ intra- capsu lar” or“Sm ith” method of extract ion . With the
l imited tim e at my disposal I am permitted to discuss only thesecond method— the “ intra-capsu lar” or
“Smi th” method of
extract ion . This method of extract ion has been for some timepast “
snb j udice,”so to speak , and in no country has i t attracted
a more tolerant,j ust or friendly medical audience than in the
United States . The period elapsed sinc e its introduct ion in thiscountry
,whi le not extensive
,has been nevertheless sufficient to
develop a more or less crystall ized opinion as to the meri ts of theprocedure .
I have attempted: to gather some authoritat ive in format ionregarding the status in the United States of the
“ intracapsu lar , o rSm i th
,method” of l ens expression . T o this end I addressed a
series ofquest ions deal ing w i th the pert inent phases of the “Smithmethod” in particu lar
,and including also some interest ing fea
tures pertaining to the capsu lotomy m ethod ,” to a l imited numberof Ophthalm ic surgeons throughout the United States . I t was am atter of cons iderable regret to me that
,ow ing to the brief period
avai lable for carrying out this invest igation , I was unable to ascer
tain the valued opinion of all the ophthalmologists of this countryThe repl ies I received w ere most grat i fying , both as to number
and interest mani fested . I avai l mysel f of this opportunity of
expres sing my apprec iat ion to those gent lemen who extended menot only the courtesy of a response to my questions , but whofavored me in addition w ith a detail ed and frank expression on
the subj ec t .In present ing the resu lts of these invest igations i t shall be
my aim to maintain an impart ial att itude . In consonance therefore w ith this deci sion I shal l make no comments , adduce no con
clusions nor present any personal Opinion , but shall simply report
first hand . By uti l izing these two valuabl e sources of in formation , viz . : the answers received to my questions and Co lonelSmith’s views on the matter , I shall avoid the possible danger ofassuming an ex par te character of presentation of the sub j ect . Ishall offer the subj ect
,therefore , for your consideration in the
following order : First , present the answers received to my ques
t ions Second,introduce excerpts from Colonel Smith’s book
apropos to the especial features of the subj ect under discuss ion .
ANSWE RS RE CE IVE D T O T H E QUE STIONS SUBM I T T E D .
The first question submitted was as fol low s :“HAV E YOU PERFORMED THE ‘SM ITH ’ OPER AT ION OF EXTRACT
ING THE CA TARACT IN CAPSULE,THE SO-CALLED ‘
iN T R A—CAPSULAR’
METHOD ; IF so, IN H OW MANY CASES?”
1 60 repl ies were received to thi s question .
Of the 1 60
I I I per cent ) had not per formed the Smith operation .
49 per cent ) had performed the“Smith” operation .
Of the I I I who repl ied that they “had not performed the
‘
Smith’
oper ation, each assigned at l east one of the fol lowingreasons . fo r not undertaking it :
“Capsulotomy method” sa fer.
In ferior because of large corneal inci sion .
I ridectomy and slower heal ing and the need of an experienced ,skilled ass istant .
More fraught with danger to vi sion ; old method satisfac
Not enthused with the method .
Dangers of operation too great .Do not fee l dispo sed to perform operation unt i l I shall have
some expert superintend a number~
of ope rations I perform .
Observation alone convinces me i t i s in ferior .
T oo much trauma .
Adhesion of posterior lens capsule to hyaloid.
Better wait ten years unti l we see how many retinal detachments resu lt .Danger of a wound of the eye-ball depends on its s ize— too
large inci sion .
Can show microscopically that capsule i s not intact in severalso-cal led “Smith” operations .
In ferior for Americans on account of nervous patients .Have studied and seen the “Smith” operation and my private
opinion i s that it i s to be used only on an occasional case .
It i s better i f i t were not more dangerous . For safety the
old ope ration i s better .
The supreme test i s the visual result . I get better results thandoes Smith and w ith incis ion lying all in the c lear cornea . Do not
have loss of vitreous .Stll sub j udice. E xpect to try it one of these days . It
’s a
case of “rock and whirlpoo l anyway .
On ly those w i th exceptional opportunities should undertakethe Operation .
My technique too imperfect .Regard r isks of “Smith” operation too great ; namely, more
danger of losing vitreous,more ri sky upon an intract able patient .
To i let of Operation difficu lt to perform properly. When woundi s gaping and vitreous protruding so that we are apt, under these
c i rcumstances , to have a very wide pupi l resulting i f not a prolapse and we incur the additional r isk of infection .
Considering ri sk of prolapse of vitreous it does not appeal tome as wise .
trauma and t rauniatism of vitreous body.
Obj ections due to inexperience of operator s in technique and
T oo much t rauma and not a sa fe operation for the ordinaryOperator who on ly has a few cases of cataract each year . For ourpatients the ordinary cataract extractions with
“capsu lotomy” i sthe sa fer method .
”
The second question submitted was as fol lows“BASED ON YOUR PRACTICAL EXPER IENCE
,Do YOU REGARD T H E
‘SMITH ’ METHOD OF DEALING W ITH THE LENS CAPSULE SUPERIOROR INFERIOR T o THE USUAL ‘CAPSULOTOMY METHOD’ ; PLEASEE NUMERATE THE POINTS OF SUPERIORITY OR
,YOUR OB"ECTIONS .
Of the 49 who had performed the‘
Smith’
operation” .
1 8 per cent ) considered the method super ior ” to thecapsulotomy method .
1 7 per cent ) considered it infer ior” to the capsu lotomy
method.
”
1 4 per cent ) expr ess ed no opinion.
N ote — Many of the answers that are l isted as “super ior were
so stated with such quali fying phrases as : “ Ideal in selected
cases ,” “Much superior , of course , provided there i s no loss of
vitreous,” “Superior only for immature and slowly progressivecataracts , etc . A number li sted as “inferior” w ere so stated withsuch qual i fying phrases as : “ I attribute it to lack of trained ass i stants ,
” “E xcept possibly in selected cases of hyper-mature cat
aracts , etc .
Of the 1 8 of the 49 who had performed the operation and
who considered it “superior "to the usual “capsu lotomy method”each gave at least one of the fol lowing reasons for cons idering it“super ior .
”
Simpl icity .
Less danger of infection .
No secondary needling requ i red .
Better V lSlon .
Ideal for immature cataracts .Better in selected cases .E ffects of detritu s to be ab sorbed are avoided .
Time is saved .
Gives Cl ear pupil .Complete absence of capsu le .
Vision continues to improve and eye wears .Secondary compl ications less num erous .I rit is or i rido-cycl it i s less frequent .Operat ion is done in one
“seance” and the risks are thereforeless than the “
capsu lotomy method .
”
Avoids al l danger of secondary operat ions .In immatu re cataract long delay caus ing distres s
,loss of time
and money avoided .
T he ideal operation .
Greatly decreased tendency to i rit is where i ri t is is mo st probable by the O-ld method .
T he superiori ty of the Smith operat ion in the rapidity of
recovery and degree of vi s ion are very mani fest,superior in the
vast maj or ity of cases .
Superior ; simpl icity , few instrum ents introduced in wound.
less danger o-f in fect ion,independent of co-Operat ion of pat ient .
Superior by far i f one can do the operat ion . First,vis ion con ~
tinues to improve and eye w ears ; second , secondary catarac ts lessnum erous ; third , i ritis and i rido-cyclit is les s frequent ; fourth ,immature catarac t may be safely operated .
Superior , because it removes the capsu le— the source of all
secondary cataract secures highest degree of vis ion by a singl eoperat ion ; avoids al l danger incident to subsequent operat ionswhich must b e done in a very large percentage of cases .
Superior in that it eliminates al l poss ibi l ity of secondary cat
aract .
Superior in two c l asses of cases ; first , immature cataracts and.
s econd , complicated cataracts or posterior synechia . Advantages :N o secondary catarac t where secondary cataract is especial ly di f
no secondary needling” required ; better Vision ideal for imma
Consider it of great value in selected cases .Ideal in an immatu re cataract of long durat ion .
Off the 1 7 of the 49 who had performed the operation” andconsidered i t “inferior ”
to the “capsu lotomy method” each gave atleast one of the fol low ing reasons for considering the method“infer ior ”
“Danger of loss of vi treous and bad repos it ion of i r is .
Necessity of keeping aged patient flat upon back for a longpe riod .
Greater difficu lty of performance .
Better on H indoos but not on white men .
Unsafe for average operator .Corneal inc i s ion inferior as to safety compared w ith old
method .
