MICHEL LOUTFALLAH THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES BOUOHT OP Chicago Medical Book Co. Congress* Honorc Ms Chicago CATARACT EXTRACTION CATARACT EXTRACTION BY H. HERBERT, F.R.C.S. LATE LIEUTE.VAXT-COLOXEL. I. M.S., PROFESSOR OF OPHTHALMIC MEDICINE AND SURGERY, GRANT MEDICAL COLLEGE, AXD IN CHARGE OF THK SIR COWASJEE JEHAXGIR OPHTHALMIC HOSPITAL, BOMBAY NEW YORK WILLIAM WOOD & COMPANY MDCCCCVIII PREFACE / / THE writing of this book has been laboured ancj. slow. The volume embodies an experience of about fiv^fnousand extractions. This is a comparatively small experience for an ophthalmic surgeon of standing in India. But on this account the material has been, perhaps, more completely handled and investigated than if the numbers had been larger. In busy seasons Indian surgeons have barely time to perform their operations, and can see little or nothing of the cases afterwards. For years I have jotted down facts and ideas regularly as they came, and have developed them for teaching purposes, both in hospital and in the lecture theatre. The present work has, in a sense, grown out of an earlier publication ' The Practical Details of Cataract Extraction ' of which two editions were published in 1903. A large portion of Chapter J, and a few isolated paragraphs and sentences elsewhere, have been taken with little or no change into the new publication. But for the most part this larger effort consists of new material col- lected from a wider experience. An attempt has been made to present an up-to-date treatise, as complete as desirable from a practical point of view, and likely to be of service even to older surgeons who may have already formed their opinions and established their procedure. The historical side of the subject has alone been very imperfectly dealt with. NOTTINGHAM, June, 1908. CONTENTS CHAPTER I OPERABLE CATARACT PAGES Definitions Progressive cataracts Stages Varieties Lique- fying, shrinking, and hypersclerotic cataracts Complicated and traumatic cataracts Operability Artificial ripening Volume of cataractous lenses - i 22 CHAPTER II DESCRIPTION OF THE OPERATION Historical outline Instruments General arrangements Pre- paration of the patient Preliminaries Initial steps The combined operation The section The iridectomy The opening of the capsule The delivery of the lens Toilet of the eye The dressing After-course and after-treatment 23 1 59 CHAPTER III EXPULSIVE HAEMORRHAGE. VITREOUS ACCI- DENTS 160-177 CHAPTER IV VARIATIONS IN PROCEDURE, AND THEIR VALUE General preliminary and preparatory details Fixation The section Simple extraction Peripheral iridectomy Pre- liminary iridectomy Other modes of opening the capsule Intraocular irrigation The open treatment of the wound Extraction of the lens together with its capsule Asepsis Results - - 178280 vii viii Contents CHAPTER V AFTER-COMPLICATIONS PAGES The infective processes and non-infective reactions- Various forms of corneal opacity Exfoliation of corneal epithelium Anteflexion of the corneal flap Filamentous keratitis Conjunctivitis Acute dermatitis Spastic entropion Pro- lapse and incarceration of iris Prolapse and loss of vitreous Impaction of capsule Intraocular haemorrhage Delayed union and reopening of the wound Transient detachment of the choroid Mental disturbance Flatulent distension of the abdomen Secondary glaucoma After-cataract De- tachment of retina - 281 364 CHAPTER VI COMPLICATED AND SOFT CATARACTS Cataract with glaucoma Cataract secondary to irido-cyclitis Removal of the transparent lens in high myopia Dislo- cated lenses The extraction of soft cataract Suction 365 385 INDEX - ..... 387391 ERRATA Page 104, line 4, delete the article at the beginning of the line. Page 107, line 8, for " is " read " was. " Page 120, line 29, insert "is made " after " counter-pressure." Page 124, line 10, for final " by " read "of." Page 140, line 19, for "is " read "are." Page 142, footnote, for " adopted " read " adapted." Page 203, line 8, for "cubic millimetres " read "centimetre." Page 227, last line, for " nuclei " read " nucleus." Page 232, line 3, for " Von " read " Van." Page 237, line 34, for " overripes " read "overripe." Also a few ' split infinitives ' have escaped detection CATARACT EXTRACTION CHAPTER I OPERABLE CATARACT Definitions Progressive cataracts Stages Varieties Liquefying, shrinking, and hypersclerotic cataracts Complicated and trau- matic cataracts Operability Artificial ripening Volume of cataractous lenses. THE term ' cataract ' denotes opacity of the crystalline lens. Its nature and varieties will be entered into here only so far as appears necessary from their bearing on treatment. The term ' capsular cataract ' does not ordinarily indicate loss of transparency of the true capsule of the lens. It is applied to proliferations of the lens cells which normally line only the anterior capsule, but which, in some cataractous lenses, may extend around over the whole of the posterior capsule also. The new formations are within the true capsule, but are inseparable from it. ' After-cataract ' also spoken of as ' secondary cataract/ thus unnecessarily introducing confusion with cataract secondary to other diseases of the eye is the opacity which frequently interferes with vision after the removal of the lens. It may be capsular cataract in the above sense, or even possibly opacity of the true capsule, or there may be opaque cortex left imprisoned between the layers of capsule. The name is also less correctly applied to deposit on the front of the capsule i.e., strictly speaking, pupillary membrane. 2 Cataract Extraction / The cataract may be partial, affecting/ only .portions of lens substance, or general. Completeness/ or a near approach to it, is considered generally ynecessary for treatment by extraction of the lens, waicX is almost the only recognized measure* nowadays fc^r/lenses with hard nuclei, absorption of opaque lens matter being practicable in young persons with lenses still soft throughout. Progressive Cataracts, those which become general or complete, are classified thus : I. Primary, independent of other recognizable affection of the eye. This includes by far the largest group, the purely idiopathic cases, mostly senile, yet occurring at any age. Senility in this connexion is in India a very relative tejrn, since the cases begin to be numerous after fortyy^ars of age.t There are also the cataracts develop- ing in diabetes, nephritis, tetany, and ergotism, and glass-blower's and bottle-finisher's cataract. II. Complicated, or secondary to obvious disease of the eye e.g., in high myopia with disease of the vitreous and choroidal changes, and in late t stages of retinitis pigmentosa. Or due to advanced glaucoma, or to the effects of irido-cyclitis, atrophy of ciliary body, and posterior synechise. Or a result of dislocation of the lens. III. Traumatic, due to penetrating wound, or to rupture of the capsule. With these may be grouped the * Depression and reclination of cataracts, still very frequently per- formed by vaids axuMhakims in India' may in very rare instances be the only treatment/Vailable. r It is not true, however, of Bombay that " the majority of cataract patients come to operation at forty years or thereabouts" (Hirsch- berg, speaking of the East Indies generally, quoted in Norris and Oliver's ' System,' iv. 324). HnBombay there are, roughly speaking, twice as-many patients over fifty as under fifty years of aga Probably in the vjtense Jieat and glare of the northern plains of fndia cataract comes earlierJ % The few traumatic cataracts recorded without evident rupture of capsule have been paitial, and in some cases transient. Operable Cataract 3 lenses needled preparatory to removal in high myopia, or for lamellar cataract, etc. The Stages into which it is cfonvpnrient to divide the development of cataract are : /(i^Lncipient, (2) unri (3) ripe or mature, and (4) overripe. Cataracts are much more often allowed to become overripe in India than in Europe. It may be roughly stated that in the incipient stage they often require a dilated pupil or dark room examination for their certain detection for their dis- tinction, for instance, from simple senile sclerosis. Unripe cataracts are at once recognizable with the naked eye, but there is still some transparent or semi-transparent cortical matter remaining. In the ripe stage the whole lens looks opaque. Overripeness is shown by certain secondary changes, and by the formation of capsular opacities, recognizable by being whiter than any super- ficial opacity of lens substance. The term ' ripeness,' indicating complete opacity of the lens, implies also that the whole lens can be removed from its capsule easily, " like a ripe fruit out of its shell," and that the cataract is therefore ready for operation. The term is still retained to denote the fullness of the cataractous change, though it has long been recognized that many lenses are fit for removal while still preserving much of their transparency. According to Hirschberg,* this style of indicating the stage of the cataractous process originated before the operation of extraction was known at a time, therefore, when lenses were merely depressed. The Varieties of cataract formation are not so clearly separable, combinations and connecting-links serving to fill in gaps between the different typical degenerations. And attempts which have been made to classify cataracts from clinical appearances alone have led to some con- fusion, owing to failure to distinguish between stages and * Cbl.f.pr. A., xiv (1890), 210. I 2 4 Cataract Extraction processes. Yet clinical grouping is decidedly useful to indicate important practical differences in the shape and size of the lens, and in the consistence and cohesion of its substance, and in the elasticity and toughness of the capsule. A sufficiently clear distinction has not been maintained between the processes at work in senile cataract forma- ^ *^ tion. Three ma"mtypes of change are clearly recognizable the first progressing through