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
<A
14 Cataract Extraction
operation ' merely mechanically. Or if perchloride or cyanide
of mercury or other antiseptic lotion is utilized, it is in no
measured and calculated systematic manner, aiming at a
definite recognizable result. And it is understood that no great
reliance can be placed upon either the mechanical or the
chemical attempts to clear/away organisms from the field.
The treatment of any conjunctivitis present must therefore be
very thorough before an' eye can be accepted as ready for
operation.
For rapidly reducing the discharge from the rough and
thickened conjunctivas with which we had to deal in India, we
found nothing equal to a daily rather free douching with strong
perchloride lotion (i in 3,000). This treatment would be too
severe for conjunctivas of nearly normal appearance.
/v y IA I once had/to delay operation for the treatment of a con-
( junctival pouch, not caring to operate with such an area shut
off from the action of the perchloride lotion.
The Lacrymal Passages. Though cataract has been success-
fully extracted numbers of times in the presence of chronic
lacyrmal disease, the risk of infection is so great that opera-
tion must be considered inadmissible whenever there is the
slightest trace of discharge obtainable from the tear-sac. No
patient should be admitted without pressure being made over
the sac, while the puncta are exposed by separation of the
eyelids. This, however, in itself is not a sufficient test, but it
is possibly enough if a ' test dressing' is always applied after the
patient's admission. This was all that we relied upon in
Bombay. On a few occasions we have been saved from
operating in the presence of unsuspected lacrymal disease by
noticing a trace of discharge and moisture on the Ud borders,
and on the lint used, after a night's application of yme dressing.
By syringeing then some discharge was washddX>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<v6autery. Haab,* using a fine point and a current
strong enough to bring it only to a faint red heat, succeeds in
closing 2 or 3 millimetres of the two canaliculi temporarily
only./ The canaliculi can be subsequently reopened by a
conical probe. Or the canaliculi may be (perhaps preferably)
rendered temporarily impervious by_ ligature with catgut or
silk, as practised by Eversbusch, Buller, and Quackenboss.
Should either canaliculus have been freely slit open, these safe-
guards are not readily applicable. Treatment by probing and
syringeing may have to be very prolonged before safety is
assured.
Some operators have found that preliminary opening of the
sac through the skin and packing with iodoform or iodoform
gauze for some days, also filling the canthus with sterile iodo-
form after operation, is sufficient to preserve the wound from
contamination. Doubtless considerable protection is afforded
also by the subconjunctival methods of operating.
Angelucci has practised division of the canaliculi with a
knife, cutting through the whole thickness of the lids, and
sealing the openings by a touch with the galvano-cautery.
Later he reopens the canaliculi beyond the occlusion.
In Bombay we ignored nasal obstruction from polypi and
thickening of mucous membrane. In cases of ozaena the nose
was simply syringed out on admission, and again shortly before
operation ; but cases with purulent discharge from the nose
were referred for treatment. Some surgeons pay much more
attention to the condition of the nose and pharynx ; but it is
accepted that infection of the conjunctiva from the nose by way
of the lacrymal passages does not take place.
As regards corneal opacity, it may be stated that if the
cornea be transparent enough in whole or in part to admit of
the state of the lens and of the pupil being made out, the
patient should see sufficiently well afterwards to justify opera-
tion. A pterygium, if large, may require removal, but if small,
may be left.
* ' Operative Ophthalmology,' p. 58.
M>*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
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the iridectomy was made
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with most of the ' milk ' absorb
large, pale, transparent nucleu
Morgagnian
anterior chamber not shallow
Slightly overripe disc
Morgagnian ; opaque capsule
Unripe greenish
Morgagnian ; anterior chamber rather shallow
tremulous
anterior chamber not particularl
anterior chamber shallow ; dark
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Nearly ripe ; cortex soft
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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<fl nrff ^nysors are sterilized upon these trays ;
their points are immersed by an assistant for two minutes in
the boiling water of the sterilizer.
Many surgeons/ ^!, de Wecker, Lagrange, de Lapersonne,
True prefer dryheat (130 to 150 C. in a stove for an hour).
FIG. 41. INSTRUMENTS LAID OUT FOR CATARACT EXTRACTION.
Stop-speculum ; fixation forceps ; strabismus hook (expressor) ;
curette, used also as repositor ; Graefe's cystitome, point downwards ;
de Wecker's scissors ; iris forceps ; knife ; curved scissors for eyelashes ;
Desmarres' retractor.
Louis Dor and Rollet (Lyons) sterilize in boiling oil at 140 C.
The oil is freed from oleic acid by maceration for twenty-four
hours in absolute alcohol.
At the C. J. Hospital, Bombay, we depended on the flame
of a spirit-lamp for sterilizing the points of cystitome and of
conjunctival and iris forceps, the curette and expressor hook,
and the nozzle of the irrigator. Simple washing with sterilized
Description of the Operation 49
lint, soap, and carbolic lotion, i in 60, was made to suffice for
the knife, scissors, speculum, and retractor.
This practice was begun at a time when the work was less
heavy than it afterwards became, when the assistants were
untrained, and when we had only a small supply of instru-
ments, and no sterilizer. The one set of instruments was used
for the whole morning's work, and I had to be personally
responsible for all details of any importance. The method
proving reliable and on the whole satisfactory, it was con-
tinued. But the few minutes of time wasted between one
operation and the next could not be well spared, and on this
account other arrangements were being made. The details
may, however, be of use to others in circumstances such as
ours.
Details of Sterilization in the Flame. To minimize the slow
destruction of the iris forceps, and especially of the cysti-
tome, by the repeated heating, the points of these instru-
ments were allowed to remain in the flame for a period just
short of that necessary to make them red hot. A trace of
black oxidized metal had to be scraped off them occasionally.
Since, as it happened, our tenotomy hooks and curettes had
bone handles, these instruments had to be rapidly cooled after
heating by being plunged into a bowl of carbolic solution.
The irrigator nozzle held in the fixation forceps needed to be
heated to a dull red before the first operation of the day, in
order to burn away matter in its lumen. It was also cooled
by immersion in the fluid to save time. Afterwards, between
one operation and the next, the nozzle was not removed from
the rubber tube. Only its tip was placed in the flame, the fluid
being drawn back from it by a slight sliding movement of the
finger and thumb which held the rubber tubing. It was only
heated enough to give a hissing sound, when a little fluid was
allowed to spurt through it to cool it again.
Some of the nozzles used were rather short for this heating
of their tips, while still attached to rubber tubing. The interior
of the tubing immediately beyond the metal got roughened
after a time, and unless it were cut away, small particles of
rubber were apt to be thrown into the eye by the stream of
fluid passing through. A few such particles were left in eyes,
fixed by blood-clot, but they gave rise to no irritation, and
were slowly absorbed.
4
5O Cataract Extraction
In depending upon simple washing of the knives and iris
scissors, it was realized that some responsibility was incurred.
The first washing of the day was in particular very thorough,
so much so that the knife edges probably suffered quite as
much as if they had been plunged into boiling water in the
usual fashion.
We used our instruments dry, simply laid out upon a rack
as they were got ready. It is more usual to immerse them in
sterile, unirritating fluid before and during the operation. Such
fluid must, of course, be changed after every operation.
Antiseptic lotions must be always made the day before use,
or earlier. Drops for instillation should be freshly prepared,
;.nd boiled for three to five minutes in Stroschein's or other
uitable bottles. Boiling once for five minutes has been found
lot to impair the action of the ordinary cocain solution.
During operation the curette in particular frequently needs
Cleansing again more than once. It is washed with bits of
lint taken from the bowl of perchloride lotion standing near
the patient's head. It is then, after rinsing in a stream of
saline fluid from the irrigator, fit for entry within the wound.
Similar treatment suffices also for the nozzle of the irrigator,
should its sterility have been rendered doubtful by contact with
the conjunctival surface. This friction with wet sterile lint
may be depended upon to remove any moist (and therefore
loosely adherent) material with which these instruments might
have become soiled during the progress of the operation.
Should any toothed instrument need sterilizing quickly in an
emergency, it may be passed through the flame of a spirit-
lamp.
Lippincott * advises continuous sterilization of knives in a
20 per cent, solution of formol, containing 3 per cent, of borax.
The knives are placed in perforated steel boxes in the solution,
and before use are rinsed in sterilized borax solution and
wiped with sterile cotton. Each knife can thus be used only
once in a day. Lippincott found alcohol ineffectual for
sterilizing purposes. Asmus recommends similar continuous
sterilization in the spiritus saponatus of the Prussian Pharma-
copoeia. [For its composition, see The Ophthalmoscope, (1904)
ii, 294].
* Arch. ofOphth., July, 1898.
Description of the Operation 51
Perchloride Irrigation. In attempting to clear away
micro-organisms from the operative field, we have douched
with i m-5?6oo perchloride lotion. Since the reaction of
the conjunctiva varies greatly according to the condition
of the latter, systematic efforts were made to keep the
effect nearly uniform by varying the period of irrigation.
Practically normal conjunctiva were treated for_i to i|
minute ; others for periods up to if minute. The time
was regulated by our estimate of the amount of douching
which the particular mucous membrane would withstand
without excessive reaction. The shorter application, one
minute, was not found to be too severe for the most
delicate conjunctiva, whereas the longer treatment was
still quite insufficient for some scarred or roughened and
thickened mucous membranes. For these a short sup-
plementary douching was added after the cocain instil-
lation.
This one particular concentration of the lotion was in
almost regular use at the Bombay Hospital for ten years
or more. But it is not recommended as certainly the
most suitable strength. We tried stronger solutions,
i in 2,000 and I in 2,500, correspondingly reducing the
quantity used ; but we did not obtain quite the same
result. There was more inflammatory swelling of the
lids and conjunctiva, and this deep reaction was precisely
what we wished to avoid. On the other hand, weaker
solutions used more freely should give more of the super-
ficial action which is desired. /For instance, the ordinary
i in 5,000 solution, employed for nearly double the
period which we found necessary with the i in 3,000,
might have been more satisfactorv^ But we were deterred
from experimenting by old experience of suppurations
encountered under the use of this weaker lotion, doubtless
used in insufficient quantity. Finding that with the i in
42
52 Cataract Extraction
3,000 we were able to abolish suppurations, and at the
same time almost always to avoid excessive reaction,
fears for our statistics made us rest content. / s'
The patient is placed recumbent beneath a jar of the
lotion furnished with rubber tube and glassAiozzle. An
assistant everts the upper lid and depresses the lower,
and keeps them both constantly mt5ving in the vertical
direction, while an attendant directs a stream of fluid on
to the exposed surfaces. The movement of the lids is to
ensure penetration of the antiseptic to the furrows and
recesses, more particularly of the upper fornix.
In the cases where it is intended to instil adrenalin the
period of irrigation should be very slightly prolonged,
because the immediate reaction to the perchloride is
lessened by the adrenalin. The reaction is delayed
simply.
Rather more lotion is used also in cases where there
has been lacrymal obstruction, whether it has been
treated or not by excision of the sac.*
The irrigation usually causes some smarting, but this
gives way rapidly to the cocain instillation.
Anaesthesia. Cocain is instilled several times at
definite intervals. It is used in solution varying from
2 per cent, to 5 per cent. (\ have instilled always a 4 per
cent, solution four times.) If this be done at three minutes'
intervals, the eye is ready for operation one minute after
the final instillation i.e., ten minutes after the first instil-
lation. /
v..
On eachNrccasion several^cfrops areTised, for though little
remains in the conjunctival sac, the trace of fluid already there
has to be displaced, and if the conjunctiva be thus flushed out,
' * Plant and Zelewsky (Klin. M. f. A., 1901, S. 369) have shown
that after extirpation of the lacrymal sac bacteria are more numerous
' //,'in the conjunctival sac.
Description of the Operation 53
the cocain solution penetrates to the fornices undiluted with
tears. The assistant should watch the patient in the intervals
to see that the eyelids are ke]3t_clpsed, to prevent drying of the
corneal surface and subsequent exfoliation of epithelium.
Landolt uses this solution five times during iwenty-five
/ ^*~~ (^^
minutes. Haab^mthe case of patients with little self-control,
and in cases in which prolapse of vitreous is to be feared, instils
a drop of 3 to 5J3ej: cent, solution every three minutes for half
an hour. It is said that, in spite of all precautions, such frequent
Instillations tend to cause opacity of the corneal epithelium,
and encourage subsequent collapse of the cornea. Haab uses
the drops in both eyes, ' to guard against the disturbing acci-
dent of reflex closure of the lid, in case a drop of fluid of any
kind accidentally gets into the other eye during the operation.'
With both eyes thus being rendered anaesthetic, watchfulness
is more essential, to prevent opening of the lids in the intervals
of instillation.
The degree of anaesthesia ordinarily attained by cocain
varies. The quantity used by us sometimes sufficed to abolish
pain ; but in other cases the pull upon the iris for the
iridectomy was painful, and some patients winced a little even
from the grip of the fixation forceps. Possibly the earlier
drops may have been often washed away by a flow of tears,
excited by the perchloride irrigation. Roller (New York)
Jnjects cocain subconjunctivally for cataract extraction, to
make the operation quite painless.
None of the other local anaesthetics which have been tested
in eye work eucain, holocain, stovain, alypin, etc. appear
likely to displace cocain. The blanching effect of cocain is
useful in operations with a conjunctival flap, especially in our
work, owing to the hyperaemia excited by the perchloride
douching. Maynard (Calcutta), operating with a small con-
junctival flap, and using alypin. found it advisable to add
adrenalin solution to control bleeding.
Of late years many ophthalmic surgeons have utilized
preparations of adrenal extract more or less regularly to
enhance the effect of the local anaesthetic and to lessen
bleeding. I have used the well known adrenalin chloride
* 'Operative Ophthalmology,' p. 128.
54 Cataract Extraction
solution, and also ophthalmic discs of ' hemisine.' The
solution, i in 1,000, unsterilized,* was not mixed with
the cocain drops, nor instilled alternately with them, but
was used only before the cocain period. It was dropped
into the eye immediately after the perchloride irrigation,
and the cocain instillation deferred for five minutes. In
cases where much perchloride had been used, and where,
in consequence, an unusual degree of hyperaemia had to
be combated, a second instillation was made two and a
half minutes after the first. This aid is quite necessary
in the subconjunctival extraction of Czermak, and almost
so in operations with a large conjunctival flap, to control
haemorrhage. It is of great value also in nervous, excitable
patients. The docility and quietude of these patients
during operation, thus rendered certainly painless, are in
striking contrast with their uncertainty and unreasonable-
ness under cocain alone. It is thus calculated to reduce
the number of vitreous losses from spasmodic closure of
the lids, and is indicated where vitreous loss is especially
to be feared, as in high myopia. The more complete
anaesthesia may be useful also in operating upon children
by linear extraction. And for eyes still congested from a
glaucomatous attack (Chapter VI), and especially in
excising prolapsed iris, the help of adrenalin is needed,
since, as is well known, cocain alone acts imperfectly in
these conditions. In some of these latter cases a third
instillation of adrenalin solution was made, and the
intervals between the cocain instillations prolonged, so
that a total period of possibly half an hour was thus
occupied. Even thus the pull upon previously congested
iris may be painful.
* To avoid frequent opening of the original bottle of solution, about
enough for the day's supply was decanted into a small sterilized
bottle for immediate use.
Description of the Operation 55
In simple extraction there are especial advantages
derivable from the combination of adrenalin with cocain,
which tend to reduce greatly the liability to prolapse of
iris (see Chapter IV).
With this combination a faint corneal milkiness is occasion-
ally noticeable at the time of operation, followed next day by a
rough surface from exfoliation of epithelium. This, in spite of
watchfulness during the instillation and frequent moistening
of the cornea during operation. When used freely upon pre-
viously congested eyes, whether for cataract extraction or
excision of prolapse, there is a possibility of a more unpleasant
after-effect. In a case of acute glaucoma of both eyes, in which
we instilled adrenalin solution three times, alternating with
the cocain drops before performing iridectomy, we found next
day both pupils and irises covered with a layer of lymph. This
took some days to become absorbed, and left some fine posterior
synechiae. We attributed it to the reaction following the
adrenalin-constriction of blood-vessels already weakened by the
acute glaucoma.
The mouth-screen or respirator shown in Fig. 39 is simply a
'layer of flannel stretched over a wire frame, and fitted with
elastic loops to hang over the ears. It is sterilized by pro-
longed soaking in sublimate solution. Gauze veils have been
largely used, covering mouth and beard, and in some cases the
nose also.
INITIAL STEPS.
The ten-minutes cocain period being ended, the patient
must be lying on a suitable table or bed. The pillow is
protected by a waterproof sheet covered with a towel,
and another towel (preferably sterilized) covers the
patient's head and forehead, to protect the surgeon's
clothing and to serve as a clean support for his hands.
In addition to the instrument tray, there must be at
hand a bowl of i in 3,000 perchloride lotion, containing
bits of sterilized lint or absorbent wool, also of gauze or
muslin.
fv^i^
56 ^/Cataract Extraction
i fr
%/ Surgeon takes up his position at the head of the
Patient, the assistant jit the same side as the eye to be
operated upon, and an attendant with the irrigator
opposite to him.
Expression of Meibomian Secretion. The lid
borders are squeezed together, with their conjunctival
surfaces in contact, between the surgeon's left forefinger
placed horizontally on the uvgfer lid and his right thumb-
nail on the lower lid (Fig. 42). Portions of the lids are
FIG. 42. EXPRESSION OF MEIBOMIAN SECRETION.
thus treated successively and repeatedly until no more
fatty matter can be expressed from the mouths of the
Meibomian glands. As it appears on the lid margins, the
secretion is wiped away by the assistant with bits of lint
from the bowl of sublimate lotion. At the same time the
opportunity may be taken to swab the edges of the
lids, as a final cleansing.
I Unless the glands are well emptied, one may find that
'during the operation the irrigating fluid used for moisten-
'ing the eye and for washing out the chamber is very apt
Description of the Operation 57
to cover the globe with a floating Iridescent scum, or with
a succession of small fatty particles, which cannot be com-
pletely washed away unless the speculum be removed and
the squeezing of the lids be repeated. The fatty matter is
seen to ooze from the mouths of the glands close to the
arms of the speculum, where the latter cross the lid
borders.
The quantity of matter which can be expressed from
some of the glands is remarkable, especially in the flaccid
lids of some old people ; and it varies much in consistence
and colour, occasionally looking like pus. There can be
little doubt that, in some cases at least, it is highly
desirable to prevent this material from entering the con-
' junctival sac during, or even after, operation. I smeared
secretion from ten unselected lids upon Loffler's serum,
but only obtained cultures in three instances once white
staphylococci alone, once xerosis bacilli alone, and once
the two organisms together.