Bandage left undisturbed for ten days i s unsurgical and positively dangerous .More risky upon an intrac table pat ient .Toilet of Operat ion difficu lt . When wound i s gaping and
vitreous protruding we are apt to have under these c i rcum stancesa very w ide pupil resu lt ing
,i f not a prolapse , and we incur an
addi t ional ri sk of in fection .
Lack of trained assistants .
Lim ited field of usefu lnes s .Only those w ith exceptional Opportunit i es shou ld undertake
operation .
Requ i res much more highly developed technique such as cannot be acquired by average surgeons .C onsider it to be more fraught w ith danger to vis ion than the
method with capsu lotomy” or“capsulectomy .
Operation more prolonged and danger of loss of vitreous
greater . With a nervous patient this i s exaggerated .
More trauma and traumatism of vitreous body .
Method inferior for Americans on account ofnervous patients.
More l iable to have escape of vitreous in “Smith” method.
Inferior because of la rger corneal incision and. i ridectomy and
s lower heal ing and the need of an experienced,ski l led as sistant .
It i s to be use-d only in an occasional case .
It i s better i f it were not more dangerous . For sa fety theold method i s better .
Theoretical ly, I think only those with exceptional Opportunitiesshou ld undertake the operat ion .
”
The third question submitted was as follows“H A S THE ‘SMITH ’ OPERATION
,IN YOUR EXPERIENCE
, SECUREDEITHER AN INCREASED OR A MORE SATISFACTORY VISUAL ACUITYTHAN THE USUAL ‘CAPSULOTOMY METHOD’
Of the 49 who had performed the‘
Smith’
operation1 5 per cent ) repor ted an “
incr eased and more satisfactory vision
” by the “ Smith” m ethod .
I I per cent ) reported “infer ior” vis ion by the Smith
method .
4 per cent ) reported vision equal by either method.
1 9 per cent )“expr essed no opinion
The fourth question submitted was as follows“I N THE EXPRESS ION OF THE LENS DURING EITHER THE
‘SM ITH ’ OR ‘CAPSULOTOMY OPERATION,
’
Do YOU TH INK THERE 1 5
MORE DANGER OF VITREOU S BEING LOST IF THE PATIENT ‘LOOKSDOWN ’ DUR ING THE EXPRESS ION
,OR IF THE PATIENT LOOKS
‘STRAIGHT AHEAD’ OR ‘SLIGHTLYOf the 1 60 rep li es received .
82 expressed “no opinion.
78 gave at least one of the following opinions
tw itching or squeez ing by nervou s patient .I considered position not important
,loss of vitreous due to
spasm of the orbiculari s .2 consi dered pos it ion not important , loss of vitreous due to
Siz e of incis ion and pressure in del ivering lens .I considered loss of vitreo‘
us dependent upon patient and ski llof operator .
2 considered loss ofvitreous due to adoption of extreme positions” for the eye .
I considered loss of vitreou s due to mu scul ar act ivity .
The fi fth question submitted was as fol lows
I N THE ‘CAPSULOTOMY METHOD OF EXTRACTION WHAT HASBEEN YOUR EXPER IENCE AND OBSERV ATION W ITH THE REMAIN INGCAPSULE?
“
(a ) I N REGARD T o THE CAPSULE AND RETA INED CORT ICALMATERIAL CAUS ING IRIDO- CYCL ITIS?
“
( b ) DIFFICULTIES FOLLOW ING ‘NEEDL ING’ OF THE CAPSULE,
SUCH A s INFECTION,IRITI S
,IRIDO-CYCLITIS
,ETC P”
Of the 1 60 repl ies received ( a ) in r egard to the capsule and
r etained cor tical mater ial causing ir ido-cyclitis
’
65 ,-expressed no opinion.
95 ,-gave at leas t one of the follow ing opinions
5 ,-bel ieved i r ido-cycl it is to resu lt in the following percentage
of cases
1,-in I O per cent of cases ;
I,-in I per cent of cases :
I,-in 2 5 per cent of cases ;
I,-in 50 per cent of cases ( sl ight )
I,-in 2 0 per cent of cases ( some i rritation ) .
6 ,
-bel ieved irido-cycl it i s dependent upon amount of retainedcortical material .
2,-reported “mild i rritation .
.1 3
le or retained cort ical
1 6 - reported i rido-cycl itis uncommon9,
-bel ieved that remnants of cortical material do cause ir itis .5 , remove cortical material by irrigation and have no trouble .
3,-report that i rido-cycl iti s does not occur in otherwise norm al
eyes” ; when patient has rheumatism or gout or arterio-sclerosi si t precipitates inflammation .
2,-report i rido-cycl itis ‘‘very sl ight .
2,-repo rt i rido-cycliti s only in very immature cataracts .
1 9 ,-reported “no trouble .
4,-reported mild i rit is .
3,-reported as common .
I,-bel ieved cortex i s a mechanical and possibly a chemical
irritant .
I b eli eved that under 60 years, and i f cataract i s immature ,remaining corti cal matter i s apt to produce an i ri ti s .5 repo rted
“ some trouble .”
I reported not much trouble .I reported trauma incident to forcibl e intra-capsu lar extrac
tions may cause i riti s or i rido—cyclitis .”
The character of some of the answers to quest ion (a) I n
r egard to the capsule and r etained cor tical material causing irido
cyclitis”in the
“capsulotomy method” are of value
“Never can tel l What i t wil l do.
Depends upon amount left behind .
Irido-cycl it i s not caused by capsule or cortex contained incapsule .
I s caused by cortex in anterior chamber .Use i rrigation freely to remove cortex and try to have cap
sule W i th shreds as l ittl e as possibl e which are likely to l ie in the
Question whether iriti s i s caused by remnants of retained capsu l e ; in cases Where most cortical material was le ft in , pat ientsoften did the best .Retained capsul e and cortex are frequently, almost invariably,
provocative of post-Operative i riti s .
of capsule,i ri s
,etc .
Does not do i t in otherw i se normal eyes .Where pat i ent has rheumatism , or gout
,or arterio—sclerosis
it precipitates inflammation .
Doe s not caus e a predisposition to i ritis .Often have it and have blamed either the capsu le , cor tical sub
stance or nurse .Do
(not bel ieve the retent ion of cort ical material per se i s par
ticular ly l iable to induce irit ic or cyc l i t i c inflammation .
Bel ieve the remaining cortex produces low-grade i riti s,but
not particu larly harmfu l .E ach case a law unto i tsel f .Cortical material always a source of danger .Under 60 years of age
,i f catarac t i s immature
,the remaining
cortical matte r is apt to produce an irit i s .With a c lean “
capsu lotomy operat ion the lens capsule givescomparatively litt le t rouble and early disc i s s ion a good eye.
D isciss ion is often disappointing,when lens substance has
remained .
Who can say it i s caused by corti ca l material?A lways find it .Wait for mature cataract .I s more or les s of a menace .
Impossibl e of absorpt ion in many cases and unquestionablymay cause iriti s .
Does not material ly increase danger .
Only in very immature cataract s .”Of the I 6o repl ies received to divi sion ( b )
“Difficulties fol
lowing‘
needling’
of the capsule,such as infec tion,
iritis , ir ido
cyclitis ,
60,
-expressed no Opinion .
I OO,
-expressed one of the follow ing opinions4 ,
-reported “ in fect ion .
8,—reported i riti s . ”
7 ,-reported irido-cyc l it is .
brane in each direction w ith a de Wecker scissors .
Have had some difficu lty w ith a persistent,tough and thick
capsu le .
N o difficu lty especial ly when done w ith two needles .By u sing capsule forceps I do l es s “needling” than when I
s imp ly lacerate the capsu le or do not i rrigate .
L ittle danger i f not attended w ith too much traumati sm .
In Old cases w ith much exudate find: that the opening i s l ikelyto c lose from further exudate .
Have had all of above and Ophthalm i t i s necess itating enucle
at ion .
Needl ing necessary in maj ori ty of cases .
NO serious troubl e except where needl ing is delayed a long
t ime after extract ion .
The capsu l e becomes tough and have had to needle tw ice .
Requ i res “needling” in 60 per cent of cases .I ritis and iri do-cycl iti s fol low operat ion only where capsul ar
mass is thick and huge and the resu lt of corti cal m atter remainingbehind a fter the primary operat ion .
N o difficu lt i es providing the conj unct ival sac be steril e .
N O difficu lties experienc ed ; shou ld not expect it i f gentle andasept ic .
Maj or por tion requ i re needling unless preliminary i rideetomy has been done .