liquefaction towards ultimate absorption ; the second leading, by slow shrinkage of the lens, to the formation of a more or less flattened disc enclosed in very opaque capsule ; the third forming the comparatively uncommon black cataract. These divisions are the same as those made by A. Graefe* in 1884, but they read differently, because he did not follow the changes in their various stages. I. Liquefying Cataracts. We have been long familiar with the changes which, in traumatic cataract, follow from the simple admission of aqueous through a rent or cut in the capsule. Bluish - white opacity, swelling, softening, breaking down and disappearance of non- sclerosed lens substance takes place. In many idiopathic cataracts similar changes are so early and pronounced that they constitute the main clinical features. But the fluid which gains an entrance, and in which the broken-down cortex is suspended, remains for long unabsorbed. It does not disappear rapidly, as in traumatic cataract, where the opening in the capsule precludes an accumulation of fluid contents, i It seems that the admission of aqueous may be due to degeneration of the capsular epithelium, for similar changes are brought about in Forster's ripening of cataracts by trituration of the lens, which trituration has been shown \ * A.f. 0., xxx. 4, 211. Operable Cataract 5 rabbits) to result primarily in breaking down of the epithelial cells. And in some advanced stages of this form of cataractous degeneration Complete disappearance of the cells lining the capsule has been observe^. The incipient stage of each variety of cataractous change does not concern us here. In the typical unripe lens of this class the anterior chamber is frequently shallowed, owing to swelling of the lens, and possibly also to an alteration in the shape of the lens. It may become more nSarr3r~spherical by distension of the capsule and softening of the contents. The rounded apices of opaque bluish-white glistening sectors of varied breadth are seen within the normal pupil, separated by a little clear cortex. Since the opacity affects the superficial fibres of the lens, the iris throws no shadow. There are other cases less typical, in which the anterior chamber is less often shallow, and the soft cortical matter is uniformly clouded and dull. The ripe stage of this form of cataract appears to be a short one, as it is not very frequently seen. In the overripe stage there is definite liquefaction, at first of the superficial cortex only, but soon involving the deeper cortex, and eating away more or less of the nucleus also. Thus we get the Morgagnian cataract, with nucleus floating free in milky fluid. The nucleus may be small, transparent, and amber -coloured, or larger, dark, and opaque. The capsule is either quite transparent, or there is faint diffuse opacity only, or this with numerous small brilliantly white dots.* The opacity may be limited to the anterior capsule or may extend more or less over the posterior portion also. The anterior chamber may still * These discrete opaque points were found exclusively in our practice in Morgagnian cataracts, and in lenses which had passed through the Morgagnian phase. Occasionally some capsular opacity develops early, when the cataract is barely mature. 6 Cataract Extraction be shallow, and actual measurements taken in Bombay show that /some Morgagnian lenses are above the normal in volume) But absorption of the milky fluid tends to gradually progress until nothing remains but the nucleus in the collapsed capsule. /Very rarely the nucleus disappears entirely, in adults beyond middle ageA while the sac is still distended with fluid. The fluid tnen has a creamy tint. In India the overripe stage of congenital or infantile cataract is not rarely seen in children as a thin layer of milky fluid in an opaque flattened sac. In adults some of the very overripe lenses have still quite transparent capsules, others opaque. Some become tremulous, others do not. Those without tremor are not clinically recognizable through the undilated pupil. The capsule having retracted away from the iris, a narrow space is left through which a shadow may be cast by the iris. In our practice the nature of the cataract was some- times not known till an iridectomy had been made during operation, revealing a dark space above the shrunken nucleus. Opaqurcapsules are not only thickened and toughened, and therefore difficult to cut during operation, but are also inelastic. The edges of any opening made in the membrane at the time of the cataract extraction or later tend to come together again. Apart from these shrunken overripe lenses and from sub- luxated lenses, marked tremor of the lens may be taken to indicate possibly both fluidity of vitreous and atrophy of zonule. In the cases now dealt with there may be no notice- . - j able/softening of the vitreous, and, where liquefaction is present, the change may be confined quite to the anterior portion of the humour, and may, perhaps, be explained by the repeated impact of the shaking lejj/ Atrophy of the zonule is com- monly assumed also, but I do not know upon what grounds. The tremor is sufficiently explained by the loose state of the almost empty and inelastic capsule. I have a strong impres- sion that in the cases where only the nucleus remains in the Operable Cataract 7 sac, and where yet the lens is not tremulous, the capsule is always, or at least generally, transparent, and therefore pre- sumably still elastic. ^In the overripe stage of the second variety of cataract formation mentioned above the shrunken disc there is, according to our experience, never any tremor. These lenses have not passed through any swollen stage, during which the elasticity of the capsule might have become reduced by over-distension. II. Shrinking- Cataracts. In most cataracts at a very early stage, and in many throughout their whole course, there is no evidence of an excess of fluid within the lens. On the contrary, when the degeneration is well advanced, the cortex is distinctly firmer and apparently drier* than normal. A slow progressive reduction in size takes place. Priestley Smith showed that in incipient cataract the lens is commonly reduced in bulk. In the later stages the shrinkage is often very striking. In patients of middle age and under, in whom nuclear sclerosis is not very advanced, the shrinkage tends to be especially noticeable antero-posteriorly. It may be stated generally that this progressive loss of substance and loss of transparency this evidence of defective nutrition of the lens as a whole may pass through its whole course uncomplicated ; but it is liable to be modified at any stage by the addition of changes recognizable as due to the admission of fluid, indicating probably, as above stated, diminished resistance of the subcapsular cells. Thus the frequent blending of the two types, rendering rigid classification impossible. The typical unripe cataracis^een through the pupil have usually a diffused greenish appearance, perhaps tinged with olive from nuclear sclerosis. In a few cases the opacity is greyish, but is then quite deep nuclear or * This may be shown in the staining and decolouring of micro- scopical sections. 8 Cataract Extraction perinuclear. There is a quantity of perfectly clear cortex, through which a very distinct shadow is thrown by the iris. This deep central uniform cloudiness may remain with but little change for years, affecting vision greatly from its position, but remaining quite unfit for operation. In other eyes the (greenish) opacity comes well up to the iris, but it is so slight that a faint shadow is transmitted from the iris through the superficial layers of the lens. The transparent appearance of such a lens after removal is remarkable ; there may or may not be a small central haze or cloud of opacity noticeable (after removal). The superficial layers, though so clear, are fairly firm and coherent, and shell out easily entire. In the ripe stage these lenses vary considerably in size and appearance. The diminution in size, especially in thickness, varies inversely with the degree of nuclear sclerosis, and therefore to a large extent with the age of the patient. A broad thick disc may result, with sharp edge ; but more frequently the contraction is lateral as well as antero-posterior. The nucleus ranges from opaque white or cream-coloured in a few rather young lenses with defective sclerosis, through the average smoky brown, to the larger dark hypersclerotic nucleus. The lenses with whitish nucleus may appear perfectly ripe clinically, while on extraction the equatorial rim of cortex may be found quite or nearly transparent. This thin transparent or translucent rim is, however, firm, and separates whole from the capsule. In other lenses the distinction between nucleus and cortex is not very evident ; the loss of trans- parency seems uniform throughout, but very incomplete. There may be fine superficial radial slits or cracks on the anterior surface. The overripe lens is remarkable for its flattened discoid shape, and often for its small size ; also for the amount Operable Cataract 9 of capsular thickening and opacity that develops, often with a large anterior central untearable patch, possibly containing lime deposits. What remains of the cortex consists chiefly of a broad equatorial ring, cream-coloured and coherent, but separating readily from the nucleus. The latter varies in size and colour, as in Morgagnian cataracts, but it is commonly rather larger and less clear. Its colour is seen clinically through the scanty remains of anterior cortex. Very rarely the nucleus may have disappeared, only scanty cheesy cortex remaining. III. The third variety of cataract formation is a very slow hypersclerosis pathological excess of the normal nuclear sclerosis by which almost the whole lens may become hard, dark, and considerably opaque. It is relatively common ir^rpyopir fiyej; In pure hypersclerosis the colour attained is finally pure black, after passing through a