Often so much pressure is required that it becomes a
little painful. But patients are not allowed to demonstrate
by groaning or drawing in their breath or moving their
heads. Otherwise there is great risk of their presuming
upon the licence allowed them, giving trouble later by
attempting to close their lids, with dire consequences.
-JlThis Meibomian expression, and also the lid manipula-
/ Jjtions now to be described, are useful as a test of the
behaviour to be expected of the patient during the
operation. A warning of the need for special care is
frequently thus obtained. /
If perchloride has been used as directed, the lids are /
now everted and moved freely\upon each other laterally,
while a stream of physiological^sartt solution is directed
upon them from the flask by the attendant. We expect
to find in fairly normal conjunctive, in response to the
5 8 Cataract Extraction
irritative and coagulative action of the sublimate used for
douching, an accumulation of mucus in the fornices, with
perhaps a trace of shreddy membrane lying over the tarsi.
This is washed away, any adherent threads being detached
with a bit of gauze from the bowl of lotion standing near.
The curette may be used to remove particles of mucus
lying in the hollows about the plica. Already, also, we
may generally detect some slight swelling of the lids
perhaps only a barely perceptible fullness as compared
with the lids of the fellow eye. In spite of this sign of
reaction, it is well to use a little more sublimate now
from the bowl of lotion, squeezed out of a pledget of lint
at least once. The lids are then released, and the remains
of the lotion washed away with normal saline after the
insertion of the speculum.
When too much of the antiseptic has already been
applied, there may be loose pseudo-membranous exudation
covering the greater part of the upper tarsus. The bulbar
conjunctiva towards the fornices may be a little swollen,
and the swelling of the lids will be more noticeable, with
slight injection of the lid borders. Though by the end of
the operation these signs will have become slightly more
marked, but little further increase need be anticipated
later.*
It is much more common to find the reaction insuffi-
cient ; there may be scarcely any mucus secreted at all.
Rather more lotion must then be used, squeezed out of
the pledget of lint perhaps three or four times. In con-
junctivse diffusely scarred or thickened, roughened, and
indurated, the formation of mucus is always very scanty
or entirely wanting. Here the supplementary perchloride
* Throughout our experience the conjunctival lesions known to
have been produced by the perchloride patchy pseudo-membranous
conjunctivitis from destruction of epithelium could be counted on
the fingers of one hand.
Description of the Operation 59
treatment is even a little more free, being continued in
the case of the chronically thickened palpebral membranes
till a faint superficial paleness is seen, evidently due to
change in the superficial epithelium. In the diffusely
scarred conjunctive this sign is not commonly obtained.
(It will be remembered that a few of the worst conjunctive
we had to deal with in Bombay had already had two
applications of the perchloride, the first being at the
early morning inspection. They were thus treated three
times in all. They never reacted excessively, and, on
the other hand, we had reason to believe the treatment
efficacious, for we never had any infective after-troubles in
these cases.) In any case, this supplementary douching
is much shorter than that carried out before the cocain
instillation.
Should perchloride irrigation not have been practised,
the surgeon having decided in favour of simple mechanical
cleansing, this is now carried out. This is preferably by
irrigation with warm sterilized normal saline solution,
combined with careful swabbing, more particularly of the
palpebral conjunctiva and of the fornices, and of the
recesses about the plica. For the retrotarsal folds a
number of small swabs are required, mounted on glass
rods or held in forceps. Some surgeons use simply boiled
water, others boric acid lotion, or some weak antiseptic
solution, such as mercuric cyanide, i in 5,000, or
weaker.
The irrigator attendant is required for the one instrument
throughout the operation. It is his duty, apart from the execu-
tion of particular orders, to prevent drying of the cornea. He
should drop a little fluid upon the eye in most of the intervals
between the steps of the operation ; he should not use an
unnecessarily large quantity, flooding the conjunctival sac.
He must avoid allowing the sterilized nozzle of the tube to
touch the surgeon's fingers at any time. The nozzle there-
60 Cataract Extraction
fore must, as a rule, be kept at a distance of 2 or 3 inches from
the eye. He must be careful also to avoid accidentally spray-
ing the patient's face with the solution. In one of our cases a
considerable loss of vitreous was caused by reflex closure of
the lids excited in this way.
The speculum is then inserted between the lids.
In applying the speculum it is held with its arms pressed
together in the right hand for the right eye, and in the left
hand for the left eye. The upper lid is drawn forward by
seizing the eyelashes between the thumb and forefinger of the
other hand, and the upper bar (or plate) of the speculum
slipped beneath it. This lid being then released, the lower lid
is drawn down, and the other arm placed in position. The
spring of the instrument is commonly sufficient to separate the
lids to their utmost. Very occasionally the arms may need to be
pressed further apart by the fingers, or, in very prominent
eyes, a too wide separation may be reduced by finger pressure
before the instrument is locked.
If at any time after the making of the incision the instrument
has been removed, in its re-insertion the upper arm is again
placed in position first ; but during its insertion the lower lid is
drawn away from the eye by the finger of the assistant, lest by
contracting on the globe it should force the wound open.
In thin patients the weight of the speculum is apt to draw
the lower lid back so much that the end of the arm of the
speculum (Clark's model), lying in front of the lid border,
catches behind the orbital margin. In any case where the
arm (or end-plate) of the speculum is seen pressing upon the
eye it should be elevated, both to take the weight of the instru-
ment off the globe and to make room for the fixation forceps.
This is done by a forward push at the temporal end of the
instrument with the little finger or side of the hand, after taking
up the knife in readiness to make the section.
Except in extraction by downward section, it is convenient
to retain the speculum as long as possible 2.0., till the final
cleansing (curetting) of the conjunctiva. But since it gives no
control over the action of the peripheral fibres of the orbicularis
muscle, and since its . presence increases the tendency to
expulsion of the contents of the globe on contraction of the
Description of the Operation 61
muscle, its withdrawal may be found necessary at any stage
after the completion of the incision. Some surgeons always
remove it then, others at various later periods after any one of
the steps of the operation.
The outer lashes of the upper lid are cut short by
curved scissors, beyond the point where the arm of the
speculum crosses the lid border. This is only omitted if
the eyes be so prominent that the lashes lie out of the
line of the knife when in position for the corneal section.
It is obviously important that no portion of an instrument
shall touch the lashes before entering the wound, but in
this connexion removal of any but the outer lashes of the
upper lid is uncalled for.
The eye is then at once moistened with a stream of
fluid from the irrigator, otherwise it is extraordinary how
soon the corneal surface becomes dry. The excess of fluid
is run out of the conjunctival sac by momentarily tilting
the head to the side ; or, if necessary, it may be mopped
up at the outer canthus by the assistant with a pencil of
moist gauze or lint taken from the bowl of lotion.
The patient must look downwards to expose fully the
upper corneal circumference in the palpebral aperture.
Very prominent eyes scarcely need be turned down at all.
Sunken eyes need to be rolled down well ; the patient
should look towards one of his hands held up by the
assistant. Sufficient rotation of the globe may be im-
possible owing to cicatricial contraction of the conjunc-
tiva, the retracted fornices being fixed by the speculum.
In such cases Czermak's lower subconjunctival section
(Chapter IV) should replace the ordinary one.
It is well that instructions to the patient regarding the
position of his eyes should be given by the assistant, who
stands near the position towards which the eyes have to be
turned. Nervous patients, especially those blind in both eyes,
62 Cataract Extraction
feel a natural inclination to look towards the person who issues
the commands. They are often able to respond better to the
assistant who has trained them than to anyone else. No
bystanders are to be permitted to add instructions or remarks,
and the patient must not be allowed to answer by word of
mouth to orders given, otherwise he is apt to substitute this in
some degree for compliance with the directions given. The
orders given should be as few as possible. And it is important
to avoid making the patient look downwards earlier than
necessary, lest the patient's stock of self-command should
become exhausted, and early relaxation of effort should lead to
an upward roll of the eyes.
THE COMBINED OPERATION.
The above preliminary measures apply to all the
modifications of the operation for cataract extraction by
upper section. A full description will now be given of
each step of the ' combined ' flap extraction i.e., with iri-
dectomy. This may be regarded as the standard method
of extraction, since in many cases it is the only operation
at all suitable, and is performed almost exclusively by
many surgeons, and is especially the operation for begin-
ners. After the incision has been made, a piece of iris is
removed and the lens capsule opened. The lens is then
expelled by pressure, its capsule being left behind. Later,
in Chapter IV, each step of the operation will be more fully
discussed and alternative procedures described, more parti-
cularly ' simple ' extraction, without iridectomy, and intra-
capsular extraction. Finally, in Chapter VI the ' linear '
extraction of soft cataracts will be described, together with
measures adapted for some complicated cataracts.
THE SECTION, as commonly made in the ' combined'
operation, raises a flap comprising the upper two-fifths, or
rather less, of the cornea, with or without a small con-
junctival addition at its summit. The cutting of a con-
Description of the Operation 63
junctival flap necessitates a slight encroachment into
superficial scleral tissue ; otherwise the usual incision lies
entirely in corneal tissue, and at the surface of the globe
corresponds exactly with the sclero-corneal boundary.
FIG. 43. SCLERO-CORNEAL SECTION, WITH CONJUNCTIVAL FLAP.
In Bombay the generally unsatisfactory or doubtful state
of the conjunctiva, indicating the need for an effective
covering to the wound, led to the routine inclusion of a
somewhat unusually extensive conjunctival flap, about
FIG. 44. DIAGRAMMATIC REPRESENTATION OF PLANE OF
INCISION.
(a) At the visible corneal margin, and (b) behind this, cutting into
sclera and conjunctiva (modified from Czermak, ' Die Augen. Op.').
i'5 millimetres long at the summit of the arch, and
tapering away at the sides of the wound. This involved
the addition of a complete narrow rim of superficial
sclerotic to the boundary of the corneal flap (Figs. 43 and
64 Cataract Extraction
44). Feeling that this section might be more generally
adopted with advantage, the following description is based
primarily upon it. It is to be understood that the employ-
ment of a fairly complete conjunctival flap necessitates
some provision for preventing or dealing with haemorrhage
into the anterior chamber either the preliminary instilla-
tion of adrenalin solution, or irrigation of the chamber, or
both. In Bombay, for the greater part of my time there,
we relied entirely upon irrigation, but quite lately we
made use of adrenalin more and more.
In denning the course of the incision, it is well to bear in
mind that there is considerable variation in the boundary
between cornea and sclera above. In some eyes the degree of
overlapping of the deeper corneal margin by superficial scleral
FIG. 45. OVERLAPPING SCLERA ABOVE.
tissue is so far as one can tell clinically precisely the same
above as at the sides and below. In other eyes a thin layer of
superficial sclerotic, with its covering of loose conjunctiva,
comes forward over the cornea to a distinctly greater distance
above than elsewhere. In the former case when cutting
upwards in a plane parallel to the iris, an incision begun at the
margin of clear cornea remains so; whereas in other eyes
the knife, in making such a section, cuts upwards through some
superficial scleral fibres and through loose conjunctiva.
The overlying strip of scleral and conjunctival tissue above
is too thin to present clinically the opaque, white appearance
of the neighbouring sclerotic. It is seen as a narrow, greyish-
white crescent, with a fairly well defined upper boundary (see
Fig. 45). In a few of the eyes met with in India bearing
traces of old trachoma, this uppermost deep corneal boundary
is the only recognizable division remaining between cornea
and sclerotic. The limbus merges into the marginal opacity
left by old pannus. This, however, matters little with regard
Description of the Operation 65
to our cataract incision, for one regulates the direction of the
knife edge about the summit of the arch entirely by the con-
junctival flap, according to whether it appears to need to
be lengthened or shortened in individual cases.
Stellwag found the vertical measurement of the front surface
of the cornea to vary from 9-5 millimetres to 12-5 millimetres,
whereas the horizontal measurement varied only from 11-9
millimetres to 12-6 millimetres, and the boundary of the posterior
surface was practically circular.
Most surgeons of experience, having taken up the
position already mentioned, behind the patient's head,
cut with the right hand upon the right eye and with the
left hand upon the left eye, the other hand being occupied
in fixing the globe. This plan of operation is assumed
throughout the following lines, but it is not that best
suited to the average right-handed beginner. The latter
should use his right hand for cutting. For the incision
in the left eye he must stand by the patient's left
side.*
The Graefe knife, with blade 2 millimetres broad, is
seized about the middle of the handle between the thumb
and the index and middle fingers, much as one lifts a tea-
spoon. The cutting edge is directed towards one, and
the back of the handle rests in the groove between the
nail and tip of the middle finger. The other hand, hold-
ing the fixation forceps, obtains firm support across the
patient's nose. The conjunctiva is gripped by the forceps
below the middle of the cornea. A large hold is taken to
lessen the chance of tearing ; and it is as close to the
cornea as possible, because at a little distance away from
the cornea the inelastic senile mucous membrane may be
too loose and mobile to serve in restraining the move-
* This position is for the making of the incision only, and is
changed immediately afterwards. The surgeon displaces the assis-
tant, whose services are for the moment not required.
5
66
Cataract Extraction
ments of the eye. The degree of control secured should
be tested by a lateral pull with the forceps ; it is never
absolute. The object of fixation is merely to retain the
globe in the position which it has taken up. The eye is
FIG. 46. THE PUNCTURE.
Note the wrist resting against the patient's head ; also the mode of
holding the knife.
not to be pulled into position by the forceps, though
during the cutting the grip of the forceps may have to
resist a fairly strong upward pull of the eye.
The cutting hand is steadied by resting the tip of the
Description of the Operation 67
little finger against the patient's temple, with the fingers
more or less in contact with one another. I can recom-
mend to nearly all beginners, and to many experienced
operators, additional support to control tremor of the
hand. Free movement at the wrist is not required. The
wrist is therefore carried inwards to rest firmly against the
patient's head. The hand is thereby bent back at the
wrist joint, and the point of the knife thrown somewhat
downwards. The point, thus directed inwards and a little
downwards* (Fig. 46), is inserted through conjunctiva and
sclera | to i millimetre from the corneal margin, rather
more than I millimetre above the outer end of the hori-
zontal corneal meridian. In eyes with shallow anterior
chamber the point must be directed a little forward to
escape cutting the forward-arching iris, and therefore
the puncture is begun a little farther from the cornea (fully
i millimetre). But in ordinary cases the blade lies exactly
in the transverse plane. The edge of the knife is directed
straight upwards, in a line exactly parallel with the corneal
margin, which serves to guide the knife. The sunken eyes
of some emaciated patients, and eyes with palpebral
aperture contracted by old trachoma, may have to be
rotated somewhat inwards by the fixation forceps, to
enable the blade to be placed correctly with regard to the
eye, and at the same time to lie quite clear of the outer
end of the upper lid border. The penetration of the
tissues is made with deliberation, and the point of the
knife swung up to the horizontal direction as soon as it is
well within the anterior chamber. That the blade lies in
* Formerly, when stress was laid upon the advantage of a small
linear incision in lessening the liability to suppuration of the wound,
it was held to be correct to point the knife well downwards in making
the puncture, in order that the wound should be as large as possible
at the deep surface of the cornea. With the comparatively large
section made nowadays this point is of less importance.
52
68 Cataract Extraction
the anterior chamber is shown by its bright appearance
and by its mobility.
If the anterior chamber happens to be very shallow, the
point of the knife in passing slowly inwards has to be
guided a little forward over the bulging iris ; and, finally,
in attaining the transverse plane, which it must do to
reach the site of counter-puncture, the blade may have to
press against the iris, indenting it. In such a case the
swing of the blade may tend to cause a slight leakage of
aqueous through the puncture.
Eyes which have been pulled inwards by the forceps, as
above, are allowed to roll outwards again at least, partly.
This movement of the globe, while the knife is held
stationary, takes the place of a portion of the movement
of the blade ordinarily required as it crosses the chamber.
The point engages in the posterior surface of the cornea
at the nasal side about millimetre before its disappear-
ance behind the scleral boundary. This brings the knife
to the surface barely within the sclerotic, and not at the
greater distance from the cornea* which one might antici-
pate. The site of this counter-puncture must be selected
carefully, and corrected, if necessary, more than once by
disengaging the point ; but there must be no trace of
hesitation on the completion of the counter-puncture, lest
the aqueous begin to flow away. The knife must at once
travel upwards with a steady, even, inward thrust, cutting
equally on both sides of the cornea, to bring the blade well
up in front of the iris, before the chamber can become
emptied of fluid. Usually almost the whole of the blade
is utilized in this first stroke ; but in operating upon eyes
either insufficiently turned downwards or purposely still
* The encroachment upon scleral tissue needs to be rather less at
the inner end than at the outer end of the section, owing to the fact
that the knife thrusting inwards tends to slip under the conjunctiva at
the inner side of the globe.
Description of the Operation 69
rotated a little inwards (as above), the movement may be
ended earlier by the arrival of the knife-point at the car-
uncle or neighbouring upper lid border. In other cases
the point of the knife may possibly reach the side of the
nose. A prick anywhere is likely to make the patient
wince, and attempt to close his eyes, and even possibly
move his head.
Other reasons for somewhat early arrest of the inward
stroke may be met with occasionally : (i) a tendency for
the outer part of the section to become misplaced a little
forward, so as to lie entirely within the cornea ; (2) the
FIG. 47. SECTION IN THE PLANE OF THE KNIFE, SHOWING THE
END OF THE INWARD THRUST.
occurrence of prolapse of the iris through the inner portion
of the wound, or a tendency thereto.
When not thus prematurely ended, the one thrust should
suffice to bring the edge of the knife to the summit of the
anterior chamber.* Yet still a good deal of tissue
remains to be cut (see Fig. 47), nearly always more in our
operations than can be cut easily in a single reverse
movement of the knife.
More or less aqueous leaks away as the knife passes
upwards, yet still a moderate quantity of fluid usually
remains in the chamber after the completion of the inward
thrust, when the latter is correctly made. Early loss of
aqueous, in so far as it depends upon faulty incision, is due
less to slowness in cutting than to alteration in the plane
of the blade. Any slight twist of the blade, required as
* It must be confessed that in our Bombay work, with knives not as
sharp as they might have been, in the majority of cases less than this
was accomplished by the one stroke of the knife.
