Operations On The Iris And The Crystalline Body

Operations On The Iris And The Crystalline Body
By HERMAN KNAPP, M. D.,
OF NEW YORK.

General Precautions. The patient should be free from acute disease and from exacerbations of chronic general disease. The time of the year makes a difference only in so far as constitutional infirmities are influenced by it ; for instance, fat persons should avoid the hot season, patients with pulmonary and kidney disease the coldest Winter months, etc. Cleanliness of the skin and hair, as well as regularity of the bowels, should receive due attention.

The operations on the iris and lens can be most conveniently performed on an operative chair, which can be moved (on casters), so that the best illumination of the eye, either by day or by artificial light, earl be readily secured and disturbing reflexes avoided. For cataract extraction it is of advantage to operate on the patient in his bed, if the bed can be moved to the source of light, because the patient will not be disturbed by taking him from the chair to his bed. This advantage is counterbalanced by the greater case the surgeon and his assistant enjoy when the patient is placed upon a chair.

The patient should keep as quiet as he can during the first twenty four hours after the operation, for quietness is an important factor in obtaining primary union of the wound. He may, however, sit up in bed for his meals and get tip for calls of nature. In case he is not nervous and his attendance good, the degree of success of the operation will be greater if for one or several days both eyes are bandaged ; otherwise, the non operated eye may be covered with a patch which the patient occasionally may raise.

No septic condition should be present in any organ of the patient at the time of the operation ; in particular, the conjunctiva and the lachrymal sac must be free front suppuration. Chronic non suppurative disease of these parts is no absolute counter indication.

The operations should be done tinder aseptic conditions as perfect as we can have and make them. Immediately before the operation the eye and its surroundings are washed with soap, then with a I : 5000 solution of corrosive sublimate, with which also the edges and mucous surfaces of the everted eyelids are washed by means of pledgets of absorbent Cotton.

Cocain anesthesia is sufficient and preferable in most cases; only in children, nervous and unruly adults, and in cases of high eyeball tension, complete general anesthesia' should be administered.

Besides a nurse, the operator should have at his disposal two or three trained assistants one to take charge of the instruments, the second to hold the fixing forceps and cleanse the wound, the third to throw day or artificial light on the eye with a hand lens, which is indispensable in at least 50 per cent. of the operations.

The eyelids are kept open by a wire speculum that does not press on the eyeball, and is strong enough to prevent the spasmodic closure of the lids.

The eyeball is steadied with fixing forceps, the teeth of which are numerous and large enough to be firmly inserted into the episclera. They are provided with a catch that closes them fast, yet can be opened without a jerk.

OPERATIONS ON THE IRIS.

1. Iridectomy i. e. Excision of a Piece of the Iris. Its indications are twofold.

1. To Make a New Passage for the Pays of Light. Artificial or Optical Pupil. This is done

(a) When the natural pupil is more or less occluded by malformation or disease.

(b) When the axial portions of cornea or lens i. e. those situated right before or behind the pupil are so opaque or misshaped as to intercept the rays of light or cast on the retina a less defined image than would be formed by light passing through a peripheric portion of the cornea and lens. This is the case in closure of the pupil, and opacities, or abnormities of curvaiure in the center of the surfaces of the cornea and lens (keratoconus and lenticonus). An artificial pupil should, however, never be made before an examination with a stenopeic apparatus by dilated pupil has positively demonstrated that the new pupil will afford better sight than the old. This precaution applies particularly to macule cornea .

2. To Relieve and Cure Inflammations of the Eye and their Sequels. Antiphlogistic or Curative Pupil. This is done

(a) In chronic recurrent iritis, when broad or circular synechie impede or prevent the current of the aqueous humor from the posterior to the anterior chamber. The strongest indication for an iridectomy is furnished by the socalled crater shaped pupil, which when left alone will not only cause blindness, but the ruin of the eve by irido eyelo choroiditis, and may even have a prejudicial effect on the other eye.

(b) In all affections in which prolonged increase of eyeball tension is a pronounced symptom i. e. in primary and consecutive glaucoma.

(c) To remove tumors (cysts, sarcomata, etc.) and foreign bodies if they are located in the anterior part of the eye, and cannot be removed without sacrificing a piece of the iris. Foreign bodies in the iris formerly were never removed without excising the piece in which they lay imbedded.
(d) As a step in ripening immature cataract, and as a preliminary operation for subsequent extraction of cataract (see later).