brownish-red tint, which, however, appears muddy only as seen through the pupil clinically. These lenses are always large, but an exact comparison of their volume with the normal at given ages yet remains to be made. Since there may be always a trace of normal cortex at the surface, capsular opacity is very rarely present. VisiorKcommonly remains equal to the counting of fingers at a foot or more from the eye at least, with dilated pupils long after the cataract is ready for ex- traction. At any stage of the sclerosis the unaffected cortex may undergo the ordinary grey degeneration, resulting in one of the mixed forms of cataract. In possibly half the primary cataracts seen in Bombay the second form of change persists alone. There is pro- gressive shrinkage and pacification. There may be abnormal proliferation of lens cells, producing dense capsular opacities, but little or no excess of fluid enters the lens. Taking the final results only, Morgagnian io Cataract Extraction cataracts are much commoner than overripe cheesy discs ; but this represents the greater rapidity, rather than greater frequency, of the liquefying process. A very late combination may rarely be seen in an overripe cataract, partly fluid, but containing also a coherent equatorial ring of cortex. An earlier combination is sometimes clearly seen in fairly young patients well-marked whitish nuclear opacity, together with ripe, soft, flaky cortex. On rare occasions the two types of degeneration may be seen in the one patient typical shrinking cataract in one eye, liquefying in the fellow eye. Duration of the Changes. The most rapid formations are the swollen liquefying ones, as, indeed, one expects from a slight acquaintance with traumatic cataract. In a month a great change may take place in such lenses. To go to the opposite end of the scale, we have the deep central haze and hypersclerosis, both extremely slow, perhaps changing very little in the course of several years. To formulate a rough-and-ready rule, one may say : the deeper the opacity, the slower it will be ; the more super- ficial the change, the faster it will progress. COMPLICATED AND TRAUMATIC CATARACTS. In the incipient cataract of advanced chronic glaucoma a centraKhaze is very often the only form of opacity. Cataract secondary to choroidal and vitreous changes is apt to remain long limited to the posterior surface. In- cipient cataract, developing in a highly myopic eye, is classed as secondary if there be disease of the vitreous ; it may be of very slow formation. When too advanced to allow the fundus to be seen, a limitation of the field of pro- jection would suggest detachment of the retina, especially if the tension of the eye were low, and would contra- Operable Cataract 1 1 indicate operation. Traumatic cataract uncomplicated with severe irido-cyclitis affords the purest type of the swelling, liquefying degeneration. The result differs from that of primary liquefying cataract, in that more ready means of absorption is provided for broken-down lens substance ; but the soft plentiful incoherent cortex, and the swelling of the lens are the same in both. It stands in direct contrast with some of the shrinking cataracts, where the opacity may be at first entirely deep, and where the evidences point to a lack of moisture rather than to an increase of it. OPERABILITY. The question with which we are immediately concerned is whether a progressive cataract is fit for extraction or not. The rule in the Cowasjee Jehangir Hospital is to insist on threeteea^c'onditions only, with moderate general health. i. The cataract must be ripe enough. Complete maturity is not required in either of the types of cataract for- mation. The shrinking lenses with cortex firmer than normal are often fit for operation when the patient can count fingers four or five feet distant. Immaturity entails an iridectomy as part of the operation (a preliminary iridectomy in Critchett's practice), a full-sized incision, and very slow expression of the lens. The very shallow anterior chamber found with some unripe swollen lenses constitutes a difficulty, but not a serious one. Schweigger * and Hirschbergf pointed out that incompletely opaque lenses could be removed satisfactorily from the eyes of old people. Schweigger found that certainly after sixty years of age, and possibly a little earlier, operation might be indi- cated while the greater part of the lens was still transparent. * Cbl.f.pr. A., xiv (1890), 206. t Ibid., 210. 12 Cataract Extraction Hirschberg fixed the age limit even lower at fifty years. Beyond/this age the lens might be" extracted as soon a~3~ the opacity troubled the patient seriously or prevented him earning a livelihood. In Bombay we have found that the lenses fit /or extraction could be distinguished by their appearance. / They include many lenses with cortex only slightly opaque :/but the opacity, such as it is, is quite recognizable in the mos/superficial layers, and is greenish UKtint. These lenses have to be distinguished from others unfit for operation, though the opacity is more obvious and affects the superficial layers. In these cases the opacity is greyish in tint, and some slight swelling of the lens may be shown by an anterior chamber a little shallower than that of the fellow eye. rtms greyish cortex is soft and sticky, and does not separate readily from the capsule) One must expect trouble with cortex also should one operate upon a swollen lens with glistening opaque sectors, while still trans- parent superficial cortex is to be seen in the pupillary area between the apices of the sectors. 2. The pupil should react well to light. This is accepted as a nearly certain guarantee that the fundus is sufficiently sound to justify operation. Should the movement of the pupil be impaired, the tension of the eye and the projec- tion of light in the dark room are tested. When sluggish- ness is due to glaucoma or optic atrophy or other fundus affection, each case must be judged on the available data. The field of projection is the main criterion, but it is often an insufficient one. More particularly where the other eye is lost or useless, one must operate if there is any reasonable prospect of obtaining vision beyond the mere perception of moving bodies, the patient being told before- hand of the uncertainty of the result. Very occasionally a disappointing result is obtained, in spite of a previously active pupil. In highly myopic eyes testing the field of projection may afford evidence of detachment of the retina, f Central choroidal atrophy is a not very infrequent source of disappointment.} If considered desirable, the function Operable Cataract 13 of the macular region might be shown in advance by testing the patient's ability to distinguish two ^small flames placed close together in the dark room. 3. There must be no inflammation about the eye, and no iritis^or irido-cyclitis of the fellow eye. If the other eye be atrophic and tender from past destructive irido-cyclitis following perforation of the globe, it must be excised. There must be no trace of scleritis^kej^litisj^tc., nor any scabby skin eruption close to the eye. The conjunctiva and lacrymal passages require particular attention. It may be broadly stated that conjunctivitis must be treated until there is no discharge, or, if this be not quite feasible, special precautions must be taken at the time of operation. ^-- ^ -" In Ipdia the average condition of the conjunctiva is much worse than in Europe and America. Various grades of the changes produced by chronic conjunctivitis are very common, trachomatous and otherwise. Very poor patients coming from a distance must be admitted at once or not at all, and beds cannot be spared for preliminary treatment. Thus there are constant demands for operation in the presence of more or less chronic inflammation. Experience has shown that, provided the secretion is only scanty and mucoidj scarcely any changes in the palpebral conjunctiva necjjflSan^Zelay m operating. We disregard papillary roughness, thickening, scarring, minute cysts, small follicles in the fornices, and scanty remains of confluent pale, lymphoid, trachomatous tissue. Occasionally, also, we venture to admit patients with rather freer mucoid discharge and rather marked congestion of the conjunctiva. This is done, relying upon the protection which we have found to be afforded by very free perchloride irrigation of the conjunctiva before operation. In European practice, on the other hand, the large majority of the patients' conjunctiva? are of practically normal appear- ance, and operation can almost always be postponed till the surgeon is satisfied with the condition. It is usual before operation to cleanse the conjunctival surface the ' field of i ut through a canaliculus. It is doubtless^safer to instil fluorescein, and to make the patient sit for three^tu frve minutes with head bent forward. If the nose be then 'blown,' the colour should be seen on the handkerchief. If none is seen, the lacrymal syringe must be used. Some surgeons invariably wash out the sac as a test for dis- charge and for obstruction of the nasal duct. Haab receives //the fluid which flows from the nasal aperture in a black-vessel // to show turpidity. Extirpation of the sac is to be strongly Operable Cataract 15 urged in all cases of dacryocystitis. After the extirpation the eye should be ready for operation in jj^ree wgeksor less. If this radical treatment cannot be carried out, ami if the dis- charge be scanty, and especially if it can be forced down into the nose by ,pr?sure onj:he sac, the puncta may be sealed with the galvan*J fjUA. vx. Cataract Extraction The state of the fellow eye may need a small precautionary attention. If the anterior chamber be very shallow, it will be wise to instil eseriry lest an attack of glaucoma be brought on by the excitement and general conditions appertaining to the operation. We had experience of a few such cases. Very rarely a cataract may be ripe for extraction, and yet the operation