I f p reliminary iridectomy has been done the capsu le as w ellas the res iduary particl es is so much better accompl ished that thenecess ity of secondary operat ion i s very greatly dimini shed .
Trouble i s due to the trauma follow ing “needling”; that i s
needl ing” or kni fe needling” shoul d only be used on diaphanousm embrane .
Danger from operat ion i s almost ni l .Iriti s and i rido-cyclit i s are cau sed 'by the attempt to tear too
tough a membrane .
Secondary glaucoma is my dread .
Use capsu l e forcep as routine practice and am sure that
1 0 7
No trouble i f patient ’s general health is watched and localcondit ions kept under dai ly obs ervation .
N i l i f pat ient i s properly prepared and operation carefu l lydone .
S ince using Zieg ler method never necessary more than once .
Have had some irid‘o—cycl iti s,glaucoma
,even panophthalmit i s
a fter “needl ing” and I wish that a safe method of removing thelens in capsul e might be invented .
“Smith” operat ion i s to mym ind far
,very far
,from being ideal .
I f Operat ion i s done w ith the Zi egler kni fe and follow ed atonce w ith loca l treatment without bandaging, the eye qu i ets downrapidly ; especial ly i f course Of calomel i s the routine gene raltreatment .Believe Callan i s right in claiming i r ido—cycliti s is due to
pul l ing on c i l iary attachments ,“dull kni fe .
”
D ifficu lties do not occur when needle i s entered through vas
cular l imbus and used for cutting— not tearing— the capsu le .
N O difficulties with interval of two to three weeks and eyequ iet be fore operating .
E"CE RPTS FROM COLONE L SMITH’S BOOK ON T H E
TRE ATME NT OFCATARACT .
”
In reading Smith’s book on the T r eatment of C atar act the
first statement that attracts one’s attent ion and compe l s hi s interest i s that up to 1 9 1 0 he had perform ed cataract extrac
t ions by the intra-capsula r method .
” As Dr . A rnold Knapp hassaid , this number i s so enormous and so far in advance of any
other operator’s experience in thi s world that for this reason,i f
for no other,the book should be interesting and instructive to al l
ophthalmic surgeons .
TRAIN ING NE CE SSARY .— Colonel Smith gives his views
on the training necessary for becoming a successfu l operator bythe int ra-capsular method” in the following l anguage : “ I can
no more understand a man being abl e to Operate,as it should be
:ADVAN TAGE S A N D DISADVAN 'TAGE S OFT H E OPE R A T I ON .
— I n comparing the relative advantages and disadvantages of the operation Colonel Smith writes : “Advocates ofthe ‘capsu lotomy operation ’ admit the occurrence of escape ofvitreous in about five per cent o f their cases . In my hands at thepresent time it occurs in a fraction over five per cent ofmy casesofextraction in the capsu le done as a systemat ic operat ion w ithoutselect ion . E scape of vitreou s in the ‘capsu lotomy operation’ i s a more serious complicat ion than in the ‘intra-capsul aroperation .
’ In the ‘ intra-capsu lar ’ the whole of the offending
body is removed ; in the “capsulotomy ’ when V itreous escapes , thelens capsule i s partial ly dislocated and is left behind w ith a con
siderab le amount of lens matter , which causes ir it i s and iridocycl itis . The ‘intra-capsu lar operation’ with escape of vitreous i sdevoid of this compl ication .
”
COMPLICATIONS— With regard to compl icat ions , hew rites : Detachment of ret ina immediately follow ing either operation i s so rare an occurrence that i t may be neglected in comparison of these two operations . Complex or late detachment of theretina follow s the ‘capsu lotomy operat ion ’ more frequently thanthe ‘ intra-capsu lar ’ operation . Detachment of thechoroid occurs w ith about equal frequency in either operation inmy experience . I rit is and iri-do- cycl it i s occu r with incomparablygreater frequency a fter the ‘capsu lotomy ’ than after the ‘intracapsu lar ’ operat ion . I think I am not overstat ing the case by saying that one or both of these condit ions fol low s in about ten percent
,of the cases , after the capsu lotomy operat ion and is wel l
under one per cent , after the intra-capsu la r .”
VISUAL RE SULTS— As to visual resu lts , Smith w ritesIn the ‘capsulotomy operation ’ without treatment of the after
cataract , a high average would be six-twel fths ,— at the end of
three months,eight-eighteenths ,— and at the end of s ix months
,
six-tw enty-fourths , w ith suitable spectacl es . Such
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bered the patient i s a tranqui l and adocil e one. I prefer leavingthe blepharostat
,i f i t i s o f a trustworthy kind
, and going aheadw ithout a break . I would
,however
,make one exception ; this
would be in the event of corneal collapse . H ere expulsion of the
cortex i s not practicabl e w ithout at least a partial restoration ofthe anterior chamber . The fewer times the aqueous i s dr awn off
during the operation the better . I also prefer to proceed: unaidedwhenever poss ibl e for the actual steps of the toilet , rather thanrely upon untrained or unfami liar ass istants . The great safe
guard against‘
squeezing i s firm ,even forcibl e
,holding up of the
brow . This the Ope rator himsel f may do,and would better do,
though it hampers somewhat his hand,i f a competent aid be not
present . I f the speculum seems to rest rather heavily upon the
globe,the assistant may hold that up ,
too .
When there is a conj unctival flap it i s kept turned down overthe cornea until a fter the l ips of the corneal section are put inapposition .
Making use of the l id-s as the medium for milking out the
cortex is,I bel ieve
,largely a th ing of the pas t . The rubber clad
finger,applied directly to the globe
,for th is purpose, as recom
mended by C zermak , i s much less to be deprecated .
1 . T he R emoval of C or tex .
Next to the section the expulsion of the secondary masses
that remain a fter the del ivery of the nucleus of the cataract i s ,perhaps
,the most important step of the ex traction . In many
instances the two forward chambers may be freed of cortex byexternal manipulation with the spoons ; that i s , by depressing theposterior l ip of the inci sion with the edge of one
,and gently
stroking the cornea in an upward direction w i th the back of the
other . I f any of the lens remains prove refractory to these
maneuvers , it i s time to introduce the spatula for i ts inverted shoehom effect , to make of it a chute, as it were , working withoutwith the smaller rounded spoon
,and taking care not to inj ure
the delicate membrane of Descemet with the extremity of the
Posterior cortex wil l sometimes resist both external and
internal manipulation to such an extent that i t i s expedient to
abandon further efforts at its removal . It may even be obdurate
to intra-ocular irrigation . I f the i ri s is intact and in place , as
a fter s imple extraction,the spatula may be used to push that
membrane backward,and the ext remity of the instrument be
di rected backward, through the pupi l , in order that the cortex inthe posterior chamb er can be made to sl ide up the blade and out
at the inci sion .
With regard to intra-ocular ir rigation,. or lavage, there seems
to be a singular,theoretical unanimity of sentiment in its favor
“as applied to ce rtain sel ected cases ,” and as s ingular a disregard
of i t in practice . That it is effective in ridding the eye of cor
tical remains there can be no doubt, but that , in the vast maj orityof instances
,it i s an act of supe rerogation , i f not positively inad
visable,i s no less certain . I f lavage i s resor tedt o the s impler the
irrigator the better . Rubber tubing and rubber bulbs are ob j ectionab le because of the loose particles of rubber or other detritusthey are apt to contain . My pre ference would be for an al l-gla sssyringe
,barrel , piston and nozzle . Such an instrument may be
readily rendered per fectly steri le, can be used without assistance ,and the force of the inj ection can be regulated w ith great precision . Moreover, the small quantity of l iquid it would conta in
i s preferable to the large quantity usual ly thrown int-o the eyefrom the large automati c i rrigator s . It i s not always nec es saryto pass the tips of the irrigator thr ough the inc i s ion , in order towash out the cortex
,but often suffices to merely depres s the pos
terior l ip and al low only the s tr eam to ent er the eye . Repeatedintroductions of any instrument are to be di scouraged
,and when
one is re-entered, as the spatula, for example, i t should , each time,be previously fl i rted in an anti septic solution .
Some operators , V alude among them,advi se the aspi ration of
cortical matter by means of a Red-ard aspirator . First those port ions in the anterior chamber are sucked up
,then
,without with
draw ing the nozzl e, it i s pas sed into the po sterior chamber, andbehind the i ri s
,taking care to avoid its suction effect upon that
pupi l in s imple extraction .
2 . T he R epos it ion of the I r is .