(e) To remove prolapses of the iris after injuries and operations. When a patient consults us with a fresh wound through which iris protrudes, it may be left alone if the lens is not injured and the wound is not situated in the ciliary region near to and concentrically with the border of the cornea. In prolapses, which happen frequently after cataract extraction, the protruded iris is apt to swell, become cystic, and in all cases produce a high degree of astigmatism. In such instances clean removal of the prolapse, and, if the latter is not fresh, deep excision of the iris, is the best treatment. Also in recent prolapses of the iris through a corneal wound a clean iridectomy, if it is still possible, can appropriately be done. If the iris cannot be disentangled from the wound and the prolapse is let alone, we frequently see an undisturbed recovery, with permanently good sight, follow the natural, clean elimination of the protruded iris by a process of constriction of the base and snaring off of the protruded part.

The special instruments for iridectomy are a lance shaped (Fig. 392) or a small (v. Greets) cataract knife (Fig. 393); an ordinary iris forceps, curved (Fig. 394), or its modification by Alatbieu (Fig. 395) ; a pair of curved (Fig. 396) or straight iris scissors; a metal spatula and flexible probe (Fig. 397) a blunt hook (Tyrrell's) (Fig. 398).

EXECUTION OF THE OPERATION.

1. Opening of the Anterior Chamber. Suppose that the surgeon has to perform an upward iridectomy, the most frequent case. The patient is reclining on the operatingchair near a window or an Argand gas lamp. An assistant throws light on the eye with a hand lens. The operator, standing behind the head of the patient, separates the eyelids with a wire speculum, steadies the eyeball with the fixing forceps, which he holds in his right hand ' the thumb near the button of the catch, the second and third fingers on the other branch of the forceps opposite the catch. With the lance shaped knife, which he holds in the same way as the forceps, he makes an incision in the upper part of the cornea at or near its transparent margin (the limbus).

The point of the lance, applied at a point directly opposite to the implantation of the forceps, is thrust through the cornea, at first somewhat perpendicularly, then, when it has entered the anterior chamber, which is recognized by the bright luster the blade assumes, it is pushed forward in a direction parallel to the plane of the iris as deeply as the intended size of the incision requires. Now it is withdrawn slowly, advancing the point toward the cornea as the aqueous escapes. This maneuver should be executed with a steady hand, so that the blade of the knife advances as if moved by machinery, and avoids injuring the iris and the lens capsule on the one hand or the cornea on the other. Wounding the capsule would produce cataract, and grating the posterior surface of the cornea mostly leaves an indelible streak.

It is necessary that the tip of the knife be sharp and flexible, otherwise we may have difficulty in pushing it through the tough lamella of the cornea. Afraid of wounding the iris, we have a tendency to lower the handle of the knife; the tip, if flexible, becomes curved, with the concavity toward the iris, and can only with undue force be moved forward.

2. Excision of the Iris. The operator, entrusting the fixing forceps to the band of an assistant, takes a pair of scissors in the right and the iris forceps in the left band. He closes the forceps and introduces their branches into the anterior chamber as far as the pupillary edge of the iris. He opens the forceps, the iris passes between the branches; the operator closes the forceps again and draws the iris out of the wound (more or less of it according as a larger or smaller portion is to be removed), and cuts it off close to the cornea, the blades of the scissors parallel to the wound, or, if he wants to make a small 'incision, at right angles to it. In most cases the cutting can be done with one stroke; in some we may cut in two or three successive strokes.

The iris forceps should be delicate; the tips of the branches should close nicely and remain closed when the branches are pressed together. Some forceps close at the tip when only moderate pressure is applied, but under stronger pressure they close at a posterior point and diverge at the tip. This is a great fault, for the instrument, after having seized the iris, loses it again when the operator presses the branches more firmly together.

The tips of the branches should be carefully rounded off. They frequently have sharp edges, which make the points liable to engage in the tissue of the iris, drag it along, and produce irido dialysis and hemorrhage. Hemorrhage way also be produced if, while drawing the iris out, we exert not a straightforward, meridional traction, but a lateral one, which causes dialysis and rupture of' the large arterial circle of the iris.

3. Adjustment of the Lips of the Wound. No foreign substance, in particular no iris tissue, must be left in the wound. It disturbs the healing, and may cause, in consequence of the angular entanglement of the iris, very unpleasant irritative processes eystoid scar, corneal fistula, glaucoma, suppurative iritis, irido cyclitis, and sympathetic ophthalmia.