may be impossible. I once had to depress the Jens^ in each eye of a patient with extremely small corneas a congenital defect associated with coloboma of the iris. When one eye has been lost from profuse intraocular haemorrhage complicating cataract extraction, it is a question whether reclination should not be preferred in the second eye (see Chapter III). The possession of good sight in one eye influences the question of operation on the other eye, only in so far that it permits of waiting for complete ripeness of the cataract without serious inconvenience. The cataract must not be allowed to become hypermature, because it is then in a less favourable state for operation. After the extraction, although both eyes tdo not work together, there is the advantage of the larger field /^ of vision, and the patient has the satisfaction of being provided for during the anticipated slow onset and progress of opacity in the fellow eye. /I? has been argued" that until our methods improve so that" we can guarantee the fellow eye against loss by sympathetic ophthalmia, we have no right to operate while the fellow eye has useful vision.] The improved results obtained nowadays by a number of operators show that it should be quite possible to guard against sympathetic ophthalmia, especi- ally where patients can be kept under observation and treat- ment for a sufficient length of time after operation. In India, if we did not operate upon all cataracts ready for extraction, we should drive many patients into the hands of the travelling quacks. It is almost universally held to be unjustifiable to extract cataracts from both eyes of a patient at the same time. The possible loss of both eyes is too appalling a risk to run, and the danger from mental derangement, coughing, sneezing, etc., is more serious. Operation upon one eye may show the need of special precautions in dealing with the second eye. Finally, V* See, for example, Devereux Marshall in The Ophthalmoscope, iv (1906). Operable Cataract 17 one eye alone may after operation stand in need of atropin instillation to the full extenj, that the patient can bear con- stitutionally. The doubleT)peration is, however, still performed occasionally under the peculiar conditions of district work in India. Hnnsell* considers it justifiable, and even desirable, under certain circumstances. As regards the general health, very little is exacted. We never refused operation on account of diabetes. A little preliminary treatment and regulation of diet appears advisable. We operated always with good result upon many patients with alburninuria, even with moderate oedema. t But we feared cases with anaemia and con- siderable oedema. We refused cases, also, of simple extreme anaemia. Asthma, emphysema, and chronic bronchitis are not centra-indications, though they pre- dispose to prolapse of iris,t and more definitely in my experience to slight iritis and to haemorrhage into the anterior chamber. " Alleviation of dyspnoea and cough is, of course, desirable, and the patient cannot be kept recumbent after operation. Snellen treats a liability to [ constant sneezing by placing wool soaked in cocain I solution within the nares. Extreme age of the patient is no bar to operation, though it imposes the need for particular care afterwards. The same may be said of insanity and of moderate degrees of epilepsy. Leprosy, also, is not a centra-indication. Absolute deafness is a minor trouble. Suppurating processes, ulcers, etc., should be cured, or at least got into a satisfactory condition, if * Ophthalmic Record, December, 1903. f We were careful always to restrict traumatism by operating with gentleness and rapidity, fearing iritis ; and we sometimes operated sub- conjunctivally, feeling that the tissues of these eyes could offer little resistance to microbic invasion. (Ueutschmann saw two suppurations in seven extractions in albuminurics.^ The prognosis must be guarded also, on account of possible fundus lesions present. + Iridectomy hence imperative in these cases. 1 8 Cataract Extraction only on account of the bare possibility of a pysemic con- dition setting in and causing metastatic inflammation in the temporarily weakened tissues of the eyeball. Operation must be deferred if there is fever, of whatever origin, or recent syphilis ; also on account of menstruation or advanced pregnancy. Age of Patients. A few lines must be added regarding the age of the patient at which extraction becomes admissible. ' Linear extraction,' in which the lens is coaxed out piecemeal through a so&ll incision made with a keratome, is commonly preferred whenever practicable, to the ordinary 'flap ex- traction,' in which the lens is expressed whole or nearly whole. The former method is applicable regularly up to thirty years of age, and frequently ^somewhat later, since the absence of a hard nucleus is practically assured up to this age. But in Bombay we found that nearly all patients over twenty years of age had sufficient self-control to justify ordinary extrac- tion through a shallow flap section. The removal of the lens in bulk is commonly more complete, and is accomplished with less instrumentation and manipulation than by the linear method. At an earlier age the length of the incisionjs-ieduced as much as possibleTNm account of the want of self-control displayed by the patients both during and after operation, and possibly also on amount r>f more frpqnp.nt vitreous tension. Operation is mostly required upon lenses partly or completely transparent for lamellar cataract, or in the treatment of high myopia. Linea_r__extraction is preceded by one ormore ' needlings,' by which the lens substance is renderecTcataractous and loosened from its connexion with the capsule. The / extraction may be voluntary, as an expeditious alternative tcL/^ slow absorption, or it may be demanded by the onset of plus tension or inflammatory reaction, excited by the swollen and disintegrating lens. Some surgeons prefer primary incomplete extraction of the transparent lens, holding that the duration of treatment is shortened, and that the reaction from retained lens matter is likely to be less than that frequently experienced when the extraction is preceded by needling. In young thildren absorption by repeated needlings is aimed Operable Cataract 19 at, linear extraction, or rarely removal by suction, being under- taken as a rule only under compulsion from complications arising. ^tL^"' Cataracts treated in -infants are usually complete. The opacity must be removed as early as possible, to enable the functions of the retina and of the visual nervous mechanism to develop. At this age the shallow anterior chamber, and a difficulty in keeping the pupil dilated with the weak* atropin instillations admissible, are obstacles in the way of treatment by repeated needlings ; yet this treatment should be persisted I in, if possible. I have practised linear extraction under the age of one year, but in one case at least I regretted it. Ex- traction was performed in both eyes without preliminary needling. The cataracts were rather firm and wax-like, but were removed piecemeal with the aid of irrigation. The small incisions were subconjunctival, yet both eyes were reported to have suffered from persistent low inflammatory changes after- wards. There was an interval of some weeks between the two operations, and both eyes did well while under observation. The patient had been brought from a distance, and the relations were unwilling to stay for prolonged treatment by needlings. Extraction has been considered necessary* for this form of cataract, but discissions should suffice. THE ARTIFICIAL RIPENING OF CATARACT. Up to thirty or thirty-five years of age discission is the method adopted for rendering transparent lens matter opaque. To be safe and sure, ' ri pening,' by the admission of aqueous through an opening in the capsule, must be slow and gradual. The primary needling must be limited, lest by rapid swelling and disintegration of the lens high tension and irritation of the iris be excited. Extraction may then have to be undertaken with the posterior layers of the lens still transparent and adherent to the capsule, and with the eye congested and irritable. The extraction is incomplete, and more or less iritis ' frequently follows. But slow ripening by repeated needlings ' is very satisfactory in young subjects. (Stellwag, in 1886, tried discission of the posterior capsule.) Beyond the above-men- * See Czermak, ' Die Augenarztlichen Operationen,' p. 1094. 2 2 20 Cataract Extraction tioned age experience has shown that the eye too frequently resents the needling of transparent lens matter. It is between the ages of forty and sixty that the question of the ripening of progressive cataracts generally arises. Many surgeons apparently fix no age limit in their extractions of un- ripe senile cataract ; but others prefer Forster's ripening by trituration of the lens under sixty years of age. An iridec- tomy is performed, and the lens massaged by spoon pressure through the cornea. The ripening takes from oneNtr~6ight weeks, according to the condition of the lens and the dura- tion of the massage. Sometimes the treatment has proved insufficient, and various complications have been met with iritis, rupture of the zonule, or rarely of the capsule, and very rarely abscess of the cornea. But they all appear to be avoid- able by correct procedure. Individual operators have been able to report some hundreds of successful cases free from complication. The method is held to be contra-indicated by advanced atheroma (lest glaucoma be induced), and by choroiditis or fluid vitreous, and in some marasmatic patients. Preliminary iridectomy alone has proved effectual occasion- ally, but it cannot be depended upon. Massage through the cornea after simple' paracentesis has been fairly satisfactory. It has been combined with puncture of the lens capsule.