I f the i ris extrudes from the wound,as is often the case in
the simple extraction, i t i s best to leave it ti l l th e cortex is disposed of. It wil l usually tend to return to its place spontaneously— in many instances really before one wi shes it to do so. Thi s
tendency const i tutes a valid obj ection to the custom of waitingfor the anterior chamber to reform be fore attempting to removethe lens remains
,as these latter are pron-e then to take refuge
behind the iri s in the upper part of the posterior chamber, where
they resi st al l efforts to bring them: out . The pupi l , meanwhi le ,has become very small
,thus effectually shutting off the cortex .
I f the prolapse pe rsi sts after the cortex has been dispos ed of,
it becomes necessary to replace it . T o thi s end we first avai l ourselves of the natural tendency of the iri s to return to place . By
gently patting the cornea and the sclera in the vicinity of theincision
,either with the spoons or with the spatula
,and by j ets of
warm bori c acid solution directed upon it f rom the dropper, weencourage contraction of the sphincter . Or one may have
recourse to the very ingenious expedient devi sed by the late D r .Knapp of applying the back of the spoon to the globe be low thecornea and making a quick pres sure movement toward the center
of the globe so as to cause the wound to gape and let go of the
iri s .
Bearing in mind the extreme deli cacy that characterizes the
struc ture of the i ri s we refrain as much as possible from touchingit with the instruments . An ext ens ive prolapse may be oftenreduced by manipulations that absolutely respect the membraneit sel f . H owever
,should it remain obstinate to these milder meas
ures,one must resort to contact with the spatula . This should
be a fter such a manner as to infl ict the minimum of traumatism .
The spatula is placed on the posterior l ip of the incision to sl ightlydepres s i t, and with its edge paral lel with the direction of thewound, and the i ri s i s returned to the anterior chamber by a sortof rota ry, sl icing movement . It i s only when port ions of the irisare held so tightly in the angles of the incis ion as to resist external
5 . T he C leans ing and I r r igat ion of the C onjunc t ival Sac .
I f there has been the least bleeding, clots w i l l have formed .
Th ey cling mainly to the wound , to the edge of the conj unctivalcuts , and to the borders of the l id . They are best removed withthe aid of the del icate toilet forceps of De Wecker . This instru
ment has curved members,and the j aws are not toothed , but are
s l ightly roughened . Some surgeons also use it to replace andproperly arrange or spread out the i ris (Mul ler ) . A fter pickingoff the clots the who le conj unctival sac
,inc luding
,of course, the
field of operation , i s copiously flooded with warm bori c acid ornormal sal t solution . This serves not only to wash away al l loosematter but favors both the straightening out of the i ri s , and the
coaptation of the incis ion . This i rrigation i s di rected in such amanner as not to disturb the conj unctival flap ; whil e this usual lyremains undisturbed
,i t i s important to note that such is the case .
T he eye i s now ready for final closure . I f the bl epharostat i s
st i l l in place i t is grasped?by the handles,sl ightly l i fted from the
eye, the patient i s told to close the eyes , and the handles , whilebeing p ressed together
,are ti lted forward and pressed firmly
downward,f reeing the upper l id
,and the lower l id-holder is then
l i fted out of i ts cul-de-sac . I f this instrument has be en already
removed the Ope rator takes the tips of the upper lashes betweenthumb and index and l i fts the l id over the wound while drawingi t down into place .
The insti l lation of a myotic after the extraction is superfluous ,or actual ly harmful .
Discussion by E .". Gardiner .
D r . Beard has so thoroughly covered the ground in his paperthat little r emains to be said on the subj ec t .
L ike in the days that fol lowed the publication ofV on Grae fe’s
artic les on the modified linear section,we are now pass ing
through a process of upheaval in the technique for the extractionof catarac t . But al l the methods advocated
,excepting perhaps the
“ Indian” operation , leave the eye in much the same condition for
T H E TOIL ET 1 43
the last step, therefore the safest and best way to make the toilet
The great and fundamental principle in making the toilet i s ,to
remove the cortical masses from the anterior chamber, with as
l i ttl e manipulation as possible, and w ithout introducing inst ruments ther ein . Whatever technique the experienc ed ope rator has
found,that based on these fundamental princip les , and accom
plishes the result in a sat is factory manner , i s the proper technique
for that particular operator . I make this statement because I b eli eve that there i s in operating
,as there i s in writing
,an indi
vidual style,and that when a success ful operator t ries to adopt
anothe r man ’s methods,bri ll iant a s the results may be
,in the
other man’s hands,he i s in great danger of los ing some part of
h is individual technique that made for success . We are not al l
especial ly versati l e .
D r . Beard says A sclerosed or a hype r-mature cataract Ob
viates this step” ( the to il et ) . I would like to add that a ma
ture cataract immensely s implifies the step,there fore I would
make a plea for l ess haste in operating on senil e cataract . Actin haste and repent at lei sure is t rue of more than one activity
in li fe . It i s true that waiting for thorough. maturity entail s
some inconvenience for the patient,but the difficult ies in Operat
ing are so much lessened , and the chances for a bri ll i ant result
are so much increased,that in the ordinary run of cases the wait
ing course is much to be commended .
Making use of the eyel ids as a medium for milking out the
cortex i s I bel ieve a thing of the past .” I f by “milking” D r .Beard means , and I take it he does , squeezing the eyeball al
ternately w i th the upper and the lower eyelids,I concur in hi s
opinion ; but i f he means the use of the lower l id as a medium
with which to exert pres sure on the eyeball,I differ from him . The
soft, smooth eyel id is an excellent medium with which to trans
mit the pressure from a dexterous thumb . The obj ection some
times made that there might be infection from bacteria retained
in the Meibomian ducts , i s , I be l ieve, more theoretical than praetical ; nevertheless , it i s advi sabl e to express the content s fro-mthese ducts when the patient i s be ing prepared for operation .
There is one warning in the paper that I would like to seemo re strongly emphasized , viz .
,the danger of repeated trial s to
remove posterior cortex . It sometimes happens,especial ly in im
capsule . A l l the loose particles should be careful ly removed bygently st roking the cornea w ith the eyel id or with the spatul a,adherent shreds should be dealt with by the repository movements of the spatula so wel l described D r . Beard’s excell entpaper .
"A l l surgeons are agreed fewer the number of steps
to an operation the less the danger of compl ications . S imple extract ion may be done in every case of mature, uncomplicatedcataract in persons under s ixty . It is rightly cal l ed “s imple” as
only three step s are necessa ry, the inci sion , the capsulotomy andthe expression . A s a rule very l ittl e toi let i s necessary — E di ]
Smi th’s‘ latest avai lable statistic s Of the intracapsular Op
c ration show -i ritis , or I per cent . ; loss of vitreous , per
cent . ; first-class results , per cent . ; second-class results ,
per cent . ; fai lures , per cent .
Indian statistics cannot be fairly compared with those j ustgiven , because as a rule they are not based on tests of vision ,which are nex t to impossible to secur e
,but are b ased on the ap
pearance of the eye eight to twelve days after the operation ;while it i s general ly possible to tel l a good result f rom a poo rone in this way
,i t does not compare w ith visual tests in estimating
the success of an operation .
In discuss ing the subj ect I shal l refer to the principal compl i
cations which are met with in the capsular and intro-capsularmethods ofoperating,
and to certain constitutional conditions of
the patients which may favor them , j ointly or separately as may
seem best . I shal l also advise methods Of treatment which have
been Of serv ice to me , w ith such re ference to authorities as ar enecessary to i llustrate some points not covered by my own ex
perience.
N O one w i l l di spute the propo sition that there i s no step whichmay not complicate cataract operations and that all methods Of
Operating are a compromise w ith greater or l esser ev i l s ( C ompl ications ) . In othe r words , no method has a monopoly Of all that i sdesi rable
,and the converse of thi s must be true .
Accidents dur ing the Operation ar e few in number and ar e
largely preventable . When they occur,mor e harm usual ly re
sults from the complications to which they give rise than f romthe acc idents themselves . Some complications ar e the results Of
acc idents during the operation introducing the kni fe upside downi s an example . A few times I have turned. the kni fe and com
pleted the section w ithout difficulty . I think this the proper wavout of the trouble . Rupturing the capsule or hyaloid w ith the
del ivery hook is another example . Some accidents of extractionar e due to complicated conditions , which are either not recognized
‘Sm i th ’
s A r ch . of Ophthal V ol. xxx iv, p . 602 .