7o Cataract Extraction
soon as one notices the slightest tendency to departure from
the planned line of incision, of necessity prises the wound
open a little and allows some fluid to escape. Other
occasional sources of premature leakage, in addition to
the sloping sclero-corneal puncture necessitated by a
shallow chamber, already alluded to, are : (i) uneven
faltering tension on the cutting edge, due possibly to
movement or attempted movement of the eye, or to spasm
of the lids, or to tearing of the conjunctiva by the forceps ;
and (2) partial withdrawal of the knife for any particular
reason (see below). A rather quick stroke is advisable in
eyes with shallow chamber, and whenever the aqueous is
seen to be flowing.
In the brief rest which follows the first long thrust the
opportunity is taken to note (i) the condition, and (2) the
direction of the knife. Possibly some portion of the blade
may have already touched the stumps of the cut eyelashes,
or the upper lid border at either end. Or some rotation
of the eyeball by the forceps, carrying the knife with it,
may be advisable to remove the knife from risk of such
contact during the completion of the section. This soiling
of the blade* is frequent in operating on sunken eyes im-
perfectly rotated downwards, and it may be quite un-
avoidable in cases where the palpebral aperture is much
* Earlier fouling of the knife may be caused by sudden spasm of
the orbicularis, bringing the outer part of the upper lid border into
contact with the blade, in spite of the speculum. The contact may
be only with the under surface of the knife, where one cannot see the
soiled patch. If ojie has reason to suspect that this has taken place,
it is better to withdraw the instrument than to risk infection of the
wound. I remember doing this on two occasions only. Once, when
the puncture only had been made, the cleansed blade was reinserted
satisfactorily and the operation completed. On the other occasion
the counter-puncture had also been made, and the patient was nervous
and unreliable, so the eye was bandaged up and the operation post-
poned.
Description of the Operation 71
contracted* from old trachoma. And yet one dare not
allow any soiled portion of the instrument to enter the
wound. Where there is no difficulty of this kind, the
section is completed by leisurely to-and-fro sweeps of the
knife. But soiling of the blade at one or both ends may
leave very little of the cutting edge available, and thus
may shorten the movements very much indeed. Then a
most helpful practice is to combine a rocking t motion with
the sawing action of the knife. The section can be finished
by very short thrusts with the knife pointing upwards as
well as inwards, and withdrawals upwards and outwards
(the knife pointing downward and in). Unless the surgeon
be keenly alert with respect to this matter, infection may
readily be carried from the lid margin into the wound,
unsuspected.
There should be no hurry in completing the incision.
During the sawing movements attention is directed to the
outlining of the conjunctival flap at either side (see below),
and this determines any slight forward or backward
twist of the knife which may be necessary. The edge
of the knife frequently has to be turned somewhat forward
to follow the corneal margin above, as the wound tends to
open. The blade at once slips upwards under the loose
conjunctiva as soon as it gets through the firm sclero-
* Not only is the aperture small in these cases, but full rotation of
the globe downwards frequently impossible, owing to anchoring of the
eyeball by retraction of the fornices. In five marked examples of this
condition I had to divide the outer canthus with scissors (at the time
of the cataract operation) to obtain room for the play of the knife.
Nowadays I should always operate upon such eyes by Czermak's
subconjunctival section, with scissors.
f This rocking action of the knife tends to be added on to the to-
and-fro movements without intention if the instrument be quite loosely
held. I have frequently combined it when not really necessary,
because with the anterior chamber empty it appears to complete the
section with less rubbing of the iris than by simple transverse move-
ments.
72 Cataract Extraction
corneal tissue (see Fig. 48). If allowed to come through
with a jerk, the patient may be startled and try to close
the lids. To cut through the conjunctiva above, the knife
FIG. 48. COMPLETION OF THE DEEP INCISION.
The knife edge must now be turned forward. The conjunctival flap
will be larger than usual. (This is the same patient as shown in
Fig. 46. Note the changed position of the hand. The palm is now
partly seen.)
edge is turned forward at the selected distance above the
cornea.
Only with a keen knife can due gentleness be assured
in cutting. Fig. 49 shows the wrinkling and slight
Description of the Operation
73
distortion of the cornea, with displacement and elongation
of the pupil, produced in some eyes by the slightest drag
on the knife. From this it will readily be seen how the
first reversal of the movement of the blade, altering the
direction of the folds of the cornea, is commonly accom-
FIG. 49.-
-SAWING MOVEMENT OF THE KNIFE.
PULL.
OUTWARD
panied by a small gush of fluid from the anterior chamber.
This occurs even though the pressure upon the edge of
the knife be evenly maintained throughout, as it should
be. The photograph also helps one to realize how the
pull of a blunt knife, distorting all the neighbouring
structures, may stretch and even rupture the underlying
74 Cataract Extraction
zonule.* This risk of tearing the zonule still exists during
the cutting of a large conjunctival flap. A broad strip of
loose elastic membrane, such as is seen in Fig. 48, is by
no means easily divided unless the knife be very sharp. t
Several to-and-fro movements of the blade may be needed,
during which the deep wound is pulled open. Blood from
the episcleral vessels thus finds its way into the anterior
chamber, t This occurred especially often in our Bombay
work, because until lately adrenalin was never used, and
an extensive flap (sometimes completely covering the
* An accident possibly signalized at once by partial dislocation of
the lens and perhaps escape of vitreous, but possibly on the other
hand passing unrecognized at the time, and giving rise to loss of
vitreous later when pressure is put upon the eye to expel the lens.
Twice in children and once in a woman of twenty years, among our
operations, the zonule gave way, and escape of fluid vitreous occurred
on completion of the section. (Only two of these operations, however,
were flap extractions. The third was a linear extraction, the incision
being made with a triangular keratome.) Particular care and gentleness
are demanded to avoid causing loss of vitreous in making the incision
for tremulous or dislocated lenses, also in congested glaucomatous
eyes, both because of the vitreous tension, and because of the pain
and consequent spasm of the lids likely to be produced by the knife
rubbing upon the iris. Danger is also experienced in non-glauco-
matous eyes with vitreous tension.
t One dare not pull much upon the conjunctiva. Repeated light
sawing movements are effective, though their repetition may prove a
little tedious. In one of our operations the drag of a rather blunt
knife upon the conjunctiva appeared to be partly responsible for loss
of sight in the eye. It was a case of black cataract in a highly myopic
eye. While a large conjunctival flap was being cut the lens became a
little displaced upwards, so that its equator presented in the wound.
Though this was probably due to fundus haemorrhage, it appeared
quite possible that the pull on the conjunctiva was partly responsible
for the haemorrhage. The lens was delivered by a touch with the
cystitome, and was immediately followed by vitreous. Next day
the wound was found distended and the eyeball filled with blood-
clot.
J The entry of the blood is due to the forward pull of the knife.
This is shown by the fact that the chamber may be momentarily
emptied by turning the knife edge upwards, while the chamber refills
as soon as the cutting of the flap is resumed.
Description of the Operation 75
wound) was frequently cut in a conjunctiva congested by
exceptionally free perchloride douching, both of these
precautions the conjunctival covering and the free per-
chloride treatment being combined to guard against the
one danger, infection from an unhealthy conjunctiva. By
the time the flap has been cut, the knife exchanged for the
irrigator nozzle, and the latter introduced into the wound,
the blood in the chamber may have partly clotted and
become adherent at one or more points to the iris firmly
enough to defy attempts at complete removal by irrigation.
(The clot is usually, however, partly expelled later with
the lens.) Further haemorrhage into the chamber may be
prevented by turning the conjunctival flap down over the
cornea, except in cases where the flap forms a complete
covering. The lower portions of a complete flap, cover-
ing the sides of the wound, serve to direct the blood
inwards.
During the earlier part of the cutting the surgeon's
mind is fully occupied with the incision. As soon as he
has time to notice the position of his hand, he will find
that it has changed slightly from the position above
described and shown in Fig. 45. The wrist has straightened
a little and rotated, turning the palm of the hand more to
the front (Figs. 48 and 49), and bringing its inner border
close to the patient's head. The inner border of the
hand or of the little finger, if the patient's head be
small and round may now be pressed firmly against the
head for support. This does not at all restrict the neces-
sary movements of the knife, which are amply provided
for by movements of the fingers, with slight pronation
and supination at the wrist.
The above general description now needs amplifying by
the consideration of slight voluntary and involuntary
76 Cataract Extraction
variations of technique, and by the recognition of occa-
sional difficulties.
The right-handed beginner should be in no hurry to cut
with the left hand in operating on the left eye, and unless
he is likely to operate much will be consulting his patients'
interests by not acquiring the habit. Many experienced
operators are content to cut always with the right hand.
Most men will find that a very considerable expenditure
of time in training and exercises will be necessary, apart
from actually operating, to enable them to cut as ac-
curately and easily with the left hand as the right. If
one is prepared to give up the necessary time to the
training it is doubtless well to use the left hand, for one
has more natural and easy control over one's fingers in
cutting towards one than away from one. But for myself,
I must confess to a slight remaining clumsiness in using
the left hand, revealed in results mainly by a larger pro-
portion of irises cut by the knife in the left eye than in
the right. In using the right hand upon the left eye the
wrist is unsupported.
Fixation. The pull of the forceps resisting the inward
push of the knife sometimes raises a fold of conjunctiva
covering the nasal margin of the cornea. This interferes
with the accurate locating of the counter-puncture, and it
also directs the knife-point far under the loose conjunctiva.
The grip of the forceps may be momentarily released
to enable one to see the point of the knife as it enters the
posterior surface of the cornea, or a fresh hold may be
taken farther outwards below the cornea.
Where the fornices are moderately retracted by scarring,
the ocular conjunctiva may be rendered so tense by the
speculum as to be difficult to seize by the forceps below
the cornea. A much stretched conjunctiva is very liable
to be torn by the forceps while the section is being made.
Description of the Operation 77
Other causes of tearing are (i) straining of the globe
upwards ; (2) the use of forceps with too few or too long
teeth ; and (3) the brittle texture of some senile mucous
membranes. One must finish the operation as best one
can. Usually a fairly effective hold can be got elsewhere.
But if the tear be a large one and take place early, and
the eye perhaps unsteady, it may be very difficult to
complete the incision without soiling the knife on the lid
margin. The patient's co-operation in turning the globe
downwards is essential for the correct use of the knife.
However, the worst that has happened in our practice
from this trouble has been the completion of the section
by turning the knife edge forwards, and thus sacrificing
the conjunctival flap. We have never used other instru-
ments to replace the forceps, such as Pamard's spear, or
other forms of double hooks, nor have we attempted to
seize the internal rectus tendon, nor have we practised
fixation with a broad conjunctival suture. Speaking
generally, frequent tearing of the membrane by the forceps
may be taken as an- indication of insufficient training of
the patients.
During the progress of the section, the beginner, with
his attention wholly engrossed in the incision, may find
that he is unconsciously pressing upon the globe with the
forceps, forcing out aqueous and perhaps iris* through the
wound. To avoid the liability to this mistake, it is suffi-
cient to obtain a firm support for the hand, and to make
sure that a slight forward pull upon the eyeball is being
maintained with the forceps before beginning the in-
cision.
The size of the section may frequently be reduced in
combined extraction. A corneal flap 3 millimetres high,
* Possibly also vitreous on the completion of the section if the
pressure be not relieved.
7 8 Cataract Extraction
or slightly more, including about one-third of the corneal
circumference, suffices for the easy exit of lenses with
fully ripe soft cortex. In dealing with a Morgagnian
cataract, supposing for any reason, such as the presence
of capsular opacity, combined extraction is decided
upon beforehand,* an even smaller incision is ample,
and perhaps preferable, for the passage of the smaller
nucleus. The full-sized incision is needed for lenses with
firm cortex and dark (and probably, therefore, large)
nuclei, and for all unripe cataracts.
No increase in size of the flap beyond two-fifths of the
corneal circumference can be of any service in combined
extraction. The base line of this section has practically
attained the maximum, and the height of the flap is sufficient
to permit of wide opening of the wound. And there is not the
pupillary reason for a low base line, which applies in the simple
operation (Chapter TV). One is inclined in combined extrac-
tion often to make the opening slightly larger than is really
required, perhaps a little from the force of habit, if one
operates frequently by 'simple' extraction, and still more from
the general feeling that the evils of too small an incision are
decidedly greater than those of an unnecessarily large one.
It is held that an incision including one-third of the corneal
circumference is sufficient for the combined operation in
patients under forty-five years, and that any increase beyond
the actual needs of the case is to be avoided, because it pre-
disposes to subsequent incarceration or prolapse of iris in the
angles of the wound. For the iridectomy protects only a limited
central portion of the incision from iris entanglement. And
the sphincter of the pupil, considerably disabled by the
iridectomy, is less able to retain the iris within a large wound
than in simple extraction. It might be added that accidental
reopening of the wound is more likely with a large section, but
such reopening applies chiefly to the central part viz., that
guarded by the coloboma.
The drawbacks of too small a section are more obvious.
And the enlargement of the incision with blunt-pointed
* Simple extraction is generally preferable for these lenses.
Description of the Operation 79
' secondary ' knife, or preferably with scissors (e.g., by Stevens'
tenotomy scissors), though a little troublesome, is entirely
preferable to squeezing a bulky hard lens through too small an
opening, bruising the iris and the lips of the wound, stripping
off cortex, and running the risk of rupturing the zonule by the
amount of pressure necessary.
A somewhat smaller and less peripheral incision has been
recommended in highly myopic eyes, and a proportionately
larger section in eyes with small corneae. But minute care in
proportioning the section is uncalled for.
Intentional variation in the size and shape of the con-
junctival flap is mostly in the direction of increase beyond
the dimensions and design given above. We have to
operate upon many eyes in which the provision of a
conjunctival covering complete from end to end of the
incision is specially indicated, to guard against infection.
When the needs in this respect appear particularly
definite, Czermak's or other sub-conjunctival operation
should be done. But there are other eyes concerning
which one may feel just a little doubtful. The conjunctiva
may be secreting a little mucus, or there may be a little
albumen in the urine, with a trace of redema about the
ankles, but not marked anaemia ; or there may be some
liability to prolapse of vitreous, shown by a tremulous or
subluxated lens or ' vitreous tension,' or by nervousness
and unreliability of the patient. The need for a protec-
tive covering to the wound is naturally greater where any
two of the above indications are combined.
In making a complete conjunctival flap, though the site of
puncture through scleral and corneal tissue remains un-
changed, the conjunctiva is penetrated a little farther outwards.
And in making the counter-puncture, the posterior surface of
the cornea is not entered till the point of the knife is about to
disappear behind the scleral rim. A very small alteration of
the point of emergence of the blade through the sclerotic may
be counted upon to result in a considerably greater alteration
8o Cataract Extraction
in the site of perforation of the conjunctiva, owing to the
tendency of the knife to slide under the conjunctiva here.
Apart from the haemorrhage at the time of operation, the
drawback to a large conjunctival flap is the separation of the
underlying wound,* which takes place afterwards. At one
time I attempted to prevent this by notching the apex of the
flap, excising a small bit with scissors. In the combined
operation iris and conjunctiva can be excised together. But
the result was not altogether satisfactory, apart from the fact
that protection of the wound is most needed at its summit.
The notch frequently became filled up with lymph and blood-
clot sufficiently to retain some aqueous, and so to permit of
slight separation of the deep incision. And in simple extraction
there was a slight tendency for iris to protrude at the site of
the notch. The better way to prevent any noticeable separa-
tion of the sclero-corneal surfaces is to cut the flap very short
not more than a millimetre over a considerable portion of
its extent (Fig. 50).
FIG. 50. A COMPLETE CONJUNCTIVAL FLAP, SHORTENED TO
PREVENT GAPING OF THE DEEP WOUND.
Involuntary variations in the section are comparatively
small and infrequent, so far as the scleral and corneal
tissues are concerned, but they occur almost constantly in
the outlining of the conjunctival flap. One may ensure
that the latter shall be complete or incomplete, but one
cannot always regulate its length and extent at the sides
of the section with any degree of exactitude. The elastic
mucous membrane, fixed only at the corneal rim, gives
to the slightest pressure. Perhaps the most frequent
departure from the intended conjunctival outline is a
* This separation does not take place after Czermak's or other sub-
conjunctival operation, in which the mucous membrane is kept
normally tense.
Description of the Operation 81
broadening of the flap at the inner side, due to a scarcely
recognizable deepening of the counter-puncture.
Small modifications in the boundary of the conjunctival
appendage are, however, not usually of much importance.
A defect or excess down the sides of the cornea can be
partly compensated for by broadening or narrowing at the
summit of the arch. Should the conjunctival fringe be
quite absent down the sides of the incision, owing to
straying of the knife into purely corneal tissue, it may
be well to add to the area of the small apical flap, which
is all that remains possible, by increasing its length con-
siderably (Fig. 51).
FIG. 51. A SMALL APICAL CONJUNCTIVAL FLAP, CUT LONG.
The making good of any deficiency of the conjunctival flap,
recognized sufficiently early, necessitates turning the edge of
the knife a litte backwards in completing the sclero-corneal
section. To restrict the necessity for this movement of the
knife as much as possible, one may utilize the following small
observation : During the inward stroke of the knife the con-
junctiva tends to be pushed into the temporal portion of the
wound, and tends to be cut closer to the cornea there, while, on
the other hand, the blade slides readily under the conjunctiva
at the nasal side of the cornea, and the tendency is towards
lengthening of the conjunctival fringe there. Exactly the
opposite tendencies with respect to the conjunctiva are notice-
able in withdrawing the knife. One may therefore enlarge the
conjunctival flap a little by rocking the knife, as above
described, so as to cut at the nasal side only during the inward
movements, and to cut at the temporal side only during the
return movements.
Deviations from the correct line of incision in the cornea
and sclerotic are due most often to the incision being begun
6
82 Cataract Extraction
with the plane of the blade at a slightly incorrect angle. It
is very difficult to judge always whether the angle of the
knife is absolutely correct until the whole breadth of the
blade is engaged in the puncture. The error more often
consists in the edge of the knife being turned a little for-
wards than backwards. It may pass unnoticed until the
blade in its course upwards becomes a little displaced
forwards into the cornea.