* Direct massage of the lens with a small spatula after para- centesis has been preferred by Ricaldi, Bettmann, and others, to Forster's method. McKeown's and Jocq's attempts to ripen by injecting fluid within the capsule appear to have worked mainly as simple discissions. Wolff berg f has ripened cataracts with a hot-air douche, directed upon the closed lids by means of a ' kalorisator.' With two or three applications a day maturation was accom- plished in about a week. Maynard J thinks extraction in the capsule, as practised by Smith, often a very effective means of dealing with unripe cataract. ) * Fage, Ann. (FOcul., cxxix. f Woch, f. Ther. u. Hygiene des Auges, September 22 and October 6, 1904. % ' Manual of Ophthalmic Operations,' Calcutta, 1908, p. 55. Operable Cataract 21 THE VOLUME OF CATARACTOUS LENSES. Some years ago I measured a few lenses in their capsules in a Priestley Smith's lens measurer, immediately after extraction. The point brought out was that some of the cataractous lenses of the liquefying type, either Morgagnian or less advanced, were distinctly swollen beyond the extreme normal limits by the imbibition of aqueous. It is unnecessary to demonstrate by measurement the reduction in size which is seen in many shrinking cataracts. The measurements are given in tabular form, together with the extreme limit and the average bulk of the normal lens at the same age, as computed roughly from Priestley Smith's table.* But it is to be noted that the average normal Tetts of the native ^of Bombay is probably appreciably smaller than that taken from Priestley Smith's measurements in England, in correspondence with the poorer average physique in Bombay. * Reproduced in Norris and Oliver's ' System,' iv. 286. 22 Cataract Extraction tn C . aj ^ ^ * MJ^2"'^" iiJIJ < ,:AO. z O a'S ~ * a o- s 3 2 s " 3 3 " ~' < u-, < < < S- S x . gOJS-~7- .tJ -3 X g rj- IN. C> t^ O '* E | .32 S 6 fafi*.& z M * 1* M '* H ^ 'S ^j. l> e a a a I S I t^ _ i_ rrj _ c>vO r- if\ \o "-v\o r-^vo N CO OOO "1 1-1 CO OO "1 N "irOOrt-i-cOO N i-if* M M 1-1 1-1 C) M MNCSNNN : h c ::>::::: >^ :::::: -iN l/ " 1 ., ^^ rj- fO CO ^ - <* tX --uiiJio " "O^ " CO *^- in \o CD W CO W CO p O H O <: < H <: CJ fe O W. CHAPTER II DESCRIPTION OF THE OPERATION Historical outline Instruments General arrangements Prepara- tion of the patient- Preliminaries Initial steps The combined operation The section The iridectomy The opening of the capsule The delivery of the lens Toilet of the eye The dressing After-course and after-treatment. ROUGH GENERAL HISTORICAL OUTLINE OF THE DEVELOPMENT AND PROGRESS OF CATARACT EXTRACTION. THOUGH lenses dislocated into the anterior chamber had been removed early in the eighteenth century by St. Yves and P. du Petit, it was not till 1752 that Daviel published his method of extracting cataractous lenses from behind the iris, already tested in over 200 operations. Holding the lower lid depressed, he punctured with a broad needle at the lower corneal margin, and enlarged the opening at either side first with a blunt-pointed needle, and further FIG. i. BEER'S KNIFE. with curved scissors. Thus almost a semicircular flap was outlined. The anterior capsule was then simply opened with a fine lancet, or, if thickened, incised circularly and partly removed with forceps. The lens, after being loosened in its bed by the insertion of a narrow spoon between lens and iris, was delivered by pressure on the globe below, applied by the index and middle fingers through the lower lid. The manner of cutting the section was soon improved by the introduction of the broad triangular knives of Beranger, Beer, and others. With these a semicircular incision, placed 23 24 Cataract Extraction in clear cornea a little within the limbus, was completed in a single short thrust. The fairly frequent suppuration of the cornea met with was attributed then to the tendency of the flap section to gape, preventing early union. Hence followed attempts to extend the application of what became known as ' simple linear extraction,' originally employed only for luxated lenses. The slightly curved wound, made with a lance-shaped knife or keratome, was made as large as possible, and by von Graefe was placed near the upper margin of the cornea and combined with an iridectomy. But even so, it was found to admit of the easy exit only of capsular, shrunken, and soft cataracts, and of lenses with small nuclei and plentiful soft cortex, readily broken up. Critchett and Bowman (1864) increased the size of the wound, making a very shallow corneal flap section, but found it necessary to draw out the lens with the scoops which still bear their names. Jacobspn lessened the number of suppurations by the applica- tion of another principle. He returned to the lower semi- FIG. 2. JACOBSON'S INCISION. circular flap, but placed it further back behind the visible corneal margin, so that it lay partly in the sclerotic. He recognized that the vascular scleral tissue was less disposed to suppuration than the non-vascular cornea. The large size and peripheral position of the wound necessitated an iridectomy to guard against the tendency to prolapse of iris. Von Graefe in 1865 attempted to combine both safeguards against suppuration a linear wound and scleral position. The so-called linear extraction by incision with a keratome FIG. 3. JAEGER'S KERATOME. (' Lanzenextraction ') is not by a truly linear incision. The latter must lie in a plane perpendicular to the surface, in a Description of the Operation 25 corneal meridian, and such a section is obviously impossible with a keratome if made of any length. In order to ensure the closest possible contact of the wound sur- faces, von Graefe designed an incision approximating as closely as practicable to an arc of the largest possible circle, being, therefore, in line and plane as nearly as possible in a radius of the scleral curve. The lance knife had to be replaced by a narrow-bladed instrument for the new incision, at a consider- able angle to the iris. Hence the Graefe's knife, suited for transfixion by puncture and counter-puncture, which has long survived the operation which made its value generally known. With this knife a section was made with its centre close to the upper corneal margin, but its ends some little distance away in the sclerotic. In von Graefe's original incision the points of FIG. 4. VON GRAEFE'S INCISION. entry and emergence of the knife were situated a little over i millimetre from the cornea, and 1-5 millimetres below a tangent drawn through the summit of the corneal circum- ference. The plane of the section at its two ends was parallel to the iris surface, but for the rest of its extent nearly perpen- dicular to the surface of the globe. The knife edge had to be turned sharply forwards as soon as the globe was transfixed. This incision proving too short, it was slightly elongated and its curve increased, by lowering its ends. Its plane was thereby also a little altered, being directed more obliquely to the surface. In making the puncture the knife was always directed towards the centre of the pupil, to make the deep wound as large as possible. The position of the section necessitated the cutting of a short conjunctival flap. A large iridectomy was always made, and on this account the operation known as the ' peripheral linear,' was also known as the ' modified linear ' extraction, to distinguish it from the ' simple ' operation with- out iridectomy. The method had a great vogue for a number of years, largely replacing the old flap extraction. Though suppuration of the wound and panophthalmitis were 26 Cataract Extraction largely eliminated by this new method of operating, this advantage was counterbalanced by an increase in the number of deep infective inflammations and of sympathetic disease of the fellow eye. And there were smaller drawbacks. Greater skill was required than for the flap section, and there was often trouble from haemorrhage into the anterior chamber. The delivery of the lens through the narrow wound was often difficult. Owing to this and to the peripheral situation of the wound, loss of vitreous was not infrequent, and cystoid scars developed from inclusion of iris in the angles of the wound. Weber* attempted to avoid gaping of the section, both such as is liable to occur in linear wounds by retraction of the wound surfaces, and also that by forward displacement of a corneal flap. He endeavoured to make an almost linear incision large enough for the delivery of hard cataracts complete, in a plane FIG. 5. WEBER'S KNIFE. parallel to the iris, by means of a heart-shaped keratome curved with the concavity backwards. But the section, 10 millimetres long, was not sufficient for lenses with large nuclei. The instrument, perhaps, requires notice rather than the method. Used even earlier by Santarelli (in 1795) and by Jaeger (in 1866), it is again employed at the present day by Sattler for extraction of the transparent lens in high myopia. The feeling that Graefe's incision was too peripheral led to alterations in two directions. Many operators preserved the scleral site, but made the section more arched by lowering the ends of incision and bringing them closer to the cornea. Others preserved the linear character of the wound very largely, but, relying on antiseptic measures, displaced the section well into the cornea. Von Arlt and his pupils Becker, Fuchs, and others for long practised a section scarcely at all modified from von Graefe's. The puncture and counter-puncture were 2 milli- metres below the tangent of the upper margin of the cornea, * A.f. O., xiii (1867). Description of the Operation 27 and lay in the tangents of the outer and inner margins, and were i'5 millimetres from the cornea. The centre of the section was placed either a little above, or in, or a little below the corneal margin. Horner and many others lowered the ends of the section FIG. 6. VON ARLT'S FIG. 7. HORNER'S INCISION. INCISION. further, and thus the linear section became changed into a shallow peripheral flap section. Liebreich's corneal section (1872) was much practised in England. It was made by preference