To study complications it i s desirable to make a distinction between the different s tages of cataracts, and to considerthe operation which seems best suited to each stage ( the in
cipient , immature , intumescent, mature and hypermature ) together with the complications most often observed after suchOperations . I t is also important to note the difference which i sreal and not apparent only between the compl ications observed in
the intra-capsular and regular operations .With improved instruments of preci s ion , the Sphygmomano
~
meter and the tonometer , we can learn much of value concerning the stat e of the general blood pressure and the intraoculartension, two mos t impor tant points . I bel i eve the in formationfurnished by these instruments , especial ly the tonometer , wil ll im it the number of certain accidents and compl icat ions in intracapsula r del ivery especial ly .
In my experience some of the most frequent complicationsmet with , loss of vitreous , delayed heal ing of the section , prolapse , incarceration and entangl ement of i ri s and the infrequentloss of an eye from sub -choroidal hemorrhage
,i f not caused by
high intraocula r tension and’ high blood pressure,i . e .
,above 2 50
mm . ,are usually associated with it. Again the pressure ma
nipulations on the globe, which are necessary to deliver a cataract in the cap-sule , or even w ith capsulotomy when the tonometerreading i s normal
,cause rupture of a frai l zonula and loss
of fluid vitreous , when the instrument gives a high reading.
Theoretical reasoning and some practical expe rience has sati sfiedme that when the blood pressure i s above 2 50 mm . and the
tonomete r reading above 2 5 mm .,a cataract extraction should be
de ferred unti l it has been reduced to 1 90 mm . o r lower , and w ithit the intraocular tens ion .
C omplications are met with when we have least reason to expeet them , through faulty technic , or an acc ident . On the otherhand, the Operation may be per fect in al l its mechanical detai l s ,and yet an eye may be lost through severe compl ications developing from some inherent vice in the cohs titution of the patient,the operation being an exciting cause only .
dacryocyst iti s , styes , chalazia and ectropion . The mental con
dition should be favorable to sel f-control , and stimulants shouldnot be withdrawn too sud‘denly
,i f the patient i s accustomed to
thei r use . An old pe rson should not be kept on the back too
many days for fear of hypostatic pneumonia . I have lost th ree
patients f rom thi s cause . It comes on very ins idiously,often
without cough or any symptoms referable to the lungs,so that
its presence i s not recognized in time to give any treatment .E xogenous and endogenous in fections ( because of the com
parative rarity of the latter,and the fact that its etiology and
pathology are not so well understood as the former ) make it desirabl e that the conditions which are usually grouped under thevague term , autointoxication , and the r heumatic and gouty dia
thesis ofwhich we know so little, and incr iminate so much,shal l
be studi ed according to modern theories"7' 8 and the methods
of treatment which have given the best results in my hands wil lbe described.
Speculum .
A good al l-round speculum , which wil l not make undue pres sure on the globe in a high percentage of cyes
,
'
i s yet to be devis ed . The Fisher l id elevator i s an excellent substitute for
,and
should be given the preference over , any speculum ,when we fear
a patient may act badly .
T he Sec t ion.
The mos t common causes of the compl ications which relate tothe sect ion are : Poor l ight ; the use of a dul l kni f e, or one withtoo narrow and short a blade ; not manipulating the kni f e so thatthe puncture and the counter-punc ture are diametrically opposite ; and the section between them not being completed with onethrust of the kni fe
,so that every plane i s paral lel to every other
“V an N oorden— Disorders ofMetabolism and N utr ition ,
‘de Schweinitz— A utointox ica tion in R elat ion to the E ye, T rans .
Ophth. Sec tion A . M . A . ,1906, p 377 .
de Schweinitz and Fi fe— A utointox icat ion,T r ans . Ophth . Sect ion,
A . M. A .,1908, p
‘Woods— A utozntoxication and A llied I ntes t inal T r oubles , T rans .
Ophth . Sec t ion,A . M . A .
,1910, p . 400.
for ceps , not to wait for complications but to pass a. thin piece ofwood saturated with car bolic acid or some other s timulant which
has been wiped dry, between the lips of the wound to promotehealing . These remarks apply especial ly to the large section ofthe intracapsular operation
,although I have seen this compli
cation after the regular operation .
T he I r idec tomy .
Thi s should be Of medium size, but larger for the intracapsular Operation . I t i s very important that the i ris be abscised
to its extreme periphery,so that no apron is left to be c aught in
the s ect ion , and that the pi l lars are cl eanly cut for the same
reason.
In the intracapsular method,especial ly , I have thought that
wide updrawn pupi ls , from imper fect toi lette or loss of vitreous ,could be to a large degree prevented and ideal keyhole pupil s
secured by a small prel iminary iridectomy . But after an experi
ence of about one hundred such operations I have found that the
inflammatory adhes ions , which form around the base Of the iri spi lla rs , prevent stretching of the base of the coloboma and make
expression Of the lens difficult,and loss of vitreous sl ightly more
frequent , than when the iridectomy is made b roader at the op
c ration . On the other hand , I have made a prel iminary i ridectomy, as for glaucoma , in three cases of unripe cataracts in
which I intended doing the intracapsular operation,the tonometer
having shown plus tension . A broad i ridectomy six mill imetersat its base under thi s condition has rendered del ivery of the catarac ts freer from comp l ications , but it has at the same time
lowered the tension and incidentally swel l ing of the lens and more
rapid ripening of the cataracts have caused obl iteration of the
anter ior chamber .
While th i s explanation of the absence of the chamber is prob
ably correct it has not been easy to differentiate it from the conditions associated with a leaking corneal wound . T herefore ,wh i l e a prel iminary iridectomy may have some advantages as a
C apsulot omy .
When the capsule i s Opened in cases of incipient , immature ,mature and, i f po ss ible, in hypermature cataracts , I think it i s
better to do it by extracting the anterior leaf, which renders complete del ivery of cor tical dé bri s easi er, the after-cataract not sothick and tags of capsule less l iabl e to be left behind . These
are rather common complications of the regular operation , areresponsible for a certain percentage of fai lures , and ar e its weak
es t points , too much pres sure with a dull cystotome may dis locatea cataract .
Delivery of the L ens .
These complications are intimately connected with the difference in the diameter of the lens to the diameter of the cornea,
and with the s ize and pos it ion of the section,and especial ly with
the manipulations in del ivery of the lens . It i s easy to di slocate acataract and it i s a s erious compl ication .
A ny of these commications may be a cause of vitreous loss ,and I have lost vitreous in attempts to expel and wash out corticaldé bri s in the regular operat ion .
For cataracts in the immature, incipient , intumescent andalso in the hypermature stage, the bes t and safes t operation inmy j udgment i s to del iver them in the capsule . Fewer compl ications wi ll follow , and those which do fol low wil l be milderand more amenable to treatment
,and entail f ewer losses from
severe inflammatory compl ication .
From the standpoint of complications it i s not so easy to de
c ide whether it i s better and safer to extract mature cataracts byregu lar methods or in the capsule .
So much can be said in favor of each method that the personal
equation of the ope rator becomes the pivotal point around which
revolves the question of which Operation he should per form ;other things being equal , expe rience and skil l count for every
thing . I think every man who has attended Smith’s cl inic w i l l
agree that in his dexterous hands , and with doci le Indian patients, the method of intracapsular extraction of mature cataractsi s not fol lowed by so many or so severe complications
-
as occur
the regular operation w i l l show fewer complications than theintracapsula r. N O operator should attempt the intracapsular
method unless he has thoroughly mastered the principles andtechnic of the operation
,and the treatment of compl ications .
C ataracts for the regular Operation are selected,ext raction
i s not performed fr om choice until they ar e r ipe, for fear ofcomplication .
On the other hand the Smith operation is adapt ed to all stagesof cataracts , especial ly the inc ipient and immatur e, and the compl ications which come from the capsule and cortical matter are
thus avoided . This does not mean that the intracapsular opera
tion does not have its share Of complications,but in my j udg
ment it does mean that i f one hundred unselected cataracts are
submitted to operation by skil led operators, one
-hal f of them by
the capsulotomy method and the other hal f in the capsule,that
the latter wi l l furnish 50 per cent . h igher visual results,
or or even 6/3, two months a fter the operation , i . e .,before
the secondary oper ation has been done on the first class of cases ,and I th ink 2 5 per c ent . better permanent vis ion .
I am aware that only a few confreres share in this estimateOf the superiority of the intra-capsular Operation ; fortunately ,those who do know most about it , having learned to perform itat first hands in India , and have seen the high-class vi sual resultsit can furnish .
L oss of V i t reous .