Another occasional source of slight forward displacement of
the section is the obliquity of the puncture in eyes with very
shallow anterior chamber. One is apt to forget that, since the
oblique plane of the puncture (Fig. 52, a) rapidly merges into
the transverse plane of the section above (Fig. 52, b), this upper
portion comes to be placed a little in front of the superficial
(posterior) end of the puncture line, just as it is a little behind
FIG. 52. DIAGRAM TO SHOW (a) OBLIQUE LINE OF PUNCTURE
IN AN EYE WITH SHALLOW ANTERIOR CHAMBER, AND ITS
RELATION TO (b) THE TRANSVERSE PLANE OF THE SECTION
ABOVE.
the deep (anterior) end of the line. Therefore, unless the
superficial insertion of the knife be a little further back in the
sclerotic than ordinary, according to the directions already
given for these eyes, the knife tends to get in front of the
limbus near the outer end of the wound. Should this have
happened it is well to reverse the movement of the knife early,
as it is easier to deepen the wound at the outer side of the
cornea during the outward movement of the knife.*
A shallow anterior chamber may be responsible in another
manner for a misplaced incision. In the somewhat hurried
* Per contra, during the inward thrust there is often perceptible a
slight tendency to forward displacement of the outer half of the
section. Possibly this slight tendency is absent when fixation of the
globe is made with the forceps applied at the inner side of the cornea.
Description of the Operation 83
cut needed to avoid wounding the iris, one's attention being
divided between the incision and the iris, the former may suffer.
It is especially in eyes with shallow anterior chamber that
beginners, by puncturing too obliquely and too far forwards,
may ' split the cornea ' for a considerable distance. They may
fail to notice the lack of that mobility and bright appearance of
the blade which indicate its entry into the chamber. The
opening into the chamber may thus be quite small, and the
wound need enlarging considerably with scissors.
A cause of an incorrect section mentioned by up-country
surgeons in India is the use of a ' whippy ' knife i.e., an old
worn instrument, which has become too thin and too narrow.
Straining of the eye upwards or spasm of the orbicularis
muscle may also interfere with the exact execution of the
section.
An ill judged deep counter-puncture and a knife held at an
incorrect angle, with its edge directed a trifle backwards, are
the causes of an incision too deeply placed, encroaching too
much into the sclerotic. The evils of a very peripheral section
(see Chapter IV) were much in evidence when von Graefe's
' modified linear ' extraction was in vogue. Trouble from
haemorrhage into the anterior chamber is accounted for both
by a broad conjunctival flap, and by section of larger and more
numerous scleral vessels than usual. Impaction of the iris and
capsule in the wound was doubtless the main cause of the
destructive irido-cyclitis and sympathetic ophthalmia, to which
the Graefe operation was found especially liable.
A small variation in the first thrust of the knife, either
voluntary or involuntary, consists in sweeping up at the
nasal side more freely than at the temporal side, using
the knife like a scythe. The only trouble is a tendency to
protrusion of the iris at the inner side below the knife, the iris
being carried into the wound by the flow of aqueous there.
On the other hand, it may be useful to carry the incision
upwards at the inner side as far as possible, before an early
reversal of the movement of the knife, necessitated by acci-
dental forward misplacement of the temporal part of the
section, already considered.
Other troubles associated with a shallow anterior
chamber have to do with the iris :
62
84 Cataract Extraction
1. The point of the knife, in passing across a shallow
chamber, is apt to catch in the iris on the near side of the
pupil. If only a minute strand of tissue has been taken up,
it may be disregarded, as it will give way to the onward
pressure of the blade. But if the point be more definitely
engaged in the iris, to simply push the blade onward would
often mean tearing a considerable portion of the iris away
at its root, and necessarily, therefore, a very large and mis-
placed iridectomy. The instrument must be partially with-
drawn to release it, and the further proceedings must be
determined by the amount of aqueous lost in the with-
drawal. Some authorities are very much against any
reversal of the movement of the knife at this stage. But
in my experience the needful withdrawal usually entails
only a very small escape of fluid, or possibly none at all.
And it may be accepted that unless the total loss of fluid
is sufficient to bring the iris bulging quite forward above
the edge of the knife, by the time the point of the instru-
ment has reached the site of counter-puncture, the opera-
tion may be completed usually with only very slight injury
to the iris. Should, on the other hand, the leakage of
aqueous at this stage, or before, be deemed too great, there
are two alternatives : adrenalin may be instilled and
Czermak's scissor operation performed, or the operation
must be postponed. In our work any postponement must
be till the irritation from the perchloride douching has
quite passed off.
2. A more common trouble the cutting of the iris with
the knife mostly occurs in eyes with previously shallow
chamber. Indeed, with a very shallow chamber one is
perhaps more likely to cut the iris than not. But the
small accident is also moderately frequent in other eyes,
owing to premature leakage of aqueous bringing the iris
forward in front of the edge of the knife, unless the blade
Description of the Operation 85
be unusually broad. The numerous incidents and con-
ditions which lead to early emptying of the anterior
chamber have been already mentioned. The knife may
merely rub and scrape the iris, perhaps shaving off a thin
layer of it. Or the iris may be ' button holed,' the piece
removed extending through its whole thickness, but not
reaching the pupillary margin. Or, in the worst cases, a
complete coloboma may be made. This complete iri-
dectomy made by the knife * has several disadvantages :
(i) It is always unnecessarily broad. (2) I have found it
frequently not symmetrical, sloping obliquely up and
out. This appears to be due to the fact that the in-
ward moving blade does not engage so early and readily
FIG. 53. OBLIQUE IRIDECTOMY MADE BY THE KNIFE.
in the mobile central portions of iris as it does towards the
periphery, where the membrane is firmly held. A strip of
peripheral tissue (Fig. 53, a) is thus left at the inner side
deprived of its pupillary zone. There is no sphincter
muscle to pull this strip of iris into place, and this portion
is consequently very prone to prolapse subsequently. I
* Bribosia (Transactions of the International Congress held in
London, 1873) and Katzaurow (Cbl. f. p. A., 1884, S. 370) purposely
allowed aqueous to escape in order to simplify the operation by
making the iridectomy with the knife. On the other hand, Bettre-
mieux (Arch, cTOpht., ix [1889], 79) modified the Graefe knife with
the special object of avoiding any section of the iris. He gave it a
projecting under surface to raise the edge from the iris. Kuhnt's and
Critchett's knives were also designed for this purpose. And Czermak
used a very broad Graefe's knife (3 to 3-5 millimetres) to avoid cutting
the iris. Melville Black (Denver) prefers to withdraw the knife rather
than damage the iris with it. After waiting for the aqueous to
reaccumulate, he introduces a special probe-pointed knife to complete
the section.
86 Cataract Extraction
have several times noted this particular form of prolapse.
(3) This mode of cutting the iris, with its accompanying
rub and drag, is generally a little painful, and is therefore
apt to provoke movement of the eye or blepharospasm.
(4) A minor fault is that the pillars of the coloboma are
left scraped and bruised.
Nearly all surgeons, when the iris comes forward above
the knife, proceed as if nothing had happened, and the
results are as just given. The bit of iris excised is
removed with the iris forceps or washed out by the
douche.
Prolapse of the Iris at the time of operation, unasso-
ciated with prolapse of vitreous, occurs almost exclusively
in our experience through the nasal portion of the wound
during the first long inward stroke of the knife. A
tendency to prolapse, shown by elongation of the pupil,
may be overcome by reversal of the movement of the
knife; but since this reversal commonly empties the
chamber of any remaining aqueous, it is not practised
unnecessarily early. Should the iris have actually pro-
truded, it is easily and completely replaced by the back
of the blade of the knife, the point of the latter being well
depressed. The outward movement of the knife is then
made with the blade inclined thus upwards and outwards,
as in the rocking action already described. The main
objection to allowing a prolapse during operation to
become large is that the stretching and nipping of the
sphincter muscle in the wound must predispose slightly
to a recurrence of prolapse after operation.
Any protrusion near the temporal end of the incision
might be reduced in a similar way. Should the iris
protrude above, from too sudden completion of the sec-
tion, with or without pressure of the lids on the eye, the
opportunity might be taken to perform the iridectomy
Description of the Operation 87
before returning the iris (if the combined operation were
intended. This would not, however, suit those operators
who prefer to seize the iris at its pupillary margin).
Among rare mistakes and accidents may be noticed :
1. The rather humiliating contretemps of finding that one
has introduced the blade with its cutting edge downwards. I
have had no personal experience of this, but have been saved
from it on more than one occasion by the watchfulness of my
assistant. It may be possible to rotate a moderately narrow
blade 180 degrees while still in the puncture, without much
escape of aqueous (according to Czermak and others). But
most surgeons would prefer to withdraw it, and to attempt its
reinsertion through the same opening (or parallel to it, Haab).
The position and procedure are the same as are discussed on
p. 84, the determining factor being the amount of aqueous lost.
2. Knives after resetting have on a few occasions been
returned to us with very attenuated points. Once at least, a
minute particle was broken off the tip and left in the tissues
at the counter-puncture, without giving rise to any trouble.
Terrien and others have mentioned similar breakages.
3. Once a sudden outward movement of the eye drove the
point of the knife through the iris at the inner side. A little
vitreous afterwards apparently found its way into the anterior
chamber, though none entered the section.
4. In one memorable case I operated upon an eye with
conjunctival fornices much retracted by scarring. The patient
became excited at the close of the operation and jerked the
eye about. The globe was so anchored to the lids that the
movements pulled the wound open and ruptured the zonule.
Loss of vitreous occurred, and was repeated next day at the
first dressing, and the globe afterwards shrank. The only
operations suitable for such eyes are the subconjunctival ones
(Czermak's, Desmarres', etc.). It is well to bear in mind that
fornices only a little retracted may be so fixed by the speculum
that extreme vertical movements of the globe may tend to pull
the wound open. This, however, is more noticeable with an
ordinary downward section (Chapter IV) than with the upper
one, because of the comparative shallowness of the lower re-
flection of conjunctiva. Where there is a moderate degree of
88 Cataract Extraction
retraction the stretching of the ocular conjunctiva by the
speculum may prevent any but a very small conjunctival flap
being made.
A final word is necessary in closing this somewhat
appalling and bewildering account of the difficulties which
beset the accomplishment of an apparently simple step of
the operation. The beginner cannot hope to bear in
mind all the possibilities, but fortunately this is not alto-
gether necessary. Though the intention be often imper-
fectly carried out, and though faults in the section be very
obvious, the penalties incurred are seldom of any gravity
except in two respects. The main essentials are (i) gentle-
ness throughout, much facilitated by the use of a perfect
knife ; and (2) watchfulness against infection of the wound
through soiling of the blade.
The temporal end of the speculum is now at once seized
by the assistant, and the instrument thus raised, and ever
afterwards kept elevated as steadily as possible. The
fixation forceps are handed over to the assistant, who
takes them in his disengaged hand. If, however, there is
any decided tendency to spasm of the orbicularis, it is
better to remove the speculum now and to trust to separa-
tion of the lids by the assistant's fingers, or, better still, to
Desmarres' elevator for the upper lid and finger depression
of the lower lid. In this case the assistant is not available
for manipulation of the forceps.
Unless the speculum be raised promptly and maintained so,
its arms, pressed down upon the globe by spasm of the lids, may
force the wound open and be the means of producing a large
loss of vitreous. Expulsion of vitreous may take place in
spite of elevation of the speculum, but much less readily. The
lids beyond the tarsi may still be pressed down upon the eye.
The assistant in raising the instrument should take care that
the outer canthus is pulled away from the globe, otherwise the
Description of the Operation 89
pressure of the outer end of the lids may tend to expel the
ocular contents. The thrust on the speculum therefore may
have to be a little outwards as well as forwards if the eyeball
be prominent.
To minimize the tendency to reflex spasm of the orbicularis
the patient must keep the other eye open, and in many cases
his mouth also, and he must breathe regularly. Some-
times it may be necessary for an assistant to keep a continuous
watch upon the patient with regard to these points. The
instillation of cocain in the other eye has already been men-
tioned. (We have never practised it.) Should the patient show
signs of pain when the iris is seized, it may be wise to remove
the speculum and to wait for a couple of minutes while the
effect of further cocain instillation is obtained. A few reassur-
ing words from the surgeon may be useful at any time. But
some of our poorest patients failed to respond to kindness.
Accustomed to rough treatment all their lives, they could be
controlled only by sharp, angry tones.
Timid people often behave better during the actual operation
if the Meibomian expression and conjunctival cleansing have
been done a trifle roughly. The comparative quiet and gentle-
ness afterwards are by contrast reassuring.
If the hospital arrangements are such that patients awaiting
their turn are within sight and hearing of the operations being
performed, it is most important to begin with the more docile
and intelligent ones of the batch. Quiet behaviour of the earlier
patients has a calming influence on the remainder, whereas
trouble with a stupid person at the start alarms all the others.
One would expect, in operating on the second eye of a
patient a fortnight or so after the first, to meet with quieter and
more reasonable behaviour, but one generally finds the patient
decidedly less reliable and less controllable.
Risk of reflex muscular contraction may be largely or entirely
eliminated by suitable administration of drugs beforehand. We
found sometimes that our patients had been made distinctly
drowsy by chloral ahd bromide (p. 46). These overdosed
patients could be relied upon to keep their lids at rest and
their eyes steady, but they could not keep their eyes turned
downwards. Timid, excitable persons may need narcotics or
sedatives, but stupid, dull people may be made more stupid
by them. Much assistance is derived in this respect from the
I
90 Cataract Extraction
complete anaesthesia obtainable with combined adrenalin and
cocain instillation.
To take charge of Desmavres' or other retractor, the assistant
crosses over to the other side of the patient. Before inserting
it behind the upper lid, now that the incision has been made,
the lower lid must be retracted well first by the assistant's
finger, and care must be taken not to let this lid slip while the
elevator is in position. A strip of gauze or lint is interposed
between the finger and the skin of the lid to prevent slipping.
The assistant having only one hand available, the retractor is
inserted by the surgeon and then handed over to the assistant,
who draws the lid firmly upward and forward, resting his hand
on the patient's forehead In order to ensure that no portion
of the lid muscle can still exert pressure on the globe, two
points must be attended to : (i) The outer canthus must be
removed from contact with the globe by the pull of the
retractor ; and (2) the eyebrow must be drawn up by the
ring and little finger of the assistant's hand which holds the
retractor. Smith of Jullundur insists on this point to " unroll,
as it were, the orbicularis muscle, so that a clear field right up
to the superior fornix is obtained."*
Czermakf advised the same drawing up of the brow during
the use of the stop-speculum. It necessitates the use of the
assistant's disengaged thumb, and can be accomplished with-
out inconveniencing the operator greatly. But the assistant
is, of course, not available then for fixing the eye.
A retractor may be used also for the lower lid, but it takes
up a little room in the lid aperture.
As with the lid retractor, so with simple separation of the
lids by the fingers, a fairly experienced assistant is needed. In
both methods the palpebral opening may be scarcely wide
enough if the eyes be deeply set (unless the eyes be well turned
down). It is least wide by simple finger separation, and by
this method also the elevation of the lids from the eyeball is
least. And only very imperfect control over the orbicularis
muscle is obtained. It is safer in this case to release the lids
instantly when the muscle acts strongly, the eyeball rolling up.
A firm hold must be obtained by placing gauze or lint around
* The Ophthalmoscope, v (1906), 556.
f 'Die Augenartzlichen Operational,' SS. 908 u. 914.
Description of the Operation 91
or beneath the fingers, and care must be taken to press only
upon the margins of the orbit, and not upon the eyeball. And
the lower lid is the first retracted.
THE IRIDECTOMY.
For this step of the operation the surgeon takes up
iris forceps in his left hand and scissors, preferably de
Wecker's, in his right hand. To ensure freedom from
risk of accident the eye must be fairly steady. A sudden
upward movement while the ends of the forceps are within
the globe might drive the points against the lens and dis-
locate it. Or with the forceps gripping the iris outside
the wound, the movement might tear a considerable
portion of the iris from its base, perhaps causing haemor-
rhage and necessitating a very large iridectomy. The
iridectomy is more likely to be a little painful than any
other part of the operation. The pain is felt during the
drawing of the iris out through the wound, and not par-
ticularly during its seizure and section. Pain is to be
anticipated especially if the patient winces slightly when
the fixation forceps seize the conjunctiva, or if rubbing of
the iris by the knife during the making of the section has
provoked evidences of resentment. In such cases it is
safer to remove the speculum and to instil more cocain*
and to wait for a couple of minutes, lest violent spasm of the
orbicularis be caused by the iridectomy. In these patients,
and in all who have shown restlessness or alarm, fixation of
the globe by the assistant is essential, though ordinarily it
may be dispensed with. A firm hold is taken upon the
conjunctiva close to the inner side of the cornea, and the
efficiency of the control tested by a pull upon the globe.
Fixation, now that there is a large wound in the eye, is
* Mayweg (The Hague) prevents pain by instilling a drop of
I per cent, cocain solution into the anterior chamber.
92 Cataract Extraction
necessarily imperfect. The eye must be released when-
ever there is any strong attempt at upward movement,
lest the pull should tear the zonule. Still, by restricting
and delaying all movements the fixation forceps do
much to ensure the harmlessness of the movements. If
the operation be upon the left eye the assistant must use
his left hand for fixation, his other hand being already
occupied with the speculum. The fixing hand is then
rather in the way of the operator. The wrist has to be
overlaid by the operator's right wrist.
To ensure the easy performance of the iridectomy the
eye must be turned downwards, unless it be unusually pro-
minent. The operator's left hand, holding the iris forceps,
rests on the patient's forehead. The right hand, holding
the scissors, is placed in position across the patient's face,
so that the two bades of the scissors are pointing upwards
near the wound. The points of the forceps are introduced
closed at the summit of the wound, pointing directly
downwards. During the insertion they are kept free from
entanglement in the loose conjunctival flap by slight lateral
movements, and by backward pressure upon the sclerotic.
Or the conjunctival flap may be drawn forward by the
point of one of the scissor blades, after which the scissors
are again placed in the position above mentioned. Should
the conjunctival flap have been turned down over the
cornea on account of haemorrhage, it is left so, though if
long it may prevent the operator seeing the points of the
forceps in the anterior chamber.
Having arrived at a point midway between the base and
pupillary margin of the iris, the forceps resting upon the
iris are simply opened to a distance of 2 millimetres or
less, and closed again, in the expectation that the iris will
be thus seized. The instrument is slowly withdrawn
through the wound, bringing a small loop of iris with it.
Description of the Operation
93
While this is being done the scissor blades, somewhat
approximated (Fig. 54), are pressed down upon the
incision, one on either side of the loop of iris. This tends
to limit the size of the loop drawn out, and the scissors
are ready in position to snip at once in case the eye should
FIG. 54. THE IkiDECTOMY.
begin to move upwards. And the conjunctival flap may
be also thus pressed downwards, baring the iris. But if
the flap is too large it may be left covering the iris, and
some of it cut away with the iris. The pull upon the iris
is continued until its pupillary margin lies between the
scissor blades. The latter are then closed, and the iridec-
tomy is completed.