downwards, and without iridectomy. The whole incision, including puncture and counter-puncture, was made with a very narrow Graefe's knife, inclined downwards and forwards at an angle of 45 degrees. The extremities of the wound lay in the sclerotic, i millimetre from the cornea and 2 millimetres below the horizontal corneal meridian. The middle of the incision fell 1*5 to 2 millimetres within the corneal circumference. Lebrun (1872) made a shallow flap section upwards, purely corneal. The ends of the incision were i to 2 millimetres below FIG. 8. LIEBREICH'S FIG. 9. LEBRUN'S INCISION. INCISION. the horizontal corneal meridian ; the summit of the arch was at about the upper border of the undilated pupil. It was made with the narrow blade at an angle of about 30 degrees with the surface of the iris. (What is known as Kuchler's section, forming a straight, horizontal line across the centre of the cornea, may be men- tioned here as having been actually practised about this time.) The flap section again came gradually into fashion, but for the 28 Cataract Extraction most part in slightly different form. It was now an upper flap, lying just in front of the limbus, and therefore without a con- junctival flap. De Wecker introduced his short (3 millimetres) flap in 1875. But the fear of a larger section being allayed FIG. io. DE WECKER'S INCISION. through the adoption of antiseptic and aseptic measures, and the desire for simple extraction making headway, the tendency soon became marked to enlarge the section almost or quite to the old semicircle. Thus, the main events in the history of cataract extraction have been the changes which have taken place in the section in its form, its site, and the manner of making it also changes depending upon the character of the section. Procedure in regard to the question of iridectomy or no iridectomy has in the main been dependent on the location of the section. The more peripheral the section, the more regularly has iridectomy been needed. In other matters which have been debated in quite recent years there has been no sweeping unanimity in opinion or practice. The question of simple division or removal of anterior capsule, except as decided by tenuity or thickness of the capsule, is a comparatively recent one. The method of subconjunctival extraction is one which has not yet been extensively practised. At present there is much interest taken in the intracapsular operation, owing to Major Smith's extraordinary work at Jullundur, in the Punjab, India. INSTRUMENTS. Lid Retractors. Some form of stop speculum is in almost universal use at least, during the making of the section. It affords the widest separation of the lids with the least inconvenience. There are numerous varieties of the instrument in use, some designed to lie over the nose, others over the temple. The latter Description of the Operation 29 are the better adapted for manipulation by the assistant standing in the usual position, close to the eye operated upon. Among them Clark's pattern is largely used FIG. ii. CLARK'S SPECULUM. in England. It is simple and easily cleaned, fairly light, but strong enough to resist fairly powerful contraction of the orbicularis. And it is well curved, so that it \ FIG. 12. MELLINGER'S SPECULUM, MODIFIED BY NETTLESHIP. lies ordinarily close in to the temple. The arms, however, are locked by screw adjustment. This is regarded by many as a serious defect, since it does not 30 Cataract Extraction allow of very rapid removal of the instrument when in use. Landolt's models one nasal, one temporal are fixed by a small lever and rack, worked by simple pressure of the finger. The arms of Mellinger's and Roster's ingenious instruments, working by rack mechanism, can be approximated at once for withdrawal by simple pressure between the finger and thumb of one hand ; yet they effectually resist pressure exerted by the lid muscle. They are said, however, to produce too wide a separation of the lids in some cases. Other patterns provide for easy removal, but do not control the lids so well. Miiller's FIG. 13. GAUPILLAT'S SPECULUM. instrument closes and falls away automatically on powerful contraction of the orbicularis. Some specula are fitted with solid curved end-plates to cover the lashes and lid-borders, either fixed, as in Lang's modification of Clark's speculum, or movable, as in Terson's and Gaupillat's models. In one of Lang's modifications there is a guard for overhanging upper lid. Other specula have simple bars as guards for the lashes. The benefit of such coverings is seen mainly in using a keratome for an upper section, in performing simple iridectomy or a linear extraction. It is scarcely appre- ciable in an ordinary flap extraction. In Landolt's instrument only two hooks pass behind the border of each lid, the bar connecting them lying in front of the lid; Description of the Operation 31 that is, the usual arrangement in this respect is re- versed. In specula of any pattern the curve of the bar or end- plate, upon which the security of the hold on the lid depends, may be a little too open and shallow. The instrument is thus more easily removable. But the gain in this respect is obtained at a slight risk of the instrument slipping from between lax eyelids when it is at all forcibly elevated by the assistant. Even the leverage of the weight of the unsupported instrument may cause it to slip out from the lids of patients with narrow faces, for whom the curve of the arms is insufficient. The inner ends FJG. 14. DESMARRES' RETRACTORS, SMALL AND MEDIUM SIZES. of the arms are seen to be tilted forward, and the lower lid gradually slipping back before the instrument finally escapes. On this account a few specula e.g., Webster Fox's modification of Clark's instrument and Galezow- ski's and Gaupillat's have jointed arms. Of single retractors, Desmarres' is probably most used. For cataract work the small or middle size is selected, and is used for the upper lid alone, the lower lid being depressed by the assistant's finger. The pliable German silver stem should be bent as shown in Fig. 41, so that the recurved end portion of the plate is parallel with the handle. If this be not done, the lid cannot be drawn sufficiently forward without the assistant's hand being too close to the eye, inconveniencing the operator. The 32 Cataract Extraction separation of the lids thus secured is not so wide as with the stop-speculum, but, on the other hand, fairly efficient control is afforded over the lid muscle. McGillivray's or Pellier's wire loops may be employed instead, or a large-sized strabismus hook, as used by Smith (Jullundur). The objection to the simple hook is that it tends to pull the outer canthus and outer part of the lid against the globe. FIG. 15. FIXATION FORCEPS. Fixation. Forceps used for holding the eye should have strong blades which will not bend easily, but a weak spring which will not tire the fingers quickly. The usual two teeth on one blade and three teeth upon the other commonly afford a sufficiently firm grip of the conjunctiva without tearing it. Broader ends and more numerous FIG. 1 6. LANDOLT'S FIXATION FORCEPS. teeth would not generally give a more secure grip, because the forceps have to be applied more or less obliquely to the surface of the globe. With eyes deeply set and turned well downwards the obliquity is often extreme, so that FIG. 17. FIXATION HOOK, BY BADER. the whole breadth of the ends of the ordinary forceps is not engaged. Landolt uses forceps with obliquely placed ends. In Bader's and Critchett's models each blade ends Description of the Operation 33 in a single sharp claw, capable of fixing deeply in the episcleral tissue. Weiss makes a pattern with three such claws on each blade instead of teeth. The double hook shown in Fig. 17 is practically the same as the old Pamard's spear, recommended for fixation after the con- junctiva has become torn. The Knife. Graefe's knives in various breadths are almost the only ones used nowadays for flap extraction. FIG. 18. THE GRAEFE KNIFE. The handle should be of ivory or aluminium, too heavy, and too slippery when wet. Steel is Sir Anderson Critchett uses a knife slightly modified from the Graefe pattern. " The back of the knife is bevelled and the blade is slightly rounded ; it does not permit of too rapid escape of aqueous."* Kuhnt's knife is also designed to retain aqueous. For 6 millimetres from the point it resembles an ordinary Graefe's blade, and then broadens out into the triangular Beer form. Bell Taylor's trowel-shanked knives permit of the right hand being used upon the left eye, the surgeon standing behind the patient's head, and puncturing at the nasal margin of the cornea. Iris Forceps. The pattern entered in the catalogues FULL SIZE. FIG. 19. IRIS FORCEPS. as " curved, rectangular, with tenaculum points," is very serviceable. With less curved blades there is more danger from upward movements of the globe while the ends of * The Ophthalmoscope, iv (1906), 112. 3 34 Cataract Extraction the forceps are within the wound. The ends of the forceps when closed must be smooth, in order not to catch in the iris. A Tyrrell's Hook may be of service occasionally, should the iris be buttonholed. FIG. 20. TYRRELL'S HOOK. Of Iris Scissors, de Wecker's spring scissors are perhaps the most convenient. Scissors of the ordinary FIG. 21. DE WECKER'S IRIS SCISSORS. FIG. 22. ELBOWED IRIS SCISSORS. pattern should be ' elbowed ' for use on the right eye, straight for use on the left eye. Cystitomes, etc. A straight instrument for opening the capsule may be difficult to use in a deeply placed eye unless the globe be turned fully downwards. Capsule Forceps. Couper's forceps differ from ordinary iris forceps in having a number of small teeth Description of the Operation 35 FIG. 23. STRAIGHT IRIS SCISSORS. FIG. 25. MOORFIELDS PATTERN CYSTITOME. FIG. 26. WEBER'S CAPSULAR HOOK. FIG. 24. GRAEFE'S BENT CYSTITOMES, RIGHT AND LEFT. FIG. 27. RECTANGULAR LENS HOOK. FIG. 28. TERSON'S CAPSULAR FORCEPS. FIG. 29. TREACHER COLLINS' CAPSULE FORCEPS. 