The adjustment of the lips of the wound can be made satisfactorily in most cases by passing a spatula over the wound, flat and at right angles to the line of the section, so that the columns of the coloboma are moved back into the anterior chamber. Should we fail to accomplish this by outward pressure, we must pass the spatula through the incision, push the stump of the iris back of the wound, and particularly stroke the iris out of the corners, so that the sphincter is clear in the anterior chamber at a good distance from the wound.

During and after the operation a few drops of a mild antiseptic may be dropped, over the line of incision and the cornea, as the latter, owing to the action of the cocain, becomes dry.

4. Dressing. Both eyes are covered with pieces of corrosive sublimate gauze, upon which are placed pads of absorbent cotton, which are held in position by the classic binoculus (double figure of eight bandage), and the patient is put to bed.

The recovery in the great majority of cases is without disturbance. The eye is inspected every twenty four hours, but need Dot be opened each time, unless some irregularity takes place. The patient is discharged in from seven to fourteen days, which, of course, does not mean that he shall have his full liberty so early.

Different Methods of Performing Iridectomy called for by Special Morbid Conditions. (a) Optical pupils should be small. The incision is situated 2 mm. from the limbus in the clear cornea, and is 3 to 4 mm. in length; the iris is seized with a Mathieu forceps (Fig. 395) or a blunt book (Fig. 398), and only the central portion excised. The coloboma should be situated where the optical conditions of the cornea as to curvature and clearness are best. If we have the choice, the situation nasally and a little downward gives the best sight.

(b) The glaucoma pupil should be large and peripheric, I mm. at least behind the limbus. In acute glaucoma with high tension cocain anesthesia is mostly insufficient and perilous; because the diffusion currents being directed peripherally, prevent the cocain from penetrating into the eye sufficiently to produce much effect. If the cornea be made tolerably insensible by it, the iris is not affected at all. The patient does not feel the corneal incision very much, but as soon as the forceps touch the sensitive iris be is apt to give a sudden jerk with his head ' which may drive the tip of the iris forceps into the lens. General anesthesia is to be preferred in these cases.

If one iridectomy in glaucoma gives only temporary relief, a subsequent one is better than a selerotomy (compare with page 570).

Glaucoma occurs in about 1 per cent., after extraction of primary or discission of secondary cataract. If instillations of a myotic eserin I per cent., solution or pilocarpin 2 per cent. do not cure the attack, an iridectomy is sure to succeed (probably also a paracentesis of the anterior chamber). The iris in such cases, as in all aphakial eyes, frequently escaping the ordinary forceps, should be seized with Mathieu's or other forceps the teeth of which are at the lower surface near the tip, not straight at the tip. If even these (capsule) forceps fail, a Wunt book, passed into the pupil, will grasp the pupillary portion of the iris and draw it out of the anterior chamber, where it can be abscised.

11. Other operations performed on the iris are

1. Iridotomy is practised when, after a cataract operation, the pupil is closed and drawn toward the sear left by the wound.

The so called pince ciseaux of De Wecker (Fig. 399), a kind of cutting forceps, are introduced into the anterior chamber through a small corneal incision. The sharppointed branch is thrust through the iris, the other remains in the anterior chamber, and in this way one or two incisions are made through the iris and pseudo membranes that may be adherent to it. It successful, an artificial pupil can be obtained.

The author's personal experience is not sufficient to pass judgment on the value of this operation. After several trials, which were not very satisfactory, he has returned to

2. Irido cystectomy in such cases, which have become very rare in his practice.

An incision is made with a Beer's cataract knife (Fig. 400) through the cornea, iris, and the adherent thickened lens capsule; next a Tyrrell's hook, or one branch of a pair of capsule forceps (Mathieu's, Fig. 395) is passed into the opening in the iris; the edge of the iris is seized, drawn out of the wound, and cut off close to the cornea, The results of this procedure have in general proved successful.

3. Corelysis (synechiotomy), the detachment of posterior (Streatfeild) or anterior (Lang) synechie, has not been found sufficiently beneficial to be regarded as a standard operation.

4. The iridencleisis of earlier surgeons and the iridodesis of George Critchett, by which pieces of the iris were healed into a corneal wound, and thus the iris drawn away from a central opacity, have been abandoned in favor of the easier and, less hazardous iridectomy.