In either operation this is usually the result of an accident in
completing the section , or it occurs w ith del ivery of the lens , but
it sometimes occurs afterwa rd in dressing the eye . It may be
caused by a weak zonula,by faulty pressure in del ivery , f rom
coughing,or sneez ing at the time of the Operation , or vomiting
a few hours afterward . It may be caused by a badly-fit ting spec1 2Greene —T rans . Gph . Sec tion,
A . M . A .,1909, p . 188-9 .
”Wood— T rans . Gph . Sec t ion,A . M . A .
,1909
, p . 195 .
having his advice and guiding hand to help one, los s of vitreouscomplicates the Operation more than twice as Often as in the regular operation ; in Old cataract patients the vitreous is usual ly fluidand loss of fluid vitreous seems to be a les s ser ious complicationof the heal ing than i f it i s normal . 1 8 The amount is usually smal lbecause the position of the patient’s eyes does not favor loss ;it occurs under such different conditions in the intra-capsularoperation , because it is not exposed to the action of the chemica llydegenerated cortex . Therefore , I bel ieve that loss of vitreous
is not so serious a complication as it i s in the regular Operation .
A fter an experience of about 70 0 intra-capsular operations Ihave only seen two eyes lost from excessive loss of vitreous , andin each of these the patient was responsible .
L oss of vitreous in either operation may cause delayed healing of the section
,and primary in fection and Opacity of the vit
reous itself rather than detachment of the retina . While it i s
generally bel i eved that opacities of the vitreous fol lowing cataractoperation may result from its loss , w e must remember that cataract i s a di sease of advanced l i fe , and operations are per formed
at the time when chor oidal disease is mos t common. Therefore,we should be sure that we are not mistaking a pos t hoc for a
prop ter hoc ; a condition incident to age and disease of choro idfor the result Of an accident o r a compl ication of the operation .
Pr olapse, I ncar cerat ion and E ntanglement of I r is .
These oc cur during or a fter the s imple operation in 5 to 1 0
per cent . of cases ; the percentage is smal ler a fter the combinedoperation and is not greater in the intracapsular . They somet imes result from undue pres sure of the speculum ,
or f rom the
patient squeezing the eye and losing vitreous,and they are some
times the result Of imper fect replacement of the i ri s in either
operation . (Toilet )When these compl ications follow later , and are not the result
Of operative accidents , I have most frequently observed them innervous and restless patients
,who do not keep quiet
,who finger
the dressing or strike the eye and reopen the wound . H igh intra
Woods—Sec t ion on ophth .,A . M. A .
,1907. p . 142
lay ing heal ing or reopening the wound . A high degree of astigm ia usually fol lows these conditions .T he question of how and when to operate for prolapse of
iris is an impo rtant one, made doubly so by the fact that the conjunctival sac is not l ikely to remain long in as sterile a conditionas when the operation Of extraction was performed thereforeinfect ion of the eye may follow .
It i s generally considered sa fe to absci se a prolapse withinthe first thirty-six , or poss ibly forty-eight, hours . A fter thattime it i s not safe to make an abscission , which to do any good
must Open anew the anterior and poss ib ly the posterior chamberand expose the eye to the danger Of infection a second time .
Later, however, when the bandage has been left off, and the secre
tion oftears , or possibly medical treatment , have restored the conjunctival sac to i ts normal condition , we may abscise a prolapseand cauteri ze its edges with the galvano—cautery , Todd’s cautery ,or we may use a strabi smus hook or a heated probe , i f the prolapse i s small . The same treatment i s indicated for cystoidheal ing.
L et me emphasize two points which are essential to successFirst . I f discovered early
,draw the prolapsed h is well out of
the wound so as to break up the adhes ions,and cut it Off smoothly,
so that it wi ll recede inside of the eye . I f not seen unti l the adhesions are too firm to break up
,a cautery point should be passed
through the pr olapse to evacuate the aqueous and des tr oy as much
ofthe iris tissue as is necessary, so that cicitrization shall be com
plete and cys toid healing and late bacterial invasion shall be
avoided. I know the Obj ections which have been urged againstthe use of the cautery for thi s purpose
,and that some serious
compl ications have been reported from its use ; notwiths tandingthese
, in my experienc e, i t has been the b est means for curingsmal l prolapses or even large ones
,a fter they have been absc i sed.
In about 5 per cent . of my cataract Operations I have at
tributed delayed heal ing, or fai lure of the anterior chamber tobe establi shed , or it may be reopening of the section , to high intraocular tension and high blood pressure , probably the results ofarterio-sclerosis .
In these cases the above explanations of the delay in heal inghave seemed cons istent with all the facts
,and although I cannot
In a few cases after examining the section with forceps for
a foreign body cauterization w ith carbolic acid , or stim
ulating the l ips Of the wound with si lver nitrate,60 per c ent .
solution of alcohol , or the use of the galvano-cautery , I havenot been able to secure firm healing of the sect ion and the estab
lishment of a chambe r unti l I have made a smal l glaucoma iri
dectomy downward, which has never failed in its purpose . Theseremarks refer particularly to cases complicated by a leakingwound and minus tension . It i s wel l known that a leaking cor neal
wound seldom becomes infec ted. Nevertheless,certain milder
compl ications may be avoided by prompt closure of the section .
On the other hand , I have seen a few cases in which the sectionhealed , the anterior chamber did not form but remained shal
low and the tension became plus ; an ir idectomy has always lowered the tension and secured a chamber in these conditions .
E serin or p ilocarpin , or repeated tapping , or drugs to reduceblood pressure , have not succeeded as well in curing the com
pl ication . I have not tried sodium citrate in thi s condition .
I have seen two cases compl icated by delayed healing afterthe intracapsular method , as follow s — A fter the delivery of the
l ens,the patient suddenly looked down , the wound gaped, vit
reous pres ented , the hyaloid did not r up ture as it generally does .
but remained bulging in th e wound,which healed slow ly with a
gaping section and poor vi sion from opacity of the hyaloid , and ah igh degree of astigm ia . It is good practic e in such a compli
cation to intentionally los e vitreous so that the lips of the sec tionshal l come together and firm heal ing result .I r ido-dialys is .
I have seen thi s as a complication a few time s , from the patient turn ing the head and tearing a portion of the i ris loose fromits periphery . In each method of operating i t makes an unpleasant compl ication .
I have tw ice caught the loose pilla r of i ris and drawn i t into
modern surgical treatment of other wounds . The argument advanced in favor of early inspection
,viz .
,to be ab le to treat in
fection i f present , has l ittle weight , because purulent infectionsare very rare now ,
2 to 3per cent . , and I have never seen a purulently in fected eye saved by any method of treatment when thevitreous was invo lved.
E xperience has shown that a fter intracapsular delivery i t i sof the greatest importance in avoiding complications of the healing, to let the eye alone unti l four days have passed , unless painor di scomfort indicate that something is w rong . I f removal of
the dressing shows that al l i s well,we should not Open the eye ,
but s imply change the dressings and bandage it again,and then
wait three or four days more . On removal of the dr essing aboutthe eighth day it i s sometime s noticed that a l ittle redness , or
signs of reaction, are present within normal l imits ; however ,
these are l ikely to increase later when we discard the bandageand replace it w ith dark glasses and the brow shade ; they arenot pain ful but seem to be caused by i rritation,
and are not in
flammatory conditions . In complicated cases the redness and re
action are more severe,and w i l l now be considered w ith compli
cations Of the regular operation , under different causes .
St r ipped and L at t iced Ker at it is .
Are frequent complications of the regular,but are perhaps
more o ften observed a fter the intracapsular ope ration . unless the
cataract has been quickly and smoothly del iver ed . They ar e
easi ly recognized and usual ly pass away in a few days as thewound heal s .Some years ago I had a case in which after a smooth com
b ined extraction the gray l ines in Descemet ’s memb rane persi sted and lowered vision to and the condition became
permanent in spite of treatment . They are be l i eved to be causedby disturbance in Descemet membrane from p res sure of the de
l ivery hook or spoon , and are thought to be mor e frequently ob
Detachm ent of the C iliary Body and A djacent C horoid.
Th i s i s an infrequent complication , I have recognized in one
cas e . The condition was first described by Von Graefe and
L eib reich in According to Wooten2 4 it was recognizedby Knapp in 1 886 , and lated descr ibed by Fuchs .
2 5 It has alwaysfollowed operations with iridectomy
,and is probably often over
looked . I t i s not regarded as a serious compl ication .
Sub -ch or o idal H emorrhage .