32 36 Cataract Extraction along a portion of the lower margin of each blade near its point. De Wecker's instrument has the usual teeth at the ends, like iris forceps, and, in addition, each blade has a small tooth projecting down from its lower edge. The blades of Terson's forceps are slightly curved beyond the bend, to correspond with the posterior surface of the cornea. The blades remain separated at the bend when closed at the point, and the teeth are few in number. Thus they are not likely to grip the iris when used in simple extraction. L. Muller's forceps remain open similarly at the bend. Rochon-Duvigneaud's forceps are similar to Terson's, but each blade has numerous teeth extending from the point to the bend. Treacher Collins' FIG. 30. EXPRESSOR HOOK. FlG. 31. TORTOISESHELL SPOON. FIG. 32. PAGENSTECHER'S SPATULA. pattern is like the Fischer-Arlt iris forceps, but with a number of teeth arranged for seizing the capsule. . Lens Expressors. I have followed Mulroney and /\ Smith, of the Indian Medical Service, in using a large tenqtomy hook for expressing the lens. The hook is improved by increasing its curve nearly to a semicircle,* * Easily done after heating the instrument in the flame of a spirit- lamp. Description of the Operation 37 as shown in Fig. 41. And I have had one made by Weiss, thickened and a little flattened about the curve, r to broaden the surface mostly used. The curve corre- sponds fairly well with the circumference of the cornea FIG. 33. IRIS REPOSITOR. and of the lens, and is therefore particularly suited for the alternation of pressure and indentation, at either side and below, by simply rocking the instrument. But the same FIG. 34. CURETTE. shifting of the pressure may be obtained with less curved instruments by sliding them from place to place. The point is obviously of only minor importance. The well- FIG. 35. SNELLEN'S VECTIS. established tortoiseshell spoon is fairly well suited for the work, but its curve might well be increased, and the edge of the bowl is not sufficiently thick and rounded, and is O FIG. 36. TAYLOR'S VECTIS. not quite in the same plane as that of the stem close to the bowl. Various curettes and spatulas are also used straight, curved, and bent at an angle. Pagenstecher uses a curved glass spatula. 38 Cataract Extraction For assisting in the delivery of the lens by supporting it when the zonule has been ruptured, Bowman's or Critchett's or Pagenstecher's spoon may be needed. The two former are flat from side to side, being curved only in the one direction. They are well suited for holding back the vitreous, and Bowman's, with fine grooving only at its extremity, is better suited for passing down between lens and vitreous than Critchett's, with thickened rim. FIG. 37. BOWMAN'S SPOON. Pagenstecher's bowl is unnecessarily large for supporting the lens, but is possibly better for actually extracting the lens. For this purpose, however, Snellen's or Taylor's wire loop is well adapted. One of these instruments should always be at hand, to be rapidly sterilized in the flame in case of necessity. Iris Repositors. A flat spatula, such as shown in 33, is in common use. I have used a curette in order FIG. 38. PAGENSTECHER'S SPOON. not to add to the number of instruments in use. It is of the pattern shown in Fig. 34. The groove in its concave surface should be shallow and its edges thick and rounded, and the curette itself not broad. Being made of German silver, the instrument is sufficiently pliable to be easily bent by the fingers. It may be used, not only for replacing iris, but also in simple extraction for applying counter-pressure above the wound. For this purpose, Description of the Operation 39 used upon the right eye and held in the left hand, the instrument must be considerably curved. We also em- ployed the curette for removing mucus from the palpebral conjunctival surface at the close of the operation, and very occasionally at the beginning of the operation to detach mucus lying in the recesses about the plica. Irrigators for douching the anterior chamber. The ordinary laboratory ' wash-bottle ' arrangement of flask and glass tubing served us in Bombay for over ten years, FIG. 39. i. IRRIGATOR FLASK. 2. NOZZLE. 3. MOUTH SCREEN. fitted with an extension of rubber tubing, ij to 2 feet long, and a readily removable silver nozzle. This was the locally obtainable substitute for McKeown's more elaborate apparatus. At first we used to blow into the flask through a plug of sterilized wool to start the syphon action. Afterwards we used a ball syringe (not shown in the figure) to start the flow. Each flask of fluid frequently served for half a dozen operations, and the syphon action once started was usually kept going with- out stoppage throughout, the fluid being retained in the outflow 4O Cataract Extraction tube between the successive operations. Thus the rubber ball was only attached for the moment when it was needed. The tubing, glass and rubber, was kept in strong perchloride lotion always when not in use, and the same fluid was passed into the tubes by syphon action, and retained there by a clamp some hours before operating.* The small nozzle was made of silver, sufficiently pure that it did not blacken when heated in the flame of a spirit-lamp. The array of cannulae supplied with McKeown's apparatus was not found necessary. Lippincottf passes the rubber tubing close to the nozzle through a holder provided with a ' shut-off,' to prevent backward flow when the reservoir is allowed to drop below the tip of the tube. A simpler apparatus, which has been used by Wicker- kiewicz, Uhle, and others, is the ' undine,' a retort-like flask with long bent outflow tube, bearing a nozzle. The pressure of the outgoing stream is changed by altering the inclination of the flask. f Simple pipettes with rubber nipples ordinary medicine droppers have also been employed, sometimes fitted with nozzles. On the same principle, large rubber bulbs have been used by Kuhnt and Wanless (Miraj, India). It is I stated that these rubber syringes may throw bubbles of air into the eye, and the force of the current produced by compression of the bulb cannot be so accurately measured as when the propelling force is simply gravity. An advantage claimed for the rubber ball is that it can be used with one hand, enabling one to dispense with an attendant. Wanless's bulbs are fitted with McKeown's eannulas by bayonet-joint attachments. Piston syringes are somewhat liable to be out of order * It is obvious that the irrigating fluid which first passed through these tubes from the flask must have contained a trace of perchloride, and was therefore fit for use only on the surface of the globe. f Amer.Journ. of Ophth., xxi (1904), 193. 7 Description of the Operation 41 when needed, and with them the force of the current is more difficult to regulate than with ball syringes. But the double-current instrument introduced by Chibret* in 1895 stands in a class by itself. Its essential principle is that, by its double cannula, fluid is sucked out of the eye in quantity equal with that introduced. Thus the tension within the chambers remains unaffected unless the outflow tube should become blocked. Chibret's syringe is made by Aubry. Lagrange and Aubarett use a very similar instrument made by Creuzen and Soulard, 47, Cours de PIntendance, Bordeaux. FIG. 40. DOUBLE CURRENT SYRINGE, BY LAGRANGE AND AUBARET. Intra-ocular irrigation is intended primarily for washing away cortical remains, but is useful also for removing blood, iris pigment, or a piece of iris isolated by the knife, also air bubbles. The stream of fluid can be em- ployed also for douching the conjunct! val sac before operation, and for keeping the cornea moist during opera- tion. It has been used also for filling the anterior chamber in eyes with collapsed cornea, whether after loss of vitreous or not. The fluid in general use is physiological salt solution, 0*7 per cent. Lagrange and Aubaret, desiring a closer approximation to the composition of aqueous * Ann. d'Ocut., cx\ii (1895), 120. t Arch. d'OphA, f&rrier, 1905. 42 Cataract Extraction I humour, use the following: Water 1,000, sodium chloride / 6'8go, calcium chloride 0*113, potassium sulphate o - 22i. The solution must be sterilized, and should be used at a temperature a few degrees above blood-heat in the flask, to allow of a little cooling as it passes through the tube. Chibret used i part of cyanide of mercury in 20,000 boric acid solution. He injected 20 to 30 grammes of fluid i.e., three or four times the contents of his syringe. GENERAL ARRANGEMENTS. For the general arrangements fittings, furniture, lighting, etc. of the operating room, works on eye operations in general must be consulted. The conditions under which most suc- cessful work is done in India would astonish surgeons accus- tomed only to the elaborate provisions for asepsis in well fitted hospitals. But in India much of the work is done practically in the open. The windows are kept constantly open, so far as the strength of the prevailing wind allows, and this renders of no account dirty surroundings, furniture, patients, and assist- ants. The operating room in Bombay was the out-patient room just cleared of the morning crowd of out-patients. In our private work at patients' houses sometimes every- thing in the room was more or less filthy, and the floor perhaps cow-dunged, so that care had to be taken to avoid raising any dust in the room. The light was sometimes poor, from small, low windows, opening on to a verandah, or partly covered by weather-boards. The light from a small window near at hand is ample, if other sources of light are shut off to avoid multiple corneal reflexes, and if the window be sufficiently high ; and it should face away from the sun, lest there be any dazzling reflexion from below. Unless the operation can be performed upon the patient's bed, some provision must be made for placing the patient in bed afterwards without any effort from him. An