OPERATIONS ON THE CRYSTALLINE BODY.

The crystalline body, consisting of the lens and its capsule, gives occasion for two kinds of operative procedures which, as to delicacy and precision of execution and to brilliancy of results, are excelled by no other department of surgery.

A. Operations on the lens. When the lens becomes opaque in some way or other, either partially or totally, it intercepts the rays of light on their way through the pupil. If the lens is removed from behind the pupil, the object of the surgeon is obtained. This can be done b displacement, by extraction, or by solution.

I. Displacement at the present time is only exceptionally practisednamely, for certain forms of shrunken or secondary cataract. It is described by Celsus, and was used long before him. It was practised in two ways(a) by depression (keratonyxis). A broad needle was introduced through the lower part of the cornea into the upper part of the pupil, ,N liere by the raising of the handle it dislocated the lens into the lower part of the vitreous. (b) by reclination (couching, scleronyxis). The needle was introduced through tile sclerotic and lateral part of the lens into the tipper part of the pupillary area, from where, by a curvilinear movement, it turned the lens back and down into the vitreous.

The immediate results of displacement were often brilliant, but in most cases sight was subsequently lost by ascension of the lens, or by irido choroiditis and glaucoma.

II. Extraction also seems to be an old method, but has been systematically practised only since the French surgeon Jaques Daviel in 1845 rediscovered it. It soon obtained favor, and for the last forty years has been the chief operation for cataract.

The following instruments are required: A wire speculum (see Fig. 390); fixing forceps (Fig. 391), as for iridectomy; a narrow (v. Graefe, Fig. 393) or a triangular (Beer, Fig. 400) knife, with a firm, non flexible point, which, like the cutting edge, is of the utmost sharpness; a cystotome, the shaft of which may be straight or bent at an obtuse angle, in which case two are necessary one for the right, the other for the left, eve (Fig. 401), and the point of which, with its short cutting edge very fine and sharp, is to be cautiously handled in cleansing and sterilizing; a Daviel spoon, flexible (Fig. 403) ; a blunt (olive tipped) flexible probe (Fig. 397) ; a curved, flexible, and slightly grooved spatula (Fig. 397), and a wire loop, curved like a spoon (Fig. 404).

EXECUTION OF THE OPERATION.

First Step. The Corneal Section. The eve is cocainized. The operator, standing behind the patient, inserts the teeth of the fixing forceps firmly into the episcleral tissue, and makes the corneal incision with a narrow Graefe Knife held between the thumb and the index and middle fingers of the other hand. We suppose we have to extract, by a superior section, a hard, mature, senile cataract, the anterior chamber being normal dept. the knife pierce the cornea (puncture) in its transparent margin (limbus) slightly above the horizontal meridian, passes straight through the anterior chamber, and emerge (counter-puncture) on the other side at a point corresponding to the puncture. The section is continued by advancing the knife its whole length, and at the same time cutting upward without changing its direction, parallel and close to the iris, until it emerges at the upper end of the vertical meridian, where a small conjunctival flap is formed.

Second Step. The Opening of the Capsule. The cystotome is introduced, with its point backward, gently into the anterior chamber as far as the pupil; then its tip is pushed under the upper part of the iris, turned backward, and drawn across the capsule of the lens, so as to incise it 1 or 2 mm. below the equator, concentrically with the corneal margin. This maneuver requires some judgment in order to be sure that the capsule is opened without displacing the lens or rupturing its suspensory ligament, which would favor escape of vitreous during the operation and prolapse of iris later.

Third Step. Expulsion of the Lens. The speculum is removed; the operator takes the wire loop in one hand, and Device's spoon in the other. The patient looks steadily down; the convex surface of the spoon is applied to the lower portion of the cornea and pressed gently and steadily toward the centre of the eyeball, which causes the wound to gape widely and the lens to slip out gradually. When the greatest diameter of the lens has passed out of the wound the lower part is followed up with the spoon, so that the whole cataract is expelled. If during the expulsion the pupil does not dilate well and the upper part of the iris is pushed out bulgingly, the operator enlarges the pupil by pressing the bulging part of the iris backward with the wire loop.