94
Cataract Extraction
There are many patients, however, who are unable to
maintain the desired downward rotation of the globe. And
it is a great mistake to worry the patient with repeated
urgings to look down. For when control has been lost
FIG. 55. THE CORNEA is FORCED DOWN BY THE IRIS SCISSORS,
TUCKED INTO THE CONJUNCTIVAL FLAP, TO EXPOSE THE
IRIS FOR SEIZURE BY THE FORCEPS.
to a great extent, the greater the movement of the eye
from the position of rest, the earlier and more certain will
be the recoil movement, passing beyond the position of
rest. Even in the case of a deeply set eye, if it only
be kept comparatively motionless, the iridectomy can be
Description of the Operation 95
done without any downward rotation, thus. The wound
now lying behind the upper lid (which is pressed well
forward by the supported speculum), the iris forceps can
no longer be passed down through the incision. It is
necessary that the wound shall be opened by displacing
the corneal flap downwards, to expose the iris sufficiently
for the forceps to be used with points directed laterally or
backwards. It is to be reckoned as one of the definite
advantages of a conjunctival flap that it furnishes a ready
and safe means of thus opening the wound. The closed
scissor points (de Wecker's). directed backwards or side-
ways, are utilized to push down the conjunctival flap.
They readily obtain a hold upon the loose tissue, and
thus enable the edge of the cornea to be forced down-
wards for a moment (see Fig. 55). The forceps points
in gripping the iris need not enter the globe at all. The
cutting of the iris must not be done with the scissors
held transversely, as this would produce a wide coloboma
instead of the very narrow one desired. Therefore no
pull is made upon the seized iris until the scissors are
in the correct position for cutting, lest slight pain excited
by the pull should cause the eye to rise upwards. The
iris must be quickly released when any movement of the
globe appears too powerful to be controlled by the fixing
forceps, lest a large irido-dialysis be produced.
There are three details which always deserve attention.
Firstly, the iris should not be drawn out of the wound
farther than is necessary, in order that the sphincter
muscle may not be unduly stretched. (The stretching
of the pupillary zone of iris is further reduced to a mini-
mum by seizing the iris as above directed, at some
distance from the pupillary margin.)
Secondly, no more iris is cut away than is essential to
obtain a coloboma extending from the base of the iris to
96 Cataract Extraction
the pupil. Thus as little of the sphincter is removed as
practicable. Active sphincter muscle fibres are one of the
chief preventives of subsequent prolapse or incarceration
of the iris in the wound. They should suffice now to
draw the iris back into position within the globe.
Thirdly, great weight has been laid by Knapp* and
others (Horner, Snellen, Gayet, Alf. Graefe, Czermak)
upon the necessity for immediate and complete replace-
ment of the iris.
With the iridectomy performed as just described, spontaneous
retraction of the iris is nearly always complete. In Bombay,
therefore, no particular attention was found necessary in this
matter. The means of replacement are given under ' Toilet of
the Eye.' The readjustment must be repeated, if necessary, after
the delivery of the lens and after the removal of cortical remains.
But it is held that, provided the reposition is properly done after
the iridectomy, it seldom needs repetition later. Inclusion of
either pillar of the coloboma in the wound is shown by upward
displacement of its projecting pupillary angle. Impaction of
both pillars produces vertical elongation of the pupil. If they
be allowed to remain in the wound during the expulsion of the
lens, complete reposition afterwards may be impossible. For
the sphincter is likely to become weakened temporarily by
stretching of the iris, folded in front of the lens, and by
the squeezing to which it is subjected between the lens and
the cornea. The iris afterwards, nipped in the angles of the
wound, may be further held by congestive swelling of the
impacted tissue (?), or by transparent capsule lying in the
incision.
Proper care in this respect is nearly always an effective
safeguard against the complication which has been counted the
chief reproach of combined extraction subsequent incarcera-
tion of the iris in the angles of the wound, with its consequences,
cystoid cicatrix, liability to late infection, etc.
Close approximation of the pillars of the coloboma, as a pre-
liminary to expulsion of the lens, appears to be unnecessary,
and even undesirable. It has been our usual practice to push
* A.f. A., xi, (1882) 49.
Description of the Operation 97
the margins of the coloboma apart with the cystitome after
making the capsulotomy, to make way for the lens, merely
anticipating the widening which would otherwise be accom-
plished by the lens itself. The important point is that the
iris should lie quite flat and even, without any tendency to
entanglement in the wound.
Smith of Jullundur causes the iris to prolapse, and so avoids
introducing the iris forceps within the wound. " He dimples
in the cornea close to its free edge with one limb of the iris
forceps, thus causing the edge of the iris to appear outside the
wound ; at the same time the other limb, which is resting on
the sclerotic above, is slid along so that the iris is lightly
caught in its grasp, pulled outside, and cut off in the usual
manner." :: (Axenfeld has caused the iris to prolapse similarly
for the performance of iridotomy.)
During a cataract operation the contractility of the pupil is
not usually demonstrable after the section has been made. But
sometimes I have noticed considerable activity of the sphincter
muscle after making such an iridectomy as above described, in
operating for adherent leucoma. With the smaller wound,
and the anterior chamber perhaps not completely empty, the
lightest touch upon the iris with spatula may produce marked
contraction of the pupil and coloboma, repeated as often as
desired, drawing the iris away from the wound.
In attempting to remove as little of the sphincter as possible,
one is very apt to buttonhole the ins, leaving a band of tissue
separating the coloboma from the pupil. This is more likely
to happen if the iris prolapses on completion of the section.
The iris is then often seized too near its base. A bridge of
tissue is also often left when the iridectomy is unintentionally
made with the knife during the cutting of the section. The
band is commonly too narrow to be gripped by iris forceps
passed down in the ordinary way. It might be withdrawn by
a Tyrrell's hook, rapidly sterilized in the flame; but the
necessary rotation of the hook in catching and withdrawing
the band is rather awkward with the left hand, and the instru-
ments at hand suffice.
The narrow strip of tissue may be readily hooked upwards
by the cystitome (held in the right hand) after the capsulotomy
* Rutter Williamson, The Ophthalmoscope, v (1907), 558.
7
98 Cataract Extraction
has been done. If very narrow, it tears readily. Otherwise
the loop is released, and the forceps and scissors again taken
up. The forceps are used so that one blade passes down in
front, and the other, generally more or less embedded in soft
lens matter, behind the band. This will still be found lying
near the wound, retraction being interfered with by the sticky
lens substance. The points of the forceps being closed beyond
the band, the latter may then be readily hooked up and cut
away. Or if the eye be very unsteady the forceps may be dis-
pensed with. The left hand may be usefully employed with
the curette or expressing hook. Pressure is applied at the
lower edge of the cornea, as for expulsion of the lens. The
wound is thus forced open, and the little band of iris stretched
and carried forward on the presenting lens, either into the
wound or near it, so that it may be easily cut with scissors.
Usually the strip of iris may be made to present sufficiently
well for the scissor blades to be applied transversely, snip-
ping off lens substance together with the iris. Should by
chance a long tag be left attached to one angle of the
coloboma, this shrinks afterwards, but forms a posterior
synechia.
In cases where the iris has already prolapsed through the
incision, it has been recommended to reduce the prolapse in
order to seize the iris at the point desired for making the
iridectomy. But this is an unnecessary prolongation of the
operation, and is, perhaps, theoretically inadvisable on account
of infective risks where the protruded iris has come into
contact with the conjunctiva.
The presence of a number of posterior synechiae does not
alter the procedure to any extent. In order to tear away an
adhesion, the iris is seized as close to it as possible.
If the eye be unsteady, it may be convenient and permissible
to perform the iridectomy a little to one side instead of straight
upwards.
It is surprising that the section of the healthy iris should
give rise to no haemorrhage. Bleeding is almost confined to
cases in which the iris shows evidences of past inflammation.
In glaucomatous eyes it might occur were the iridectomy not
usually performed beforehand. Haemophilia and atheroma of
so high grade as to lead to bleeding from the blood-vessels of
the iris are both too rare to need special consideration.
Description of the Operation 99
The object of the iridectomy is twofold. A minor
service rendered is in facilitating the delivery of the lens
by furnishing a direct passage upwards. Secondly, much
more important, it renders prolapse of iris after operation
much less frequent than it would otherwise be. It does
this by allowing the lens to escape without stretching, and
thereby weakening the pupillary sphincter, and still more,
perhaps, by providing an open gateway for the later direct
FIG. 56. 'KEY-HOLE' COMBINATION OF COLOBOMA AND PUPIL.
escape of fluid from the posterior chamber fluid which
might otherwise carry the iris into the wound whenever
the early adhesion of the latter were temporarily broken
down.
The ' key-hole ' combination of pupil and coloboma
FIG. 57. COLOBOMA POINTED FIG. 58. SPHINCTEREC-
UPWARDS. TOMY.
appears to obtain these objects in the fullest manner,
while sacrificing but little of the valuable sphincter
muscle.
Many operators e.g. Galezowski * perform only a partial
iridectomy or ' sphincter ectomy,' taking away only a small
piece of the pupillary zone of iris. Or a slightly larger iridec-
tomy is made, removing a piece of tissue widest at the pupil
and tapering upwards to a point. The tissue excised is pre-
cisely that which can be least well spared, and the opening for
gushes of fluid from the posterior chamber is absent, or least
* Rec. dOpht., 1892, p. 262.
72
IOO
Cataract Extraction
w
wide, where it is most needed. If not effective against prolapse
and incarceration, the iridectomy might as well be omitted,
except in cases of rigid pupil.
Chibret* and Dianoux (Nantes) reduced the excision of iris to
the minimum by cutting with fine scissor blades introduced
into the anterior chamber. No iris forceps were used.
Formerly, it was a common practice for the surgeon to share
his responsibility with the assistant, the latter actually dividing
the iris, the surgeon merely fixing the globe and drawing the
iris out of the wound.
In von Graefe's peripheral linear operations under general
anaesthesia the iris nearly always became prolapsed. A broad
piece was removed by two snips of the scissors. Von Arlt, in
order to avoid incarceration, made a very broad coloboma,
dividing the iris with curved scissors along its base, and
radially at the two ends of the incision. De Weckert com-
monly made a narrow coloboma with his iris scissors (pince-
ciseaux). It was pointed or with parallel sides, and extended
to the base of the iris. This narrow iridectomy, recommended
also by Swanzy and Fuchs as an effective preventive of prolapse,
came to be adopted generally. In the making of a very narrow
coloboma many surgeons have used an iris hook instead of
forceps for withdrawing the iris.
THE OPENING OF THE CAPSULE.
The opening in the anterior capsule is designed to
serve for the easy exit of the lens in one mass, and to
provide a central clear space for direct vision. At the
same time, it is well to avoid, if possible, leaving a loose
flap of capsule above, liable to impaction in the wound.
These ends may be attained by (i) simple division with
some form of cystitome, curved needle, or sharp hook ; or
(2) tearing away a portion of the membrane with capsule
forceps ; or occasionally (3) the successive use of cystitome
and forceps.
* Rec. tfOpht., 1884, p. 77.
t ' Chirurgie Oculaire,' p. 57 (Paris, 1879).
Description of the Operation 101
CAPSULOTOMY with cystitome or sharp lens hook. In
the large majority of combined extractions I have been
content with a single vertical or oblique incision or tear
with Graefe's bent cystitome an incision considered out
of date by many authorities. It has been held that this
toothed instrument, like the sharp lens hook, commonly
tears the capsule instead of cutting it, and that all tears
directed towards the wound are contra-indicated, in that
the effect of any such pull of the tooth upon the capsule
is to produce a pointed loose tongue of membrane, with
base upwards, likely to be carried into the wound by the
escaping lens. But for some years past I have been in
the habit of examining the capsules of nearly all our
patients before their discharge, and have not seen reason
to alter our general plan of work.
Procedure. The eyeball is again turned downwards,
and the fixation forceps are necessary if the eye be
unsteady. But in a quiet patient it is better to dispense
with fixation, because it is now necessarily imperfect, and
because it is more likely to be felt by the patient, and
therefore more likely to excite attempts at movement,
than the capsulotomy itself. I prefer to use always
von Graefe's bent cystitome, employing for both eyes the
one intended for use upon the right eye (Fig. 24 a). It
is placed for introduction into the wound with its bent
end portion directed transversely. Whichever eye be
operated upon, the instrument is held in the right hand,
its end pointing to fhe left and the sharp tooth directed
upwards (see Fig. 59). The hand is supported on the
patient's forehead. The sloping stem of the instrument,
between the bend and the handle, is steadied against the
tip of the left forefinger or middle finger. This horizontal
presentation of the terminal portion of the stem that which
has to enter the globe removes all risk of its touching the
102 Cataract Extraction
upper lid margin or lashes, supposing the ordinary bar
speculum be in use. But this direction is adopted and
maintained as long as possible, mainly to guard against
the risk of injury by the instrument in case the eye should
unexpectedly roll upwards.
FIG. 59. INSERTION OF THE CYSTITOME.
(The conjunctival flap happens to be turned down in this case.)
The end of the cystitome is easily inserted under the
conjunctival flap, passed down in the chamber, and then
usually changed in direction, swinging around the tip of
the left index finger as a fixed point. In a perfectly quiet
eye a long vertical cut may be made in the capsule, pass-
Description of the Operation 103
ing exactly through the centre of the pupil. For this the
end of the cystitome is passed down beyond the lower
pupillary margin, behind the iris. It is then rotated on
its axis to direct the tooth backwards on to the capsule,
and then somewhat sharply withdrawn upwards, to make
the required capsular puncture and its extension upwards.
Usually this single movement is effective if the capsule
be not much thickened and the tooth of the instrument be
moderately sharp and free from blood-clot. In lenses
with soft cortex the puncture of the capsule is signalized
by a forward movement of some of the contents, and in
Morgagnian cataracts the escape of fluid is at once seen.
In those with firm cortex the impression of the point of
the instrument in the cortex may usually be seen, unless it
it is obscured by blood in the anterior chamber. If there
is any doubt about the opening of the capsule, an up-and-
down " scratching " movement of the cystitome is added.
A horizontal movement of the instrument to either side
near the wound serves to ensure a wide opening of the
slit in the capsule, and to separate the pillars of the
coloboma of the iris. The cystitome is then again rotated,
so that the tooth points sideways. It can then be with-
drawn from the wound. It is most important throughout
to avoid pressure upon the lens, likely to displace it back-
wards, rupturing the zonule.
The ordinary short tooth, i millimetre or less in length,
is used pointing directly backwards. Some cystitomes
are made with distinctly longer teeth. A rather long
tooth must point only obliquely backwards* lest it
become embedded in firm lens substance, displacing the
lens upwards and tearing its suspensory ligament, or lest
* A minor disadvantage of the long tooth directed very obliquely
is that one cannot see exactly what portion of the slanting edge of the
tooth is cutting the transparent capsule, and so one has not perfect
command over the location of the incision.
104 Cataract Extraction
the direct pressure of the tooth, working in an empty
anterior chamber, depress the lens and thus rupture the
ligament. A slight upward displacement of a lens with
a firm cortex is not uncommon even with a short-toothed
instrument. It is merely sufficient, however, to place the
upper margin of the lens behind the scleral lip of the
wound. And if recognized, or even suspected, it can be
at once rectified by a small downward stroke of the
cystitome.
In operating on a Morgagnian cataract the oblique
direction of a long ' tooth ' is essential also to avoid the
risk of puncturing the posterior capsule on the collapse of
the sac.
Blood-clot in the anterior chamber is a minor trouble.
It prevents one seeing what is being done, and unless the
cystitome happen to be insinuated quite behind the
coagulum, the tooth becomes entangled in it and thus
prevented from cutting. Yet one may prefer to proceed
at once with the capsulotomy rather than make any
prolonged attempt to wash away the clot with the douche.
One must use the cystitome with to-and-fro scratching
action to penetrate the hidden capsule. Perforation of
the membrane will be shown by the appearance of cortex
in the clot beside the cystitome, if the cortex be soft.
But in lenses with firm cortex there is no immediate
evidence of perforation obtainable in these cases. A sharp
cystitome is advisable. And since one must work by the
sense of touch alone, little more than the weight of the
instrument should be allowed to press on the lens. After
three or four up-and-down movements, one may assume
with a fair degree of certainty that a sufficient opening
has bsen made. One proceeds to express the lens, and
one relies upon refusal of the lens to pass upwards as
evidence that the attempt at capsulotomy has failed.
Description of the Operation 105
Another difficulty lies in restlessness of the eyes. Since
uncontrolled movements of the globe are nearly always
primarily upwards, there may be considerable danger in
introducing an instrument far within the globe, directed
vertically or nearly so. Therefore, unless steadiness of
the eye can be confidently expected, the cystitome must
only point obliquely, and if the eye be very unsteady the
direction of the instrument can depart but little from
the horizontal. And these inclinations are the only ones
available in patients who cannot at this stage any longer
look downwards. The tooth, with flat sides and single
cutting edge, can only be expected to cut by withdrawal
movements in the line of the stem. A long oblique, or
even transverse, division of the capsule furnishes an
opening perfectly satisfactory for vision, provided that it
passes through a point a little below the centre of the pupil.
Indeed, the direction of the cut appears to be immaterial
provided its position is correct. In a large proportion of
cases the elastic retraction of the membrane cannot be
depended upon to effectually widen the slit. If an oblique
cut be made across the pupil, the lower leaflet of the
anterior capsule will frequently remain in position, only
the upper leaflet being permanently displaced upwards
and to the side behind the iris. Unless the line of division
pass below the centre of the pupil, the edge of the lower
portion, therefore, lies across or near the line of vision,
uniting with the posterior capsule, and disturbing sight by
opacity developing in its epithelial lining. This single-
leaf displacement may be anticipated frequently even
where the deviation of the line of incision from the vertical
is quite moderate.
Though the instrument lie in the chamber obliquely, it
may, if preferred, be withdrawn vertically in an attempt
to tear the capsule vertically with the side of the tooth,
io6 Cataract Extraction
especially if the capsule be thin and transparent. But
such tearing is apt to be productive of loose points of
capsule liable to impaction in the wound.
It is necessary now to consider how the single long
incision or tear, preferably vertical or nearly so, fulfils
the requirements laid down.