I s for tunaely a rare complication . I have seen two cases ,the first occurred in India
,in an aged H indoo
,the right lens
was del ivered in the capsule w ithout accident , but on completingthe section in the le ft eye , blood began to ooze from the wound ,and a moment later the lens and vitreous were expel led . A p ress
ure bandage helped control fur ther bleeding . This was the onlytime this compl ication occurred in about 1 2 0 0 operations . The
other case followed three hours a fter a normal operation w ithi ridect omy , in an inmate of the Sold-ier s ’ H ome near thi s city .
These are the only cases I have seen in an experience of about
1 50 0 operations .
I r it is .
C onsidering sy nechiae alone as evidence of a mild attack , andall grades of i ri s inflammation be ing included
,probably 50 per
cent . of all s imple and combined operations w il l show some evi
dence of its presence . Iriti s,cycliti s
,and i rido-cyclo-choroiditi s
,
which may cause occlusion and seclusion of the coloboma,are a
triad of complications whose evi l influence on the future integrityof the eye i s without limit .
A fter the intracapsular operation in Smith ’s cl inic,i riti s ,
kerato- i ritis , ir ido—cyclitis and irido—cyclo-choroiditi s are rarecompl ications , especially after an oper ation per formed by Smithhimsel f .
”A . H ill Gr iflith— N or r is and Oliver , Dis eases of the E ye, p . 359 ."Wooten— I n C laiborne’s C atar ac t Sympos ium , p . 162
”Fuchs’ T ext Book ofOph thalmology, 3rd, A mer ican E dit ion, p . 385 .
be governed by the conditions which have been referred to in thepaper and elsewhere under endogenous inflammations . ( See reference on the last page of thi s paper . )D iab etes .
D iabetes complicates the operation in about 4 per cent . ofcases . A diabetic patient should not be operated unti l the percentage of sugar has been reduced as low as possible, and acid
auto-intoxication,i f present , should be rel ieved for fear diabetic
coma may compl icate the operation . The section in a high pe r
centage of diabeti c patients w i l l heal well provided they are opc rated under favorable conditions , and other com pl ications of
the operation are not material ly increased .
A lbumur ia.
A lbumin appears in the urine in quite a high percentage ofindividuals with cataract . R othzugel found small quantiti es o f
albumin in of the 1 0 2 patients w ith cataract which he examined
,and larger quantities in 2 per cent .”— Weeks . 2 6
The possibi l ity of uremic coma compl icating convalescenceshould not be forgotten . H erpes of the cornea sometimes com
plicates an operation,about the end of the first week ; the attacks
are usual ly mild , however . Seni le entropion may also requiretreatment .
A fter -catarac t .
This i s the most frequent complication when the capsule i sopened and left behind . During the l i fe of cataract patients
probably 75 per cent . have an amount ofw r inkl ing and opacifica
tion of the capsule suffic ient to lower vis ion to and r equire
a disci s sion to restor e a higher grade of v is ion .
Knapp , the great apostle of ear ly disc i s sions , adm itted 70
per cent . of disc i s sions in his operations , and Bull and others 50
per cent . It i s general ly considered much sa fer to perform discission as soon as possible a fter the operation , than later , but
“VVeeks— D iseases of the E ye, p . 586-87 .
fulness . Serum therapy seems to promise something.
*f
N on-purulent in fections are milder in character and are favored by vices in the constitution of the patient ; in thi s sensethey are endogenous . They are among the most Obscure conditions we have to treat empirically because of our l imited knowledge concerning them .
I f the patient i s young and his physical condition good , hemay be able to throw off or minimize the effects of a non-sup
purative in fection ; on the other hand, i f h i s vital resi stance i s
low, or the in fection a severe one, he w i l l not be able to throwit off, and ser ious damage o r total loss of the eye may fol low .
The medical treatment of these condi tions promises better t esults than that of some other complications which have been con
sidered. The most hopeful a re those as soc iated w ith choroiditi sand opacities of the v it reous , which under powerful , alterative andeliminative treatment Often improve beyond our expectations . But
a ful l di scussion of endogenous inflammations and their treatment
would lengthen this paper beyond reasonable l imits,and I have
so lately written on these conditions that I do not know of anv
th ing new to add. There fore,I w i l l refer the reader who w i shes
to fol low the subj ect further to my paper,
“T he M edical T r eat
ment of the Patient Befor e and A fter the C atarac t Oper ation.
” 2 9
Discussion by C assius D . Wescott .
I w i sh to endorse all that has been said in regard to the importance of a careful study of the patient and thorough preparation
,general and local
,before operation. And right here l et me
express my personal obl igation to Dr . Greene for his studies ofthe cataract patient
,especially with re ference to hypertension
and arterio—sc lerosi s , and for so generously shar ing w ith us thefruits o f h i s Operative experience in India and this country .
The general examination should include taking the blood pressure
*VVeeks D isease of the E ye, p . 900 et seq.
TDavis Pyles’
Sys tem of Oph thalm ic P rac t ice, p . 5 1 et seq.
”T rans . Ophthal. Sec t ion, A . M . A .
,191 1 , and "ournal Amer ican
Medical A ssoc iat ion,Dec . 3, 191 1 .
to Operate when the sphygmomanometer regi ster ed 2 0 0 mm . unti l
al l means had been exhausted for lowering the pressure . It i s
surpri sing what can be done with rest , diet, and drugs , and evenif the reduction is only temporary , it serves our ends and may
prevent delayed healing or di sastrous h emorrhage .I w i l l not be hur ried in my care of these patients . We should
have them under observation long enough for adequate study andpreparation— regulation of diet , cl eansing of the bowels , skin , etc .
,
and putting them in the best possible condition . I am in favor
of scrubbing the face w ith hot water and soap and flushing theeye with warm boric acid so lution two or three times a day for
many days,and dressing the eye over night w ith White ’s oint
ment the night be fore operating . I f this i s done faithfully it i s
not necessary to irritate the eye,chemical ly Or mechanical ly , j ust
be fore the operation . I have a culture made when t he patient
enters the hospital and am guided by the results as to other treat
ment of the conj unctival sac .
I do very few cataract operations , and w i l l probably never doa s imple extraction
,or an extraction in the capsule
,intentional ly .
I am quite w i l l ing to grant , however, that in the hands of thosewho have been trained by C 0 1. Smith , the intracapsular operationshould give a larger percentage of bril l iant results in cases of
immature,swollen
,and hypermature cataract than the regular
operation . I always do a preliminary i ridectomy,i f my patient
wi l l consent , and feel confident that it inc reases the percentageof good results in my hands . The possibil ity of infection isnegl igible and the danger Of i r iti s follow ing the subsequent extraction is very much lessen-ed,
I am sure . The patient , havinghad the experience of the minor ope ration , loses his f ear, has bet
ter sel f-control during the extraction,and the safe del ivery of
the lens i s faci litated . The preliminary iridectomy gives us avaluable Opportunity to study the mental state and behavior of
the patient before the more serious operation i s attempted . A fterseeing Prof. Fuchs pul l capsule , l ens , and some vitreous out of
an eye with hi s capsule forceps,I decided to stick to my c ysto
tome and do more disc i ssions i f necessary . I have not had an
in fection a fter a needl ing and only one glaucoma,and thi s in a
not ir rigate i f I could remove most of it by gently stroking thecornea and freeing the lips of the wound with the spatula. Alarge inci sion is the best safeguard against retained corti cal sub
stance , and it has been my practice to introduce the kni f e only a
l ittl e above the horizontal meridian in al l cases except when asmal l , hard lens was Obviously present . I believe that White’sointment is of value in the dress ing of al l wounds of the eye anduse it habitual ly .
I do not use a bandage except after enucleation and in chil
dren , but employ a light dressing secured by adhes ive strips andprotected by a R ing mask . I have always dressed these ca sesdai ly except when vitreous has been lost . In such cases
,and in
very nervous patients,it may be better to delay the first dress ing,
but I have seen no compl ications which I could re fer to the
daily dressing ; and many ofmy pati ents , who are all p rivate cases
and mostly intel l igent Americans,have spoken of the comfort fol
low ing the cleansing oi the l ids and renewal Of the dres sing . We
may encounter fluid vitireous and weak zonula whe re we leas texpect it
,and must “take our medicine .
” In my experience
cycl iti s i s apt to fol low , with more or less permanent opacities ,even when the eye b ecomes and remains quiet .I am indebted to D r . Greene for the suggestion to do i ri
dectomy downward in case of fai lure of the wound to close . I
have not torn an i ri s s ince I adopted the plan of fixing the eye
and d rawing out the iri s mysel f,and having a trained assistant
use the scissors .