Fourth Step. Cleansing of the Wound. During the operation and cleansing of the wound it is desirable to instil a few drops of an antiseptic solution, which will keep the eye wet and wash small particles away. Remnants of lens should be driven out by pressing with the finger the edge of the lower lid upward over the cornea. Neither the upper nor the lower lid should touch the open wound. Pieces of cataract lying between the lips of the wound must be removed with a well sterilized spatula. Also small particles of lens lying still in the anterior chamber can be stroked out with the spatula.

If the iris does not return into its normal position spontaneously or by gently pressing a few times the lower lid with the finger on the lower margin of the cornea, the tip of a blunt probe has to be introduced from the side into the anterior chamber and passed onward along the iris angle beyond the vertical meridian, in order to disengage the iris from the sinus of the anterior chamber, where it is crowded, and stroke it toward the center of the pupil. If this maneuver should not succeed or the iris should show a tendency to become displaced again, it is best to excise a small portion of it, and with a probe carefully push the corners of the defect out of the wound back into the chamber. Care should also be taken to stroke the conjunctival flap out of the wound.

Fifth Step. Dressing of the Wound. When the patient is put to bed the wound is inspected once more, and, if everything is satisfactory, both eyes are bandaged. A piece of sterilized gauze is put wet on each eye; upon it is placed a thin pad of absorbent cotton, the whole held in position by a roller bandage or strips of isinglass plaster.

The patient should lie quietly on his back as long as he feels comfortable; otherwise he may lie on the side of the non operated eye. It is advisable to give an anodyne to the majority of patients soon after the operation,

Modification of the Operative Procedure. The corneal section is placed more or less in the opaque border of the anterior chamber. This favors prolapse of iris and vitreous, as well as inflammations of the ciliary body.

The section is placed within the transparent cornea. This, by closing less accurately, tends to adhesions of the iris to the scar, especially at the corners of the wound, and is more liable to primary and secondary infection. The section is made downward. This section is less protected by the lids, and optically at a disadvantage if an iridectomy has to be made.

The opening of the capsule is made with a cystotome or a hook, extensively and in different directions. In this way the capsule is torn, not incised. It has the advantage that in a certain number of cases the shreds of the capsule are drawn to the periphery and leave a sufficiently clear pupil, but the laceration and promiscuous opening often cause posterior synechim, and Dot rarely more or less obstruction of the pupil by inflammatory' products which it is difficult and risky to deal with. The opening of the capsule by a peripheric incision permits as easy and complete an expulsion of the lens as the central opening, and tends much less to iritis and capsular deposits. If later we wish to give the patient permanently the greatest possible sight his case admits of, we can do it by a simple discission of the wrinkled but not thickened capsule.

A piece of iris is excised either before (preliminary iridectomy, Mooren) or during the operation for cataract (combined extraction, von Graefe). This is indicated in all the cases about 10 per cent. in which the natural pupil does not admit of an easy exit of the lens or in which the protruded iris cannot be reduced or is likely to form a subsequent prolapse. That combined extraction is a safer operation than simple extraction is an assertion not confirmed by the writer's practice (in more than 1000 carefully recorded cases of each method). Simple extraction has the disadvantage that it is followed by prolapse of the iris in 5 to 10 per cent. of the cases. This can be remedied without much trouble and danger by excision of the prolapse within 24 hours after its occurrence. In all other respects simple extraction is superior to combined extraction.

The expulsion of the lens can also be accomplished as follows:

Cataracts may be extracted with the ca sule. A. and H. Pagensteeber have tried this old operation as a general method, but bad to limit it to hypermature cataracts where the capsule is thickened and the zonula Zinnii frail or ruptured. For such cases it is the best method.

In soft and traumatic cataracts, including those produced by operative interference e. g. discission in excessive myopia, zonular cataract, etc., the so called linear extraction is appropriate.

With a lance shaped knife the cornea is cut to the extent of 5 or 6 mm. near its border, and the capsule opened by piercing it with the lance, or it may be lacerated with a cystotome. The soft lens substance is let out by backward pressure with the tip of the lance. If this is not sufficient, the posterior lip of the wound is pressed back by a wire loop, and as much of the cataract is coaxed out as will follow a moderate pressure. The reaction is mostly insignificant, but a subsequent capsulotomy is needed in most cases.

In tremulous and dislocated. cataracts, or when vitreous escapes before the, lens, the fixing foreeps and speculum should be removed immediately after the opening of the capsule and the lens expelled by pressing with the edge of the lower lid toward the center of the globe, while the upper lid is pressed gently on the sclerotic above, near the section. In this way the lens is moved into the wound, plugs the gap, and by a little additional pressure mostly comes out without, or with but little, loss of vitreous.