Knapp* believes that "the vertical splitting is unfavourable
for the exit of the lens ; the horizontal, parallel to the corneal
section, offers its easiest escape. . . . The next and worst
drawback of the vertical splitting is that it produces a more or
less dense scar, which is much in the way of the light, and
which is very unpleasant to divide by a later capsulotomy.
Graefe made not only a vertical split in the capsule, but also a
horizontal one at the periphery of the coloboma. He opened
the capsule horizontally in the upper part with a cystitome,
which he then turned, and with it ripped the capsule from
below upward to meet the horizontal incision. In this way he
obtained a broad T-shaped opening, which did not always
remain large enough, and my imitation of his procedure in
Heidelberg and in New York proved no more obliging."
The single slit is evidently the simplest procedure applicable ;
it necessitates the retention of the instrument within the
anterior chamber for only a very short period of time. Thus,
we never had to chronicle accidental dislocation of the lens
from movement of the globe, driving the lens forcibly against
the instrument. The deliberate manipulation by some opera-
tors with the cystitome or hook directed downwards far within
the chamber, appear to indicate that the average European
patient is much quieter and more reliable than in Bombay.
In most of our work the risk of accident from prolonged
insertion of the cystitome certainly appeared to outweigh any
possible benefit from an elaborately planned capsulotomy.
We had to be constantly wary to withdraw the instrument
quickly on any movement of the globe.
And it is well recognized that in working upon a practically
invisible and more or less elastic membrane, additional move-
ments of a toothed cystitome after the first opening has been
made may serve merely to widen the opening instead of
* Amer. Journ. of Ophth., September, 1905.
Description of the Operation 107
incising the capsule afresh. The sharp point must be carried
well away from the primary incision to puncture afresh for any
additional division.
We frequently used a cystitome with tooth blunted from
numerous passages through the flame of a spirit-lamp. Yet sub-
FIG. 60. Y-SHAPED CAPSULAR OPENING. (About two weeks after
operation.)
sequent evidences of incision, as distinct from tearing, were quite
numerous in the forms shown in Figs. 63, 65, 66, and 67. Until
we realized how frequently the displacement of the capsule is
due, largely or entirely, to the passage of the lens, we several
FIG. 61. V-SHAPED OPENING, WITH TONGUE OF CAPSULE
ABOVE. (Seen on discharge from hospital.)
times had to ' needle ' after an oblique incision, passing across
the centre of the pupil, simply because of insufficient displace-
ment of the lower leaf, as shown in Fig. 64. Doubtless the
blunt point frequently tore the membrane, however, and this
FIG. 62. V-SHAPED OPENING. MARGINS SHOW A DEPOSIT OF
FIBRIN. ANTERIOR CAPSULE SHOWS SLIGHT PUNCTATE
OPACITY. (Eight days after operation.)
'probably accounted for many triangular openings, as in
Figs. 60, 61, and 62, with apex downwards and base generally
not visible. That this form of opening had resulted from a
V-shaped tear of the capsule is evident in Figs. 60 and 61,
from the displaced tongue of membrane seen above. But
usually no such projecting piece of membrane could be seen
io8 Cataract Extraction
above, and the opening (Fig. 62) might well result from a
vertical or oblique incision, plus a horizontal tear above. Both
the tear and the widening of the vertical slit above may result,
either from the lateral movement of the cystitome or from the
FIG. 63. OBLIQUE INCISION IN CAPSULE, PARTLY BORDERED BY
PIGMENT. (Eleven days after operation.)
a. Cortex.
passage of the lens, and the permanent widening of the slit
may be maintained by the posterior synechiae seen in Fig. 62
at the angles of the coloboma. Some of these openings were
FIG. 64. OBLIQUE INCISION, Too HIGH. LOWER LEAFLET NOT
RETRACTED. (Eleven days after operation.)
a. Cortex.
defective from being too highly placed (Fig. 61). The short
incision or tear was made either with the point of the cystitome
entangled in blood-clot, as already mentioned, or with blunt
FIG. 65. NARROW SLIT, WITH ADHESIONS TO POSTERIOR CAPSULE
PRODUCING TRANSVERSE FOLDS. (Sixteen days after operation.)
a. Cortex.
point sliding over the surface of the membrane a little before
engaging in it, or possibly the eye was unsteady and the instru-
ment not introduced far enough within it. Fig. 63 shows a
minor degree of defect, and Figs. 65 and 66 a more marked
degree from inelasticity of the capsule, the edges of the slit
Description of the Operation 109
having come nearly into apposition. This was most often
seen after operation for Morgagnian cataract with punctate
capsular opacity. Fig. 67 shows also a narrow slit, the margins
having possibly become drawn together by contracting blood-
clot and lymph.
These narrow apertures are the only ones in which it is
evident that the single division of the capsule in one straight
line failed to provide a clear space, such as might more reason-
FIG. 66. NARROW SLIT ENDING IN AN OPAQUE BAND BELOW,
APPARENTLY FlBRINOUS. MARKED FOLDING OF CAPSULE.
(Twelve days after operation.)
a. Cortex.
ably have been expected from complex or multiple division.
In rare cases also of tough capsule the simple straight incision,
insufficiently widened by the cystitome, resisted appreciably
the exit of the lens during operation.
Figs. 8 1 and 82 show very large capsular openings. In other
cases no anterior capsule could be seen ; either it was perfectly
transparent and colourless, or it had retracted so completely as
to be hidden by the iris, even though the pupil was dilated.
FIG. 67. NARROW SLIT OCCUPIED BY FIBRINOUS DEPOSIT, FORM-
ING A BAND OF OPACITY. MUCH FOLDING OF CAPSULE.
(Twenty-three days after operation.)
It was very rarely that we were able to detect any incarcera-
tion of capsule in the wound or adhesion to it so rarely that
the mode of opening the capsule could scarcely be blamed. In
eyes with 'vitreous tension' and after prolapse of vitreous
there must at times be some impaction of the capsule. Becker
has shown that entanglement of points of capsule is not always
recognizable clinically ; but such cases are the least likely to
give rise to trouble, especially when the site of entanglement is
covered with a conjunctival flap. If, then, our simple division
no Cataract Extraction
of the capsule predisposed to impaction, the predisposition was
evidently overcome by replacement of the iris at the close of
the operation and by its retention in position by an active and
nearly complete sphincter muscle.
Speaking generally, the question of the precise scheme
of capsulotomy to be adopted has lost much of its
importance since the early treatment of after-cataract
has become so safe and effective (see later). Still, it is
doubtless advisable to avoid unnecessary supplementary
treatment, and with this object the opening in the anterior
capsule should extend well below the centre of the pupil.
In simple extraction long incisions are not quite so
readily made, and are generally replaced by movement of
the point of the instrument in more than one direction.
The iris above should serve to prevent tags of capsule
from forming adhesions to the wound, though apparently
it has not always done so.
Various incisions have been planned by numerous operators,
many of them probably very imperfectly carried out. Von Arlt
tried to make a V-shaped division of the capsule with a sharp
hook. Von Graefe also at one time aimed at a V-shaped
opening ; later (1870) he attempted to outline a large square in
the centre of the membrane. Weber (1867) made two hori-
zontal tears with a double hook. Czermak, by two horizontal
tears in opposite directions, aimed at the formation of two
flaps, one with base inwards, the other with base outwards.
" Scratching " the centre of the capsule in different directions
has been the method of many surgeons. Knapp objects to
this, as especially productive of small shreds of capsule likely
to unite with the border of the iris. The formation of adhesions
is favoured by the numerous minute ruptures of the iris which
occur during the passage of the lens in simple extraction.
Many surgeons have used slightly curved needles for
dividing the membrane. The Moorfields pattern cystitome is
shown in Fig. 25. Hess uses cutting forceps.
L. Miiller* performs the capsulotomy before the iridectomy
* Kl. Mbl.f. A., (1902) xli, 358.
Description of the Operation 1 1 1
in order that the upper part of the capsule may become a little
folded up behind the iris, and thus kept away from the wound.
The consideration of other modes of opening the capsule is
relegated to Chapter IV, either because the methods are not
very commonly practised, or because their consideration comes
better after the description of simple extraction.
The toughened, thickened, and opaque capsules of some
overripe cataracts demand special consideration.
In Morgagnian cataracts, especially those with opaque
capsules, the incision must be made with an unusually
quick movement, and the point of the cystitome must be
sharp. Otherwise the soft, but frequently tough, sac of
fluid may be merely indented by the instrument, and
perhaps pulled about by it. Or, more frequently, a small,
insufficient puncture is made. This is because the rapidly
emptying sac recedes from the cutting point quite early.
Fearing lest this may take place, some slight attempt
may be made to enlarge the aperture by movements of
the cystitome in various directions while still some fluid
remains within the sac. But if the capsule be opaque,
this attempt is often unsuccessful. Any prolonged use of
the instrument might lead to puncture of the posterior
capsule unless the nucleus were sufficiently large to protect
it, and free movement might, by pulling on the tough
capsule, rupture the suspensory ligament. Because of
the difficulty experienced in enlarging a small aperture,
it is well always to make the primary cut in a Morgagnian
capsule horizontal.* The opening often has to be finally
expanded, with trouble and some slight risk, by the escape
of the imprisoned nucleus, forced out by continued pres-
sure and counter-pressure upon the globe. And this is
* Knapp's "peripheries plitting" above (see Chapter IV) is especially
applicable to Morgagnian cataracts, except in that the later discission
of these inelastic capsules required for visual purposes sometimes
provides only a narrow opening.
1 1 2 Cataract Extraction
least easily accomplished if the small puncture be situated
below. For then the nucleus tends to slip upwards
away from the opening whenever pressure is placed upon
the eye.
The dense, indivisible central opaque plaque of some
overripe, generally discoid, cataracts commonly requires
removal by the use of both cystitome and forceps. Intra-
capsular extraction of the lens may be preferred in quiet
patients by many surgeons. But I believe that the safest
procedure is the most conservative. The capsule is first
scratched through below the patch.* If the latter be
then hooked up by the tooth of the cystitome, the mem-
brane on either side is partly torn. The patch may then
be readily seized with iris forceps, and, if the remainder
of the capsule be nearly normal, slowly withdrawn. The
tearing away of the central portion of capsule is much
more likely to be successful at this stage than later, since
the lens in situ affords a certain amount of resistance to
the pull of the forceps. Should, however, the surrounding
capsule be also somewhat thickened and opaque, indi-
cating the probability of extension of opacity to more or
less of the posterior capsule also, the membrane is likely
to prove more resistant than the zonule below. To avoid
rupturing i the zonule in these cases the pull of the
forceps must be light, and must be given up as soon as
a sufficient opening has been made for the expulsion of
the lens. The extraction of the opaque capsule as a
whole may then easily be accomplished at the close of the
operation, after the removal of the speculum.
* Snellen recommends for this purpose a fine round needle, the
extreme point of which is bent over at an angle of 90 degrees (see
Haab's ' Operative Ophthalmology,' p. 150).
t Should this accident happen, the lens and capsule must be
extracted together by the pull of the forceps, aided by an upward push
with curette or hook on the surface of the cornea.
Description of the Operation 1 1 3
The same practice may be adopted for some very over-
ripe juvenile cataracts, mainly capsular, in which there
may be an anterior patch of great density. The extrac-
tion of this la)'er of membrane is much facilitated and
freed from risk by preliminary cuts below and at its side.
There is still another form of cataract requiring special
mention the previously Morgagnian cataract, with all the
fluid absorbed, consisting merely of the nucleus in a
shrunken sac, the capsule often quite transparent, and the
whole lens being possibly more or less tremulous. The
nature of the cataract may have passed unrecognized until
the iridectomy has revealed a dark clear space above the
shrunken nucleus. I believe the safest procedure is to
begin in the ordinary way.
A cautious attempt at capsulotomy is made with a
sharp cystitome passed in from the side. Here the iris
intervening between the cystitome and the zonule and
loose capsule prevents injury to the latter. If the in-
strument were passed down from above at the site of
the coloboma, its point might readily tear or puncture
the thin membranes which alone cover the vitreous
in this situation. An attempt is made to scratch through
the anterior capsule where it overlies the nucleus
with the tooth directed only a little backwards. In a
quiet patient it appears to be almost immaterial whether
this attempt is successful or not. More often I think it
fails, and instead of the capsule giving way, the suspensory
ligament below, and probably more or less at the sides
also, is torn. This greatly facilitates expulsion of the
lens in its capsule. Sometimes a mere puncture is made
in the capsule, and the zonule torn also. One cannot be
quite sure what has happened sometimes until an examina-
tion of the expressed nucleus shows whether it has escaped
with or without the capsule. Should the opening in the
1 1 4 Cataract Extraction
capsule have proved adequate for the exit of the nucleus
alone, the untorn posterior capsule and zonule may be
of great advantage in an excitable patient. The intact
diaphragm may serve to prevent a large loss of vitreous.
THE DELIVERY OF THE LENS.
This is the step of the operation in which restraint and
patience on the part of the operator are most needed.
The lens is expelled from the globe mainly by instrumental
pressure applied about the lov/er border of the cornea.
By this means the intraocular pressure may be increased,
the wound forced open, and the lens tilted to present its
margin in the wound, while the localized indentation of
the globe helps directly to displace the lens upwards.
Continuance of the pressure tends to cause the lens to
move slowly upwards, pushing the pillars of the coloboma
to either side, to enter and to fill the wound. The further
movement required to complete the passage of the lens
out of the eye is facilitated by movement of the expressing
instrument upwards over the cornea, following the lens,
and more especially by the distribution of the pressure and
indentation to either side as well as directly below the
lens. Further, the hard coat of the eye is sufficiently
flexible to allow of the expressor being sometimes used to
actually push the lens substance upwards. The effect of
repeated light upward strokes on the surface of the cornea
is particularly noticeable upon the nuclei of Morgagnian
cataracts, and rather less so upon some small thin lenses,
and upon cortical matter remaining after the bulk of the
lens has escaped.
Whether the hook or the spoon be selected (see p. 36), it is
applied at first obliquely, so that only a portion of the
curve is in use, the handle and stem inclining upwards
Description of the Operation 1 1 5
and somewhat forwards. The angle at which the instru-
ment is used is altered later, according as one may need
to utilize the two ends of the curve for lateral pressure or
the convexity for pushing strokes upon the cornea.
The expressor is held in the right hand, and assistance
is rendered in one or several ways by the operator's other
hand. In combined extraction the left hand can be
most advantageously employed with fixation forceps, used
not only directly to aid in expression, but also for sub-
sidiary small manipulations more or less helpful. The
patient should still keep the eye turned somewhat down-
ward, unless the eyeball be unusually prominent.
For all distinctly unripe cataracts it is, I believe, impor-
tant, and for most lenses with soft cortex advantageous,
to seize the conjunctiva below the cornea with the
forceps* as the first step. By a downward pull, together
with very slight backward pressure of the forceps, the
wound is made to gape a little. The lower lip of the
incision is displaced forwards, and the cornea somewhat
flattened, so that its posterior surface may serve as an
inclined plane to direct the lens into the gap above, while
any pressure exerted by the forceps quite below the lens,
indenting the globe there, must tend to displace the lens
upwards. As soon as the section is found to open evenly
thus, the expressing instrument is laid upon the lower
edge of the cornea with gradual pressure backwards. In
dealing with unripe cataracts the use of the two instru-
ments should usually be continued together thus until the
lens has begun to move upwards into the wound. In
* The grip of the forceps is at least temporarily released on any
involuntary straining of the globe upwards. And this use of the
forceps is dispensed with altogether in tense eyes, in which the lens is
pressed forwards, and in the case of individuals with tense eyelids,,
which are not drawn forward by the speculum sufficiently from the
globe.
82
1 1 6 Cataract Extraction
other cases the forceps may be removed as soon as the
pressure of the hook (or spoon) suffices to keep the
incision open.
For lenses with firm cortex, especially overripe cata-
racts, thinned particularly about the equator, the above
manipulation is not quite so well suited. The fixation
forceps may be utilized otherwise. These lenses are very
apt to slip upwards behind the wound instead of present-
ing in it. It is usually better in dealing with them to
begin at once with backward pressure at or a little above
the lower edge of the cornea, while the conjunctival flap
is seized by the forceps and the wound thereby opened for
a moment. One is thus enabled to see whether the lens
is in correct position. Its upper border should be readily
seen tilted a little forward by the pressure below, and
ready to engage in the wound. If the equator of the lens
is not thus seen, it is practically certain to have become
a little displaced upwards behind the scleral lip of the
wound, possibly having been pulled up by the cystitome
during the capsulotomy.
This opening of the wound by the forceps is often of
some slight direct advantage, since there may be already
a tendency to gluing of the conjunctival flap down by
means of blood-clot, particularly in cases where there has
been some slight delay at any time after the completion
of the section. This pulling of the corneal flap forwards
may be repeated at any time as a possible aid to the exit of
the lens. (But in operations where the forceps have just
been used upon the conjunctiva below the cornea, possible
doubts concerning the sterility of the conjunctival surface
suggest that the forceps should not be applied about the
wound margin without being cleansed upon the lint in the
bowl of lotion kept at hand.)
If it is found that the lens margin has slipped upwards
Description of the Operation 1 1 7
behind the wound, or tends to do so, it may be easily
pushed down again by the convexity of the hook or the
edge of the spoon applied on the corneal surface close
below the wound. There is usually no need to reintroduce
the cystitome within the wound for this purpose. The
upper lip of the wound is then depressed by running the
closed ends of the forceps lightly along the sclerotic above
the wound from end to end, while the upper edge of the
lens is tilted forward by the application of the convexity
of the hook on the lower part of the cornea. As soon as
the lens border presents in the wound there is no longer
need to keep up the depression of the sclera.
This upward displacement may not be always easily
recognizable in operating without a conjunctival flap, and
therefore without the means of opening the wound to look
within. It may be suspected when pressure applied to
the lower part of the cornea has little effect upon the
wound when the tilting forward of the lower lip of the
incision is very slight and more or less uneven.
Should the source of trouble pass unrecognized, and
should reposition not be effected, an attempt at introduc-
tion of a loop or spoon behind the lens may cause the
latter to revolve on its horizontal axis, the lower edge
coming forwards and upwards to escape first, and there
is likely to be loss of vitreous.
Should lateral movements have been practised with the
cystitome, some slight lateral displacement of the lens
may have been caused. The displacement should be
corrected by pushing strokes over the corneal circum-
ference before the delivery of the lens is attempted.