I fully agree w ith all that Dr . Greene has said in regard topurul ent in fection
,and have adv i sed the removal of the eye when
the vitreous has become in fected, and before panop-hthalmitis has
added to the danger .
with it a traumatic cataract in a clear lens . It i s more difficult touse the keratome and it i s more likely to puncture the lens thanthe von Grae fe kni fe, which I prefer . One advantage of the pre
l iminary i ridectomy i s the maturing of the lens in fully 50 percent . of the cases . There is also no hemorrhage during the ex
traction . The patient is trained for the second operation . T hedegree of trauma is divided between two operations .
(Geo .F. Suker ) An iridectomy should be done in every cataract extraction . As to doing the extraction in capsule or not ,that i s largely a matter of technique and select ion Of cases . One
can safely start to do the intracapsular extraction and i f he meetswith any resistance , ob stac les , or complications he can sti l l safely
revert to the capsulotomy method . This procedure does not en
danger the sa fety Oi the eye nor the ultimate end resul t o f vis ion .
The intracapsular extraction i s definitelv indicated in certain
cases , e . g . , when the cataract is hypermatur e , when there i s alarge amount of soft substance present , when the lens has undergone cystic degeneration— one that i s more than hypermature .
In these cases when the cap-sule i s Opened freely the degeneratedlens substance is di sseminated throughout the anterior chamber ,gets behind the i r i s
,lodges in the angl e of filtration
,has a tend
ency to block the pectinate l igament,and i s also absorbed . This
degenerated substance is tox ic and , there for e , i s prone to set up
either a local ized or a mor e or les s general ir iti s,i rido -cycliti s or
an anter ior choroiditi s,in fact what might be cal led a general
uveiti s . This degenerated lens substance is wel l com parable tothe contents of any cyst as the r esult of degenerative processes .A nd we know that when the contents of such a cyst gains accessto any cavity i t i s very l iable to set up t rouble -this we recogn izefrom general surgical pr inc ipl es . H ence we can see that the
int racapsular operation i s almost one of necessity in such cases
i f we w i sh to avoid a la rge percentage of di re results ."Vhen the v i sion i s reduced far below the po int of economics ,and transi l lumination shows the lens uni formly Opaque
,one can ,
w ith safety and confidence , do a capsulotomy ope ration and achieveas good a result as w ith the intracapsular method . Thi s from
his competent pupils as Vai l or Greene , to adhere to the Old capsulotomy method . Remove as large a piece of the capsule withone of the various capsule forceps , thus avoid the remainingshreds of capsule from curving upon themselves and incorporating, not only tags of the posterior surface of the i ri s , but alsolens remains , which condition i s O ften entai led with more or lesscompl ications . Then , too, a relatively large iridectomy wil l eas ierenable the lens to escape and reduce the chances of the soft substance sl ipping up behind the pil lars and remaining in the angleof fi ltration .
I am glad that mention has been made of the importance ofthe ophthalmologic surgeon being an internist . The physical condition of the patient i s of paramount importance . The merefact that a patient has a cataract i s evidence that there i s somephysical condition
,local or general
,which i s responsible for it .
For a cataract is only a local expression of a general condition ,or secondary to ocular disturbances , such as a low grade of anterior choroiditi s
,cyclo-choroiditi s and the like . Therefore by
studying careful ly the proper etiologic factor and the physicalcondition of the patient and instituting the proper treatment
therefor,many accidents and complications may be avoided.
It i s on the above points and facts that one should decide
whether or not the capsular or the intracapsular operation should
be per formed .
(H . H . B rown ) I feel that no par t of the cataract operation
deserves greater consideration than capsulotomy . Upon its suc
cessful performance depends largely not only the immediate ia
vorab le results of our operation , but has so much to do w ith theultimate vis ion obtained . There i s one point upon which we allagree
,namely
,that the prime obj ect of opening the capsule i s to
allow the escape of the lens . The more nearly the capsule i s
emptied of its entire contents , the more complete has our Obj ect
been attained . Therefore , whatever means we may resort to inour efforts to this end , i t must be acknow l edged that the largerrent made in the capsule the easier and more completely can we
expel its contents . I have had no experience in Opening the
in hypermature lens and where I expect a tough capsule . I never
attempt the use of a capsule forceps save in the case of prelimi
nary i ridectomy which,by the way
,I always pre fer . I believe
Fisher ’s capsule forceps possess special advantage,as clearly
shown by him , when it is desi red that the bal l should be di rected
upward . In the use of the cystotome our purpose i s often aborted
by it s careless manipulation . The cutting surface must be sharp
so that a clean cut is made , not a laceration or tear .
The incision is made cl ear ac ross the surface of the lens and
as near the periphery as poss ible ( from top to bottom ) , and this
inci sion should be met by a horizontal incis ion as near the equator
of the lens as possible . The capsular contraction from such ln
cision wil l allow escape of the cortical matter and tend , in a
measure,to obviate the necessity of secondary operation or op
erations , which after all i s the disadvantage of the removal of
the lens from its capsul e . N ot that I advocate that any form of
capsulotomy w i l l enti rely obviate the necessity of seconda ry Op
erations , w ith thei r more or less detrimental result s to the integ
rity of the eye,but I am certain that greater care in the use of
the cystotome,a l ittle more time and patienc e in coaxing out
cortical substance,w i l l lower the per cent . of secondary Opera
tions,lessen ri sk to the eye and enhance the visual acuity .
T he subj ect under discussion befor e this meeting to-night,V iewed from every standpoint , i s of the greatest impor tance . It
pertains to a succes s ful i ssue in the most del icate operation in
the domain of surgery . Many points have been brought out ofper sonal inte rest to each of us because they are the result of years
of careful experience . I n a hu r ried rev iew of this symposium
it i s imposs ible to attempt to discus s each paper . In my mind ,however , too great stres s cannot be placed upon the importance
of properly preparing the patient fo r oper ation . I hearti ly agreewith al l the essayist said upon the subj ect . I bel ieve that di l i
gent search should be made for every departure from the normalthroughout the entire system . I further bel ieve that the personal
equation of the operator to the patient i s important . As to the
extraction in the capsule involves more immediate risk but offers
a greater eventual prize . Beyond this the discuss ion should dealw ith the personal talents of the Operator : ambidexterity , thechoice of certain knives , forceps and scissors , because of s ize and
suppleness of the hands,o r the r everse
,plus the acuteness of the
tac ti le sense . We differ so much in these respects .
For instance , I never make the combined operation unless
compel led to by untoward events in the performance . The cos
metic effect i s no more a factor in this than it should be ; the real
reason being that in spite of a tac tile sense , pronounced by one
of my teacher s “above the average,
” I have never been able toacqui re a satis factory technique for the management of the cutiri s . Again I r emove retained cortex mor e easily by lavage
,which
i s routine practice,than by manipulation . I have tried several i rri
gator s,but Reik ’s suits me best .
A l l in all the subj ect seems to me to be a question of adapta
b ilities more than princ iples . The operator w ith only the averagetacti le sense w i l l p ronounce the Smith operation unsati s factory ;and the operator w ith large fingers w i l l be handicapped like thegynecolog ist w ith shor t fingers ."There are many steps in the extraction of seni le cataract upon
which there is general agr eement among Operators . There can
be no question about the advisabil ity of thorough preparation .
Well begun is hal f done” i s t rue here i f anywhere . The need is
not so much the teaching of such thorough p reparation but theconsistent follow ing out in p ractice .
“A smooth incision promotes a smooth heal ing ,
might wel l become a surgical adage .
The fewer the number of movements of the kni fe the be tter , i fthis result is to be obtained . The less cortical material le ft in
the eye the better . This means either maturity of the lens or the
Smith Operation . The less anterior capsule left in the eye the
less the need of a secondary operation . This again means theSmith operation or the removal of anterior capsule . The loss of
v itr eous i s an acc ident which w e all t ry to avoid and al l agr ee thati t menaces the integr ity of the eye in propor tion to the quantitv
lost . The danger of such 10 5 5 must be greater in the intra-cap
The c leansing of the incisionThe coaptation of the lips of the incis ionThe c leansing and irrigation of the conjunctival sac .
D iscussionC OMPL I C ATIONS A N D AFTER -TR EATM ENTSpeculumT he sectionThe iridectomyC apsulotomyDel ivery of the lensL oss of v itr eousProlapse
,incarceration and enlargement of i r is
I r ido-dialys isC ollapse of the corneaT he bandageStr ipped and latticed keratiti sDetachment of the ci l iary body and adj acent choroid .
Sub -choroidal hemor rhageIriti sD iabetesAl buminur iaA fter-cata rac tGlaucomaIn fectionsD i scussion