If, in exceptional cases, these external manipulations do not succeed, the lens has to be drawn out by a traction instrument a spoon, a curved wire loop (Fig. 404), or a sharp hook introduced behind the lens, beyond the posterior pole. The introduction of traction instruments should be avoided as much as possible.

For the cleansing of the pupil from remnants of cataract a Daviel's spoon has been used; the remnants also have been washed out with a syringe by injecting a very mild antiseptic lotion (irrigation of the anterior chamber). These procedures do not often succeed, nor are they free from danger. In expelling them by external manipulation care should, however, be taken lest by an unusual degree of pressure vitreous protrude.

Mistakes and Accidents during the Operation. Insufficiency of the corneal section leads to stripping off of the cortex and bruising of the wound, with deleterious consequences. Its presence is recognized if the lens presents in the wound, but does not advance. No forcible pressure should be used, but the section should be enlarged by a strong pair of strabismus scissors (those of Stevens answer well).

If the knife on its passage through the anterior chamber engages in the iris, or if the counter puncture is not at the right place, the knife should be drawn back and its direction corrected.

If the iris falls over the knife when the knife, after the counter puncture, is moved upward, in many cases the iris can be re dressed by turning the edge of the knife slightly forward; but if this fails to push the iris back, it is best to continue and to complete the section. The exsection of a small piece of iris does not much interfere with a good recovery.

Disturbances of the Healing Process. Profuse intraocular hemorrhage during or after the operation is followed by the ruin of the eye, do what we may.

Prolapse of iris is treated in the manner already described (page 576).

Iritis is treated as usual leeches, atropin, anodynes, etc.

Cyclitis with capsulitis, which mostly manifests itself in the second week by pain, marked, deep seated circumeorneal injection, with a round, clear pupil and good sight, is commonly tedious and requires patient treatment for from three to six weeks. Then the sclera gets white, the vitreous clears up, the capsule is more or less opaque, but the vision is commonly not greatly damaged, and can be improved by a subsequent discission.

Irido cyclitis, especially after combined extraction, is more deleterious. It lasts weeks, and sometimes months, damages sight greatly, leads to closure of the pupil, and dense pseudo membranes behind the iris. We should not tire in treating such cases, for not infrequently, even if sight is reduced to perception of light, a cystectomy will restore useful vision.

Irido cyclitis ruins, in rare cases, the other eye by sympathetic ophthalmia.

Suppuration may occur in the cornea, the iris, and the vitreous. In almost all cases it destroys the eye by extension to the deeper tunics panophthalmitis.

In some cases a corneal suppuration is limited to the lips of the wound and the adjacent parts. The result is partial preservation of the cornea, indrawn sear, and closure of the pupil. If the eyeball is not soft and the light perception good, an iridectomy may restore a moderate degree of vision.

Whether a beginning suppuration of the flap will be limited or progress to total destruction of the cornea seems to depend more on the nature of the individual case than on the medication employed. The author has not found that galvano cautery or any other means has a controlling, or even favorable, influence on the morbid process. Of the many modes of treatment recommended and praised, the best seems to be to open the wound and establish drainage of the anterior chamber by reopening the wound with a spatula once every day or oftener. Eyes with ring abscess and panophthalmitis are beyond rescue. Our endeavor should be to relieve the atrocious pain and establish a safe and non irritable stump suitable for wearing an artificial eye. This is best accomplished by poulticing and incisions giving free vent to the pus.

The result of cataract extraction is restoration of useful sight in about 95 per cent. of the uncomplicated cases, perception of light in 3 per cent., total blindness in 2 per cent.

III. Ripening Operations for Immature Cataract. A cataract may be mature i. e. opaque in all its parts and yet not in the best condition for extraction. This is the case when the lens is swollen by imbibition, which, through the shallowness of the anterior chamber, renders it difficult to pass the knife through the aqueous humor without injuring the iris, and to make the counter puncture at the right place. Usually in from three to six months the imbibed liquid will be absorbed, the lens will be smaller and compact, and the anterior chamber of normal depth. This is the time for the extraction.