Whatever be the variety of the lens, as soon as its
equator has engaged in the wound the forceps may
further directly assist in moving the lens upwards by
light pressure, or rather counter-pressure, at the left lower
n8
Cataract Extraction
margin of the cornea, while the hook or spoon is applied,
with more or less rocking movement, at the lower and at
the lower and right margin. Either the closed ends of the
forceps may be used (see Fig. 68) or, in operating on the
left eye, the flat of the blades applied obliquely. The
FIG. 68. EXPRESSION OF THE LENS.
The nucleus is seen already lying on the outer canthus, and cortex
is issuing from the wound.
weight of the two instruments distributed thus over a
wide area below appears to combine the greatest efficiency
with safety. After the lens has slowly passed upwards,
occupying the wound, the hook or spoon follows, pressing,
if need be, alternately on either side. The bulk of the
lens may finally be caught by the forceps as it escapes, or
Description of the Operation i r 9
may be lifted out of the wound by the forceps (or if the
spoon be used, the lens is received and removed in its
bowl).
Unless the sclero-corneal section be of full size, the
sharp edge of a large firm lens may carry the pillars of
the coloboma folded over it into the wound, nipping the
iris between lens and cornea. But we have seen very little
of this, owing to the regular use of a sufficiently large
incision, and perhaps also owing to the making of a deep
coloboma up to the base of the iris. In eyes with marked
vitreous tension, however (see below), it is not always
possible to avoid the entrance of iris into the angles of
the wound.
The above description of lens expulsion differs from the
practice usually followed, which is the same in combined
extraction as in simple extraction. Continuous counter-
pressure above with spatula or curette is combined with
pressure below. The less peripheral the section, the more
necessary is depression of the upper lip of the incision to
guide the lens forward. But it is not needed, as in simple
extraction, for drawing the iris backwards. And the path
of the lens is more directly upwards. Acute watchfulness
is required in the use of counter-pressure above, lest by
sudden upward movement of the eye the instrument be
carried into the wound.
For fully ripe cataracts the exact method of expulsion
matters comparatively little in the combined operation.
But in expressing cataracts in the least degree unripe it is
important that no trace of sticky cortex be left in the
lower periphery. It must be displaced up with the body of
the lens, otherwise later efforts to remove it will probably
fail. And for this purpose I have found the above procedure
most effective. But it is essential that the beginning of the
lens movement shall be slow and gradual.
120 Cataract Extraction
A little soft cortex may be stripped off the back of the
lens by the undepressed scleral lip of the wound, but lens
matter left lying thus near the wound is comparatively
easily dislodged afterwards. Cortex left below has always
appeared to me particularly difficult to move. It is farthest
away from the influence of the stream from the irrigator,
unless the nozzle be introduced to a dangerous distance
within the anterior chamber. And it is less responsive to
pressure applied upon the eye than lens substance which
has already been more or less displaced from its original
bed.
The earlier operators delivered the lens by finger pressure
through the lids. With the lower section spontaneous delivery
was not uncommon when the patient looked upwards. Assist-
ance was given by pressure below the wound through the lower
lid, and light counter-pressure above. The direct utilization
of the sense of touch is an advantage which is lost in instru-
mental expression. But the great objection to this use of the
lids is that in unexpected movements of the eye the margin of
the open wound is liable to sweep along the lid surfaces and
borders, and thus possibly to become fouled by material con-
taining pathogenic organisms. Contact with the lid borders is
especially to be feared. Not only are they insusceptible of
complete sterilization, but they may become more or less coated
with Meibomian secretion, squeezed out by the pressure of the
fingers upon the lid. Many well known surgeons still employ
pressure through the border of the lower lid to express the
lens. The upper lid is elevated by retractor or by the finger,
and counter-pressure above generally by spatula or spoon.
With an upper section there is not so much risk of direct soiling
of the wound by the lid borders as with the lower section. But
the danger incurred of vitreous expulsion by contraction of the
lower lid upon the globe seems needlessly great. Trousseau
presses out the lens by the back of the blade of the Graefe's
knife, occasionally aided by counter-pressure applied by the
edge of the upper lid.
Von Graefe tried various manoeuvres to expel the lens through
his comparatively narrow wound. At one time he attempted
Description of the Operation 121
to draw the lens upwards by movements of the spoon over the
sclerotic from each end of the section. He also utilized the
downward pull of fixation forceps, spoon pressure at the lower
corneal margin, and upward strokes over the corneal surface.
In the delivery of the lens two chief points are to be
borne in mind : firstly, to expel the lens as nearly as pos-
sible whole, in one mass ; and secondly, and much more
important, to ever avoid rupture of suspensory ligament, by
too heavy or improperly applied force. It cannot be too
strongly insisted upon that pressure and manipulation for
the delivery of lens or of cortical remains need never be
other than very gentle, if properly directed, and if the
sources of difficulty are sought out. Heavier pressure is
much more likely to rupture the zonule or posterior
capsule than to move lens matter which has resisted lighter
efforts. Very slow early movement of the lens is not
always a sufficient guarantee that unsafe force is not being
used, though, on the other hand, rapid early movement
may be generally accepted as evidence of the employment
of unnecessarily great, and therefore dangerous, pressure.
While the exercise of patience and restraint is vastly im-
portant, it cannot be held that any great display of skill
or dexterity is needed.
There are other occasional difficulties in the delivery of
the lens in addition to those already mentioned, viz., dis-
placement of the lens upwards or to the side, and adhesion
of the conjunctival flap and wound margins by means of
blood-clot. They occur thus :
i. There may be trouble from too small a section. This
can only happen with a badly cut section, the incision at
the deep surface of the cornea being much smaller than at
the external surface, or from the use of a short flap in
extracting a lens with large hard nucleus. One may be
122 Cataract Extraction
tempted to employ rather heavy pressure, and so cause
loss of vitreous. For the enlargement of the wound
Stevens' curved tenotomy scissors are well suited. I think
it is easier to cut with scissors than with a blunt-ended
' secondary ' knife. Melville Black (Denver) uses a probe-
pointed Graefe's knife.
2. The capsule may be intact or insufficiently opened.
(a) One is naturally alive to this possibility when one
has used the cystitome with its point buried in blood-clot.
The lens is found to move readily, but to a very limited
extent, whenever pressure is placed upon the eye. It
then stops dead. A second use of the cystitome generally
puts matters right.
(b) In Morgagnian cataracts the making of a mere
puncture, insufficient even for the passage of the smallest
nucleus, is to be frequently expected, especially with the
more opaque (dotted) capsules. Any trouble in expelling
the nucleus of such a lens may unerringly be attributed to
this source. Persistent cautious attempts at expulsion are
usually successful in enlarging the aperture sufficiently
after a time. But it is a tedious process, and at the end
one finds often that the capsule has been more or less
displaced upwards, though whether the tearing of the
suspensory ligament which this reveals has occurred more
particularly during the capsulotomy or during the expres-
sion may remain a matter of conjecture. If the capsule
has been so much displaced as to lie folded close to the
wound, and possibly in all cases when displacement can
be made out i.e., when the lower limit of the capsule can
be seen its removal with iris forceps at the close of the
operation is indicated, lest the dangerous complication, in-
carceration of capsule in the wound, should follow. Occa-
sionally the enlargement of the capsular opening under
pressure does not take place, and the nucleus is found to
Description of the Operation 123
come out enveloped in the capsule. In any case the mode
of expulsion of the nucleus of a Morgagnian cataract is
quite different from that of a complete lens. It is pushed
upwards by repeated light strokes with the convexity of the
hook applied to the cornea below it. The strokes being
directed against the lower margin of the nucleus, the latter
readily slides upwards as far as the enclosing capsule
permits. When its upper margin has arrived close to the
wound the upper lip of the incision is depressed with the
fixation forceps, or preferably with spoon or loop, to guide
the presenting edge of the nucleus forward. But the
pressure applied with either instrument, above or below,
must be very moderate. And as soon as the nucleus is
found to be held rather firmly by tough capsule, the pre-
caution is taken of substituting Desmarres' retractor for
the stop-speculum. A second attempt with the cystitome
introduced from the side, to widen the capsular opening,*
may succeed in this, or may assist in intracapsular delivery
by tearing the zonule below.
The same pushing strokes are needed for the expulsion
of overripe cataracts, formerly Morgagnian, consisting of
nucleus and capsule only. Here, as already stated, if the
capsule be transparent, one has no means of judging
whether the capsulotomy has failed completely or not,
except by results.
(c) One must expect a little trouble with very opaque
capsules, presenting the large dense anterior plaque. But if
the opening has been made with a sharp instrument,
* Care must be taken that the nucleus is behind the point of the
cystitome guarding the posterior capsule. In one case I punctured
the posterior capsule in an attempt to widen the opening, and, the
patient being nervous and unable to keep his eye turned down, I
preferred to leave matters as they were rather than to incur certain
loss of vitreous in the expulsion of the nucleus. The latter had
become displaced laterally, so that there was a sufficient aperture for
vision.
124 Cataract Extraction
and enlarged if necessary by tearing, the shrunken lens
may be expected to come through piecemeal. The
expression may be tedious, since the capsule as a whole
may be too tough for the opening to stretch or enlarge
easily. Yet less pressure is required than would have
been needed for intracapsular expulsion, as is shown by
the preservation of the zonule intact. There is generally
a broad equatorial rim of firm cortex which may need to
be washed out in sections.
Should the zonule have been torn below by pull by
cystitome or forceps on the dense anterior capsule as
shown by slight displacement of the shrunken lens
upwards the capsule lying in the wound serves as a
guide to the lens and a support to the vitreous,
preventing disturbance of the latter under moderate
pressure. The capsule may be dealt with afterwards
(see Chapter IV).
(d) There are more puzzling cases in which difficulty is
experienced with the capsule though the cataract is not
overripe. The source of the trouble is therefore not
readily recognized. Some of our difficulties have been
due to the making of an insufficient opening by a blunted
cystitome (damaged by numerous heatings in the flame).
In other cases the capsule has been seen afterwards to be
very slightly opaque, though this was not clearly recog-
nizable while the lens was in place, and the trouble was
therefore probably due to rigidity of the capsule. Soft
cortex may come forward freely through the opening, yet
the bulk of the lens is persistently held back. Or if the
cortex be firmer, continued pressure on the globe may
force the margin of the lens upwards a trifle more at one
point than elsewhere i.e., at the site of the partly opened
slit in the capsule. Finally, if the cystitome be not again
introduced, and if the attempts at expulsion be continued,
Description of the Operation 125
the capsule suddenly gives way, and the lens slips upwards
through the wound.
3. Firm coherent lenses are naturally less easy of
expression than those with soft and diffluent cortex,
though they are more likely to come out whole or nearly
so. Thin discoid lenses, especially the smaller ones, are
sometimes singularly, and somewhat unaccountably, irre-
sponsive to pressure put upon the eye. Care must be
taken to avoid making the sclero-corneal incision gape
unnecessarily. The sharp and thin upper margin of the
lens may be seen tilting forwards with the cornea, and
one fears for the stretched zonule* presenting in the
wound. A second insertion of the cystitome to widen the
capsular opening does not mend matters. The smaller
lenses must be patiently worked upwards by light, jerky
strokes with the convexity of the hook or spoon over the
lower part of the cornea. And it is an advantage to keep
the wound a little opened at the same time, either by
means of the conjunctival flap gripped by the fixation
forceps, or by a downward pull on the conjunctiva below
the cornea. Larger lenses of the same type begin to move
upward slowly under continued steady pressure on both
sides at the lower edge of the cornea.
4. Difficulty and danger may arise from early rupture of
zonule. The cases are at once divisible into two main
groups according as vitreous has, or has not, come forward
in front of the lens.
(a) Where the lens has not sunk backwards into the
* In simple extraction of these lenses there appears to.be less risk
of rupturing the zonule. Owing to the support of the iris, one
appears to be able to tilt forward the cornea to any extent with
impunity. I think that the marked difference in the proportion of
vitreous losses experienced by some operators (e.g., Drake Brock-
man ; see Chapter IV) in combined and in simple extraction, must
have been chiefly in operating upon these lenses with firm cortex
and thinned equatorial portions.
126 Cataract Extraction
vitreous, there is frequently a fair chance of finishing with-
out vitreous accident, or without increasing the vitreous
loss should some already have been lost. The tear in the
zonule may be either below or above the lens.
Rupture below the lens is much the least likely to give
trouble. There is a tendency to slight displacement of
the lens upwards, rendering depression of the upper
margin of the wound imperative before expulsion is
attempted. And if particular care be not taken, vitreous
may follow the lens into the wound. But other cases of
slight rupture occur, perhaps from the pull of the cystitome,
without one being made aware of the fact, till focal
illumination reveals it at the time of discharge of the
patient.
Rarely the pressure or pull of the knife in completing
the section may have been such as to rupture the sus-
pensory ligament above. The lens may have been seen to
slip more or less downwards. If vitreous tends to protrude
only when pressure is put upon the eye, none having yet
been lost, and if the displacement of the lens is quite
small or inappreciable, capsulotomy may still be carefully
performed and ordinary expression aimed at, because the
only alternative vectis extraction of the lens in its capsule
is certain to lead to considerable loss of vitreous, since
the lens does not come easily, being held below. On
other rare occasions the rupture may have been due to
some sudden accidental pressure of speculum or other
instrument upon the globe, or through spasm of the
orbicularis, or otherwise. A little vitreous may have been
forced out of the wound, and yet the lips of the wound
may have come together again. The eye may be ' slack,'
and there may be no apparent tendency to further loss of
the humour. The same practice may be followed here.
The scleral lip of the wound must be well depressed with
Description of the Operation 1 2 7
spoon or loop, which is ready to be slipped in behind the
lens in case of necessity. The objection to the capsul-
otomy in these cases is that cortex is apt to be left behind.
Little or no attempt can be made to extract this after the
bulk of the lens has been expelled. Hence the practice
is limited to fully ripe cataracts, in which trouble with
cortex is least to be anticipated.
In cases where the wound is distinctly occupied by a
prolapse of vitreous, broad or narrow, the spoon or loop
must be at once inserted into the globe. The introduction
of the instrument is always done in fear and trembling.
Some degree of downwards rotation of the globe (variable
according to the prominence of the eye) is essential, and
one is placed in an almost hopeless position if the patient
cannot maintain this position of the eyeball with some
steadiness, since fixation by forceps is now quite out of
the question. (Possibly further instillation of cocain
may enable a troublesome patient to keep his eye more
fixed.) The speculum is retained if the lids show not the
least tendency to contract ; otherwise Desmarres' retractor
and finger depression are substituted. The spoon, held in
the left hand, is first insinuated only behind the upper
half of the lens to serve as a guide and support. Pressure
is then cautiously applied with the hook or tortoiseshell
spoon about the lower margin of the cornea in the usual
way, and the lens thus delivered between the two instru-
ments. But should the lens not come readily thus, and
vitreous be escaping, the spoon must be passed down as
far as the lower margin of the lens, to get a purchase upon
it and to draw it upwards, pressing it against the cornea.
Even so assistance may sometimes be afforded by light
pressure with the additional instrument in front of the
cornea.
(6) In other cases the lens is obviously displaced more
128 Cataract Extraction
or less backwards, embedded in vitreous. In India this
dislocation may be the previous work of a vaid or hakim,
Or possibly, in a diseased eye, the depression may have
taken place during the section cutting. We have here
the lens in its capsule to deal with. In still other cases the
faulty position may be due to ill-advised pressure with the
cystitome, or to accidental displacement by the same or
other instrument in a restless eye. And the capsulotomy
having been performed, cortical matter may possibly have
escaped out of the capsule, mixing with the surrounding
vitreous, where it must usually be left. It may prove
difficult to pass the loop over the upper edge of the lens.
Preliminary depression of the upper wound margin by the
instrument must be tried. It may still serve to direct the
lens margin into the wound, and to enable the spoon to slip
in behind it. If it fails, the loop must be directed within
the wound, at first directly backwards.
The attempt may displace the lens bodily downwards
and backwards, to lie loosely in the vitreous humour. In
such a case it is recommended to remove the speculum
and to wait until the lens comes up again into the
pupillary area, and then to extract it with the loop. This
reposition may take place within half an hour, or not for
some weeks, if at all, necessitating in some cases reopen-
ing of the closed wound or the making of a fresh incision.*
I have preferred to follow and remove the lens, even though
vitreous were escaping through the open wound.f In other
cases the spoon or loop presses the upper margin only of the
lens backwards, causing the lens to rotate on its horizontal
* Hoor, Zeitsch. f. pr. A., 1900, p. 19.
f Twice I have lost the lens in the vitreous permanently once in a
child and once in an adult. In the case of the adult the nucleus of
the lens only was thus lost, and the patient went out of hospital with
fair vision, after a 'needling' of a thin inflammatory pupillary mem-
brane.
Description of the Operation 129
axis, the lower margin coming forward and upward to
present in the wound.
5. One must expect considerable trouble at times
simply from the patient's stock of self-command having
become exhausted for the time being. One can get the
lens margin to present in the wound fairly easily, whatever
be the position and the degree of steadiness of the globe.
And in most cases it is not difficult to get the lens or its
nucleus sufficiently delivered to be seized and lifted out
by the fixation forceps, even though the eye be directed
somewhat upward. But with an eyeball swinging rapidly
upwards at intervals there is danger of the open wound
sweeping along an imperfectly sterilized upper palpebral
surface. Also one fears lest the margin of the half-
delivered lens be caught against the lid surface and bent
forwards and downwards, carrying the corneal flap forcibly
down with it. I have, however, never yet seen accident
caused thus. It may be necessary to remove the speculum
for a couple of minutes or so, and to instil cocain to enable
the patient to regain some self-control. Afterwards as little
is said as possible to him, and one must be prepared to ex-
press the lens with the eye perhaps turned a little upwards.
Fixation with forceps may help a little to restrain upward
movement, and also may assist directly in the expulsion
of the lens.
The delivery of a cataract is thus in the great majority
of cases by expulsion or expression. The comparatively
rare extraction or withdrawal by means of sharp hook or
forceps, or spoon or wire loop, is practised where opaque
capsule needs removal, or where expulsion is inapplicable
on account of, or from fear of, rupture of the zonule.
In von Graefe's earlier modified linear operations the exit of
the lens through the narrow wound had to be assisted by
9
13 Cataract Extraction
traction with sharp hook in about two-thirds of the cases i.e.,
whenever there was a hard nucleus of some size.