ordinary domestic table, with a few coverings and a single pillow, generally places the patient's head at a convenient level, so Description of the Operation 43 that the surgeon, standing upright, or nearly so, may work with forearms flexed at rather less than a right angle. The coverings should be sufficiently strong to support the patient's weight when he is being carried to bed. A small table must be placed near the patient's head during operation, for the instrument tray and for a bowl of lotion. THE PREPARATION OF THE PATIENT. On admission the ordinary hospital rules as to cleanli- ness are observed, paying especial attention to the washing of the eyelids and neighbouring parts. A laxative is ad- ministered, and the patient's control over his eye and lid movements tested, and developed so far as practicable. In testing the patient's self-control, he is required to keep his eyes turned steadily downwards while the lids are lightly manipulated, and while eversion of the upper lid is carried out. Most of them at first roll their eyes up and close their lids forcibly, but after a little practice have no difficulty in curbing these impulses. After this they can almost always be depended upon to exercise the necessary restraint during operation. Some nervous, timid people require training for a day or two to become accustomed to the demand upon their will-power, and then behave extremely well. Patients are required also to maintain fixation of their eyes in different directions, following movements of their hands. In this test the eye upon which operation is not contemplated, if it be a seeing eye, is screened but not closed. The patient must be able to look towards his hand without seeing it, the direction of his eyes being governed by muscular sense. Otherwise, during opera- tion the eyes are apt to roll upwards as soon as the vision of the good eye is cut off by the surgeon's hand holding the fixation forceps. 44 Cataract Extraction In this test we may encounter an extraordinary stupidity. Some of our elderly patients, generally cultivators who had been blind from cataract in both eyes for perhaps a few years, had so lost the habit of fixation that they could not be induced to rotate their eyes as directed. Others, through lack of will- power, could maintain fixation of the eyes for a few seconds only in any position but that of rest. Even after some days' training by the hospital assistants, some very stupid people failed to look downwards, except by turning their heads down. Formerly much time was wasted upon them, and in a few cases the extraction was performed under chloroform. Latterly they were operated upon by Czermak's lower section. Nearly all of them could turn their eyes a little upwards. Fortunately, this stupidity is . rarely combined with nervousness ; these patients neither roll their eyes about during operation nor squeeze their lids together. A ' Test Dressing ' should be applied the night before operation to untreated cases, but not to those which have been treated for conjunctivitis. It need consist of nothing more than a strip of lint or gauze fixed over the lids by a single turn of bandage. Its object is to retain on the lint and on the lid margins, and at the inner canthus, any discharge which may form within the conjunctival sac during the night. It serves simply as a guarantee that all discharge shall be visible at the surgeon's morning in- spection. The bandage should not be removed before the time of the inspection, or, if removed earlier, care must be taken that the lids are left untouched, and that the bit of lint is available for examination. An Early Morning Inspection of the patient is strongly advisable, in order that a final assurance may be given as to the fitness of the eyes for operation. Provided that satis- factory perchloride irrigation is to precede operation, cases with chronic conjunctival changes may be accepted showing scanty, thin, dried discharge on the lid borders, or an ab- normally large accumulation of mucus at the inner canthus. Description of the Operation 45 But an additional thread or flake of mucus lying in the lower fornix suggests the need for caution. As a rule, the operation must be postponed for a few days' treatment, or at least the decision as to operation must be deferred for a few hours. If at a second inspection after this interval i.e., about the usual hour for operating any fresh mucus is found in the fornix, operation should be postponed. At this second examination, also, one may judge to what extent conjunctival congestion seen on removal of the bandage was due simply to occlusion of the eye. Such congestion will have disappeared in an hour or two, and any injection still remaining may be attributed to the presence of pathogenic organisms. /Much less importance attaches to scanty discharge from a conjunctiva roughened and thickened by very chronic inflammation,/ than from a membrane nearly normal in appearance. For in the former instance, not only may the altered mucous membrane be expected to withstand very vigorous perchlor-'de douching, but we have learnt from practical experience not to fear the result of operation performed on such an eye after the suitable douching. It seems reasonable to admit that such con- junctivse may furnish a little abnormal secretion quite independently of the action of any existing micro- organisms. And it is a matter of fairly general observa- tion that in very chronic conjunctivitis the only pathogenic organisms likely to be found are staphylococci of feeble virulence or Morax-Axenfeld diplobacilli. And there ap- pears to be little difficulty in getting rid of diplo-bacilli temporarily at least (see Chapter IV, Asepsis). We are much more afraid of quite recent conjunctival changes slight injection, with a mere trace of thickening and rough- ness and of discharge. We fear these, knowing from bac- teriological examination that the conjunctivas of some of 46 Cataract Extraction the eyes upon which we operated contained numerous pneumococci or streptococci. Occasionally, in up-country j^atients, we decided to operate in the presence of chronic inflammation with distinctly freer discharge than above mentioned. In these cases preliminary perchloride irrigation was practised at the time of inspection, lasting perhapsfor__ten seconds. The lotion, i in 3,000, was squeezed out of pads of lint, and the cases were noted for the maximum treatment just before operation. In our private practice infective iritis and irido-cyclitis have been rather more frequent than in hospital work, and we have thought that the higher incidence was possibly accounted for by the non-use of the test dressing and morning inspection. To show fitness for operation without antiseptic lotion, the test bandage must reveal no trace of abnormal secre- tion. At the morning examination, also, the^ opportunity may be taken of testing the patient's controPtrHtlis eye and lid movements. Operation may have to be postponed for further training of the patient. The administration of a nervfevSrflative may be found advisable to dull an excitable patient's fears ; or operation by loweV"section, preferably subconjunctival, may be decided upon in the case of a very unintelligent individual. Orders can also be given now as to the perchloride treatment of the conjunctiva immediately before operation, the instillation of adrenalin, etc. For nervous patients a bromide draught at night may be possibly advisable. A good night's rest, plus some of the influence of the drug still remaining, must help to make the patient collected and calm for the ordeal. At times we have used bromide and chloral fairly extensively, 10 or 15 grains of Description of the Operation 47 each, but given an hour or two before operation. The effect was often very noticeable. Morphia and other sedatives have been used also, with the object of lessening the risk of prolapse of iris after simple extraction. $ General anaesthesia by hypodermic injection of scopolamine /and morphine has been recommended in nervous and restless patients (Chapter IV). PRELIMINARIES. The point and edge of the knife are tested upon a leather drum. The selected instruments must be cleaned and sterilized, and laid in order on a rack. The hands of the surgeon, of the assistant, and of the attendant are washed thoroughly and steeped in perchloride lotion. The assistant bathes the skin of the lids and surrounding parts, and (following a practice now given up by many) douches the conjunctival sac with perchloride lotion, and follows this by the instillation of cocain solution. In many cases the use of adrenalin chloride solution, before or with the cocain, is of benefit. The surgeon and the assistant don mouth masks. The instruments commonly required are shown in Fig. 41, plus the Desmarres' retractor, which is only quite exception- ally needed. In addition, a Bowman's spoon or a wire loop should be at hand, and perhaps also a Tyrrell's hook. Some surgeons would replace the cystitome by capsule forceps. A sharp hook might rarely be wanted also. The Sterilization of Instruments in eye work is commonly by boiling in water, or, better, in i per cent, soda solution. The only difficulty is with the knife, which loses its edge by repeated boiling. Where a number of operations have to be performed in succession, more than one set of instruments is ordinarily required. For example, Elliot's arrangement in Madras is this : He has a rectangular sterilizer 22 inches long, 6*5 inches broad, and 5*5 inches deep. This holds four perforated aluminium instrument trays, each of them 5-5 inches long, 5 inches broad, and 1-5 inches deep. Each has handles at the 4 8 Cataract Extraction two ends, by which it is lifted out of the boiling water with the aid of metal hooks. This allows for one tray to be on the table containing the instruments in use, one to be cooling (in a cloth wrung out of i in 3,000 biniodide solution), and two to be boiling. This gives each set of instruments ten minutes' boiling. Nfithpr kpit