On the other hand, cataracts may be immature and yet can be extracted easily and cleanly. This is the case when the nucleus is opaque and the transparent cortex pervaded by gray lines situated in the layers next to the capsule; or when the cortex is transparent, but the nucleus ambercolored, and the patient has reached the age of sixty years. Frequently enough in cataracts not coming under the above categories the natural ripening is so slow as to cause the greatest discomfort and render the patients unfit for work. Under these circumstances artificial ripening has been resorted to in different ways:

1. Opening of the capsule with a needle, as in discission of soft cataract (see later on). This is the oldest and perhaps most efficient method, yet it has the disadvantage of ripening the anterior cortex only, so that after the extraction we are surprised by finding a considerable quantity of lens matter left behind. This may not be the case if, as Schweigger recommends, the discission goes deeper into the lens substance.

2. Iridectomy and trituration of the lens by rubbing a blunt instrument over the cornea (F;5rster).

3. Paracentesis of the cornea and trituration of the lens with a blunt probe (Born), spatula (Sasso and Piscaldi), or trowel (B. Bettman) introduced into the anterior chamber.

4. Paracentesis of the cornea and trituration of the lens through the cornea (T. R. Pooley, J. A. White).

The writer has used some of these methods, with little satisfaction. He advises his patients to wait till Nature ripens their cataracts which she always does harmlessly and if they cannot wait, be in most cases would rather remove an unripe cataract (provided the anterior chamber is Dot shallow), and deal with the remnants later, than subject the patients to preliminary ripening procedures, which are unreliable and require operations for secondary cataract not less frequently than where immature cataracts are removed.

IV. Discission of the lens is indicated
1. In all cataracts of young people up to fifteen years of age..

2. In soft cataracts of adults as long as there is no bard nucleus. In these the discission has frequently to be followed by extraction on account of the advent of glaucoma.

3. In transparent lenses in younger people suffering from excessive myopia, 16 D. and over.

Instruments. Fixing forceps, a discission needle, or small knife needle (Fig. 405).

The execution of discission varies under different conditions.

For division of soft, zonular, and partial cataracts the operator chooses a short knife needle, thrusts it through the cornea midway between center and circumference, and through the capsule, 2 mm. beyond its center draws it back to make a horizontal incision of 4 mm. through the capsule; then he rotates the instrument 90', transfixes the capsule 2 min. above the horizontal incision and cuts down into the horizontal incision; now he turns the needle 180', transfixes the capsule 2 mm. below the horizontal incision, and cuts upward into the latter. In this way the capsule is opened by a crucial incision of 4 mm. in either direction. The cuts should be superficial, lest the lens by too rapid imbibition swell too much and cause glaucoma. Yet a small particle of lens substance may be pushed with the needle into the anterior chamber, for small and superficial openings of the capsule may close again and have no effect. In most cases the discission has to be repeated several times, and the last time the posterior capsule should be divided, otherwise it will by wrinkling and dotting obstruct the pupil subsequently.

For the removal of the transparent lens in cases of excessive myopia the same precautions and repeated operations have been made, but Dr. Fukala, the chief advocate of the 11 operative treatment of myopia," now recommends breaking up the letis in the first operation by extensive discission, soon to be followed by extraction. The writer has no personal experience in removing the transparent lens in myopia. The operation has been practised of late by a number of eminent European oculists, and, on the whole, favorably com¬mented upon. It is like operating on zonular cataract, and said to have no influence on the fund ' its changes. Hemorrhage in the vitreous and detachment of the retina have been noticed after the operation. In a large Dumber of cases the visual tests after the operation have discovered a remarkable increase of the sharpness of vision (see also page, 224).

B. Operations on the Capsule, the so called Secondary Cataract. For secondary cataract many operative procedures have been recommended.

1. Discission is indicated for all obstructions of the pupil that can be cut with a small knife or a needle. It is rarely that the capsule, when partially or totally left in the eye, remains permanently clear; it wrinkles, dots, and thickens, diminishing the vision more and more. Discission should be done if the vision is less than 20/50.The best time to do it is from six to twelve weeks after the extraction, when all irritation has passed and the capsule has not yet become thick and tough. It can be done, however, at any later period. For many years the writer has operated in the following way:

The eye is cocainized, the pupil dilated. An assistant throws the focal point of an intense pencil of light (Argand gas burner, incandescent gas, or electric light; large hand lens) on the capsule, leaving half of the cornea, through which the operator looks, unilluminated. The operator has previously examined the eye with focal light and the ophthalmoscope to ascertain how much diminution of sight is attributable to the capsule. If he gets a clear image of the fundus, cystotomy is out of the question; further, he has to find out where the capsule is least tough in order to determine where and in which direction it should be split. The plan of the operation is the same as in discission of soft cataract (see above).

A straight knife needle with a sharp point, a sharp cutting edge and a rounded back is used. The blade and shaft should be so proportioned that the shaft just fills the wound made by the blade. Sickle shaped needles do not readily stab the delicate, elastic, and readily escaping pieces of capsule when the first incision has been made. Needles of so little width as here required cannot be made sharp if they have two cutting edges instead of one and a back, as on a knife. With a well made knife needle three incisions can be made without escape of aqueous humor or bruising of the edges of the puncture canal in the cornea.

The capsule must be divided by two incisions (no tearing), T shaped; sometimes three incisions, +, crucial. Bands offering resistance must be left alone; it suffices to clear the space beside them. The needle should not be entered more deeply into the vitreous than is necessary to split the capsule. The incision should be effected by the simultaneous movement of a lever and a knife which is gradually withdrawn, the corneal puncture being the fulcrum. The handle of the knife needle is to be held between the brawn of the thumb on one side and that of the index and ring fingers on the other, so, that an axis rotation of 180' can be easily and securely made. If by some accident or other the splitting of the capsule has been insufficient, no harm is done by introducing the needle again, from another point of the cornea, in the same sitting or later on.

The reaction of this operation is mostly insignificant. The writer has done this operation seventeen or eighteen hundred times and never lost an eye by it, and rarely ever damaged one. Suppuration has never followed, but glaucoma occurred every now and then ' in about 1 per cent. of the cases. It has, always been cured by a myotic or an iridectomy. The results for sight have been most satisfactory, and the sharpness of sight, once acquired, was not lost again by a disease that was in causal connection with the operation, if exception is made of cases of subsequent glaucoma which were inaccessible to, treatment. The patients should be warned not to let themselves be deluded by the absence of discomfort during the first days, but avoid exposure and over exertion, and, should irritation occur, at once consult an oculist and have a myotic instilled or an iridectomy made if glaucoma be present. The cases are very rare, however.'

2. Cystectomy, iridectomy, iridotomy, or irido cystectomy should be done if the pupil is occupied by tough pseudo membranes or closed altogether. The operations are described before (see pages 577 579).

3. In cases of tough capsules a double needle dilaceration may be done. One needle is introduced with one hand through the nasal side of the cornea and thrust through the center of the lens, and held there; another is introduced with the other hand through the temporal side of the cornea, and thrust through the aperture in the capsule which the first needle has made. By approaching the handles to each other the points diverge, and tear a hole into the capsule without dragging on the ciliary processes. By this procedure we often succeed in making a permanently good opening in the capsule. It is not hazardous.

Operations on the capsule for secondary cataract are dreaded by many experienced operators, who have lost eyes (which had obtained useful vision through extraction of primary cataract) by the severest inflammations, including Suppuration and panophthatmitis. The reason why the writer thus far has escaped such sad experience probably is that he performs the extraction with a view to supplement it by a discission namely, in such a way as to exclude, as much as is in his power, any reaction that may lead to the deposition of inflammatory products in the pupil. This object, he thinks, is obtained, more than by anything else, by the peripheric incision of the capsule, which is rarely followed by iritic processes. His statistics of many hundred cases show the average acuteness of sight to be 20/30 before and 20/30 after the secondary operation. The latter is done in about 70 per cent., of the cases, and consists nearly always in a discission. In less than 2 per cent., has he had occasion to make another operation for secondary cataract.

The after treatment of cataract operations has been mentioned above in different places, the dressing on page 578, the operative treatment of prolapse of the iris on page 576. To prevent accidental injury, in particular iris prolapse, various kinds of masks are in use. Some masks imply danger by themselves, all are more or less uncomfortable, and many patients of the author have preferred to have their hands tied. It is advisable to inspect the eye the day after the operation and remove an iris prolapse, if there should be any, at once. The bandage may be removed from the non operated eye on the third or fourth day, from the operated eye several days later. The patient may be kept in bed for five or six days, old people less, for fear of hypostatic pneumonia. Attacks of mania are combatted by hypodermic injections of byoscin, gr. 1/100 pro dosi.

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