It is more particularly during this stage of the operation
and afterwards that one may be troubled by undesirable
evidences either of excessive or of deficient tension in the
eye. On the one hand there may be an alarming tendency
to expulsion of the contents of the globe, or, on the other
hand, falling back of the cornea to occupy the space
resulting from the loss of the lens and of aqueous humour,
or more rarely some collapse of the globe as a whole.
The two conditions seldom bear any relation to the tension
of the eye as tested clinically before operation. The eyes
which become slack during operation may even feel harder
than normal beforehand, owing to senile rigidity of the
sclerotic. And, according to my experience, the ' vitreous
tension ' observable after the eye has been opened may
be absent in glaucomatous eyes. Certainly very marked
examples of it are seen in eyes apparently normal except
for the cataract present.
Though well marked cases of vitreous tension are de-
cidedly uncommon, minor grades of the tendency are
fairly frequently met with. The patients are usually com-
paratively young perhaps forty or forty-five years old
and stouter in physique than the average. Their eyelids
are sometimes noticeably tense, so that one cannot raise
them well from the globe by the speculum, and the eye-
balls are often somewhat prominent. The anterior
chamber is frequently shallow, and the lens usually
contains soft, flocculent, cortex. But the indications are
neither sufficiently constant nor sufficiently characteristic
to enable one to recognize the eyes beforehand. How-
ever, the conditions responsible for this vitreous tension
being bilateral, one is able after operation upon one eye to
anticipate it in the fellow eye.
Description of the Operation 131
As the section nears completion the lens and iris are
pressed forward against the cornea, precluding the admis-
sion of any blood into the anterior chamber. As soon as
the capsule has been opened, the lens, or the greater part
of it, tends to slip upward, presenting in the wound. The
lens may then slowly rise and make its exit spontaneously.
Or a mere touch with an instrument on the lower part of
the cornea, or a slight forward pull on the conjunctival
flap is sufficient to deliver the lens. Afterwards the section
may remain pressed a little open, and iris is apt to be
incarcerated at each end, and to resist the feeble attempts
at replacement which one may feel justified in making.
Hence possibly permanent defects considerable astigma-
tism, and all the possibilities associated with prolapse or
incarceration of iris. And if the cataract is at all unripe,
much cortex may have to be left behind, since the usual
measures comprised in the ' toilet ' of the eye are applic-
able to only a very limited extent. The speculum is
maintained most carefully elevated, and the eye kept as
quiet as possible, and the operation finished quickly for
fear of rupture of the suspensory ligament. Such eyes are
supremely unfitted for intracapsular extraction of the lens.
Any opening in the posterior capsule or zonule must lead
to a considerable loss of vitreous. And ordinary simple
extraction is obviously inapplicable. The iridectomy
should be larger than usual.
More or less evidence of the opposite condition slack-
ness of the eye is more common. It is seen more
particularly in the older patients. A considerable propor-
tion of them are emaciated, with sunken eyeballs and lax
lids. Blood and irrigating fluid tend to accumulate in the
anterior chamber until expelled by external pressure.
There may or may not be marked rigidity of the sclerotic.
In the former case the cornea falls back into a deep cup
92
132 Cataract Extraction
as soon as the body of the lens has been expressed, and this
persists after removal of the speculum. In the latter case
the cupping is less deep, and there may be some infolding
of the inelastic sclerotic. These conditions may perhaps
be seen only while the speculum is elevated. Should the
latter be released, the weight of the instrument and of the
lids may restore the globular shape of the eye. Where
the sclerotic is quite rigid, the removal of cortical remains
by external pressure is impossible unless the scleral lip of
the wound is well depressed. The lens matter may, how-
ever, be washed out and the cornea refloated by a stream
of fluid from the irrigator. These slack eyes are well
suited for intracapsular extraction, because there is no
tendency to loss of vitreous except by external pressure.
They are also well suited for simple extraction, since
prolapse of iris is unlikely to occur.
I have only seen one case of the rare extreme collapse
of the globe, of which isolated reports have been published.
The lens was overripe, consisting of nucleus and capsule
only, not tremulous. As it did not come easily, the zonule
was purposely torn by pulling on the lens with a blunt cysti-
tome. The collapse of the eye came on gradually, but there
was no evidence of escape of vitreous. The lens had to be
delivered by loop within the eye and pressure outside. Finally,
the sclerotic was much folded and the corneal lip of the wound
overlapped the scleral lip considerably.
The explanation of these conditions is largely conjectural.
Variations from the normal elasticity and firmness of the
sclerotic, and in the position of the globe as affected by
increase or absorption of orbital fat, influencing the tension
of the recti muscles, are obvious explanatory suggestions.
Possible spasm of the tensor choroideae, suggested by
Nicati as a cause of spontaneous expulsion of vitreous,
may be mentioned in connexion with vitreous tension.
Description of the Operation 133
Corneal collapse is said to be predisposed to by over-free
instillation of cocain. The gradual onset of the state of
collapse of the globe in the case just related appeared to
show drainage from an extraordinarily fluid vitreous. The
condition predicates an atrophy of the vitreous, and
possibly also an atrophic zonule (Czermak). Chodin,*
who published two cases, thought the sclerotic might have
been of extraordinary tenuity, and without elasticity.
All operators of any considerable experience must at
times have been relieved of the necessity of delivering the
lens, by its accomplishment through spasm of the orbicu-
laris forcing the arms of the speculum or the retro-tarsal
portions of the lids on to the globe. According to the
stage at which this occurs one may be relieved also of the
necessity of iridectomy, and of capsulotomy. Rarely the
lens alone may escape unaccompanied by vitreous. The
somewhat bulky list of troubles and difficulties above
detailed might well incline one to the endeavour to simplify
matters by delivery of the lens in its capsule. But many
of the troubles described are only rarely encountered.
And due recognition of the difficulties ensures that few of
them need prove insurmountable, or even grave.
TOILET OF THE EYE.
The procedures embraced by this term are to be con-
sidered in three subdivisions : I, the removal of lenti-
cular cortex, blood, and free iris pigment from within the
globe; II, the replacement of iris and of capsule and
the adjustment of the wound surfaces, free from entangle-
ments; and III, the cleansing of the conjunctiva and of
the lid borders.
* Westnik Ophth., xi (1894), 78.
134 Cataract Extraction
I. Such blood-clot as may have escaped expulsion with
the lens will be found to be held by adhesions to lens
capsule or to iris. Some of it may come away with the
lens cortex, but often it has to be left to become absorbed,
and it may render the removal of cortex more difficult.
Any small quantity of aqueous now accumulating in the
anterior chamber (in slack eyes) usually appears muddy
from admixture of traces of blood and of iris pigment. It
may be expressed through the wound by the curette or
lens expressor. Its expulsion serves to wash out the
chamber a little, and may be facilitated by depressing the
scleral lip of the wound. Any bright fluid flood present
in the chamber naturally demands expression or washing
away. But should the chamber refill at once from bleed-
ing vessels covered by conjunctival flap, repeated expression
is useless, and the blood must be left for absorption. In
a few eyes there is to be seen a considerable quantity of
dust-like pigment, rubbed off the back of the iris by the
pressure and friction of the escaping lens. It seems
better to wash out these minute particles, lest they should
aid in the lodgment and growth of any micro-organisms
which may gain an entrance.
An air-bubble may also need expulsion from the
anterior chamber by pressure or by the douche. A little
air is liable to be sucked in through the wound at times,
when the latter is opened by the introduction of instru-
ments, especially, perhaps, in eyes with collapsed cornea.
If its removal proves troublesome it may be left to become
absorbed.
But our chief concern is with any cortical matter which
remains after the expulsion of the bulk of the lens. In
few instances of ordinary cataract extraction are the
contents of the lens capsule expelled absolutely in one
mass. Even where the cortex is abnormally firm and not
Description of the Operation 135
readily separable from the nucleus, equatorial fragments
are not infrequently broken off and left behind. Where
the cortical layers are softened and broken up large
amounts may be left behind, so much so that occasionally
in a faulty operation the nucleus slips out alone. Even
in Morgagnian cataracts, in the occasional examples
when the fluid is slightly creamy in consistence, some of
this most irritating fluid may need removal from behind
the iris. In operating upon distinctly unripe cataracts with
superficial layers scarcely changed at all from the normal
transparency, unless great care has been taken to. secure
initial dislodgment from the lower periphery, very much
sticky substance may remain. Its exact limits will not
be clearly recognizable till the following day, when, by
clouding, it will have become readily visible, and by rapid
swelling it may have expanded to fill up the whole of the
pupillary area and coloboma.
The Removal of Cortex. Lens remnants may be dis-
placed either (i) by expression, or (2) directly with
curette or spoon, or (3) by irrigation. Should the first
method the least objectionable prove very inadequate,
it may have to be supplemented by one of the others.
(i) Ripe cortex, whether firm or flocculent, may often
be removed fairly completely after the delivery of the
bulk of the lens by external pressure. And even unripe,
and therefore somewhat sticky, material may be got away
fairly well if it has already been a little displaced from its
original bed during the expulsion of the lens. Those who
deliver the lens by digital pressure through the lower lid
naturally utilize the same means to express the cortical
remains ; and many who use instrumental pressure for
the body of the lens prefer to remove the speculum and
practice the ' lid manoeuvre,' for the remaining cortex. In
the time-honoured ' milking ' movements, the finger is
i3 6 Cataract Extraction
applied with light pressure over the closed lids. Rotatory
and radial movements over the cornea collect the lens
matter from the periphery towards the pupil. And the
border of the lower lid is utilized to push the cortex up
through the wound, the upper lid being drawn up from
the globe.
The same objection applies to this use of the lower lid
on the score of infective risk, as in expulsion of the lens.
Czermak used direct pressure upon the cornea with his
forefinger clothed in a sterilized closely fitting rubber
covering.
I have preferred always to continue with the same
instrumental pressure and movements as in delivering the
lens. Repeated light, quick strokes upon the cornea with
the convexity of spoon or curette or hook are commonly
effective in moving the underlying cortex. The passage
of the material out of the eye is facilitated by depression
of the posterior lip of the wound. This is particularly
necessary in eyes with cupped cornea. In such eyes,
with the sclerotic pressed well back by a curette, there is
no especial difficulty in expelling lenticular debris, whereas
without this counter-pressure above nothing is in the least
effective but irrigation. Persistent efforts to express
refractory cortex are inadvisable because the zonule or
posterior capsule easily gives way, and because of the
continued slight bruising of the iris, rubbing off its
posterior layer of pigment cells and doubtless rendering
its tissue more vulnerable to the attacks of micro-
organisms.
(2) It is a fairly common practice to withdraw a particle
or two of lens substance from the neighbourhood of the
wound by the introduction of the curette. But all un-
necessary insertion of instruments for this purpose is to
be deprecated. There is the minor risk of puncturing the
Description of the Operation 137
zonule or capsule, and the much graver danger of carrying
in infection from the conjunctival surface.
(3) Irrigation of the chambers and of the capsular sac
may be decided upon as advisable or necessary for the
final removal of cortex, blood, or iris pigment. But it is
well always first to dislodge peripheral fragments by light,
intermittent, jerky pressure with spoon or hook over the
corresponding portions of the corneal circumference and
neighbouring sclerotic.
(a) By Siphon-Douche. The flask is held at an elevation
of rather less than a foot above the eye. The tube of the
irrigator, taken from the attendant, is grasped between
the finger and thumb close to the nozzle, and a stream of
fluid directed on to the globe and into the lower fornix to
cleanse these surfaces as thoroughly as possible. If the
eyeball be at all sunken, and still more if the palpebral
aperture be shortened from old trachoma, the lids, elevated
by the speculum, form a deep cup in which the irrigating
fluid collects, covering the globe. The pool of fluid may
be drained away by tilting the head well to the side, and
by the assistant allowing the speculum to fall back upon
the eye. But more than momentary release of the
speculum is not permissible except in the case of reliable
patients. And there are eyes so sunken that, even with
the speculum unsupported and the head moderately tilted,
the wound cannot be kept above the level of the fluid
which collects in the conjunctival sac whenever the stream
is allowed to enter.*
In such eyes irrigation should be avoided altogether
unless the healthiness of the conjunctiva is undoubted.
For if the irrigator nozzle be inserted into a wound thus
* This covering of the wound by the fluid accumulating in the
conjunctival sac is impossible to avoid in most eyes if a downward
section be made. This constitutes a minor objection to the lower
section.
138
Cataract Extraction
covered with fluid, the ingoing stream (unless, possibly,
if the end of the nozzle be passed far within the chamber)
must suck in also a current of fluid from the conjunctival
sac. The risk of thus drawing in micro-organisms is
very obvious, though it may be urged that immediately
after a thorough douching there can be extremely few
surface organisms remaining so loosely attached as to be
possibly carried by a feeble current into the eye. A very
FIG. 69. IRRIGATION OF THE ANTERIOR CHAMBER.
free use of the douche should be confined to eyes with
conjunctive presumably free from pathogenic organisms,
and in which there is no difficulty in keeping the wound
above the level of the conjunctival pool of fluid.
The tip of the nozzle being then brought quite close to
the wound, a little above it, the stream from it may often
be thrown into the chamber, especially if the conjunctival
flap be lying turned down over the cornea. This may
suffice to float up through the incision some or all of the
cortex still remaining in the eye. But usually the extreme.
Description of the Operation 139
end of the nozzle has to be inserted at one angle of the
wound (see Fig. 69), its direction being transverse or
oblique, and fixation of the globe being commonly dis-
pensed with. And the stream is directed on to any
particles of lens matter within range. The same may
need to be repeated, possibly, at the other end of the
section. Refractory peripheral fragments may perhaps
be made to move by allowing the current to play all
round them. Should the douche prove ineffective, it is
stopped temporarily while light, jerky external pressure is
again applied at the corneal margin, especially in the
position corresponding with the refractory piece of cortex.
Once the movement inwards from the periphery has been
thus begun, the douche readily obtains a purchase upon
the dislodged particle.
In perfectly steady eyes the tip of the nozzle may be
passed far into the globe, behind the iris if necessary,
even below. Bringing the mouth of the tube thus quite
close to a piece of cortex undoubtedly enhances consider-
ably the effect of the stream upon it. And the force of
the current may be momentarily increased by the atten-
dant raising the flask to a height of rather more than a
foot above the eye. But it is rarely necessary to point
the nozzle directly downwards within the chamber.
When this is done, it is well for the assistant to bring the
fixation forceps into use again, to restrain any possible
upward movement of the globe likely to thrust the
cannula through the posterior capsule. It is, on the
whole, preferable to leave a little lens matter in the eye
rather than to introduce the nozzle repeatedly far within
the chamber, and rather than to irrigate very freely.
A fragment of lens substance may defy efforts at
removal through having become attached to the iris by a
thread of blood-clot, though otherwise free and movable.
140 Cataract Extraction
Another temporary annoyance is that particles are
occasionally whirled repeatedly around in the chamber
instead of coming up through the wound. The nozzle
may sometimes be of service, with the stream stopped for
the moment, to sweep up particles of firm cortex lying
fairly near the wound, whether adherent to blood-clot or
not. Small bits are occasionally driven down between
the iris and cornea into the lower periphery. They may
even have to be left there, more or less adherent to the
iris.
The ' milk ' of ordinary Morgagnian cataracts is easily
washed away. Elliot, of Madras, also washes the nucleus
out from the eye. But at times the fluid part of the
cataractous lens is of somewhat creamy consistence.
And (especially in simple extraction) there may be some
little trouble in evacuating the posterior chamber com-
pletely, without passing the nozzle of the irrigator behind
the iris. Alternations of douching with external pressure
over different portions of the corneal margin is indicated.
We had two cases of inflammatory glaucoma set up by
some of this irritating material left behind the iris.
I have always expelled any trace of fluid remaining in
the anterior chamber after irrigation by passing the
curette or tortoiseshell spoon upwards over the cornea.
Prolonged contact of the ocular tissues with a fluid differ-
ing in composition from normal aqueous, and perhaps at
a somewhat low temperature, appears undesirable. And
there are always doubts as to the possible presence of
conjunctival micro-organisms in the fluid.
(6) Of irrigation with a double-current syringe I have no
experience. Surgeons who use this instrument claim that
they avoid certain dangers and inconveniences associated
with single-current douches. They hold that a forcible
current from the latter is dangerous and productive of
Description of the Operation 141
pain lasting for some little time after operation ; and that
the stream playing in the anterior chamber may hold back
lens matter in the posterior chamber, and that when it is
directed into the latter chamber it tends to propel the iris
into the wound (in simple extraction). But these objec-
tions have very little weight. On the other hand, the
general need for the insertion of the cannula of the double-
action syringe far within the wound is a distinct drawback,
and must lead to occasional accidents. The double
syringe would appear to be much less likely than the
ordinary douche to draw conjunctival organisms in through
the wound. But to counterbalance this advantage, the
narrow outflow cannula must prove quite an inadequate
exit for many of the fragments of cortex which are com-
monly washed out of the eye, and must at times get
choked.
II. The pillars of the coloboma are now pushed together
by the curette* or iris repositor passed in horizontally at
each angle of the wound. The coloboma, after the passage
of the lens and cortical remnants, is rarely as narrow as it
might be, and its inert pillars are often slightly folded.
But it is very uncommon for any part of the iris to have
been forced into the angles of the wound unless by vitreous
(in vitreous tension or prolapse or escape). In this last
instance comparatively little can be effected in the way of
iris replacement. If vitreous is not actually escaping,
further excision of iris may be possible at each side to free
the wound. Nothing can be attempted in any case
where the patient has quite lost control over his eye
movements, and cannot keep the globe steady. The
* Now often taken up for the first time, and therefore, after the
rather long exposure upon the instrument rack, rinsed before use with
salt solution from the irrigator.
H 2 Cataract Extraction
horizontal direction of the instrument is important,* and
all tendency to elaboration in procedure inadvisable. A
mere touch or two with the point of the spatula or curette
upon the iris at either side usually suffices to obliterate its
folds, and to narrow the coloboma sufficiently. If there is
at all a complete conjunctival flap some lateral movement
of the intrument may be required for its insertion under
the flap. For horizontal insertion at the nasal end of the
wound the spatula or curette should be more or less
curved. Even so some outward rotation of the globe is
usually necessary, the patient being made to follow with
his eyes the necessary movement of his hand, directed by
the assistant.
We have found that with the narrow iridectomy which
we have always made, this replacement of the iris is quite
effective also in reducing possible entanglements of capsule
from the wound. We have not found any special atten-
tion to the capsule necessary if the pillars of the coloboma
be approximated as well as they can be. Some operators,
especially in simple extraction, prefer to replace iris and
capsule, particularly when prolapsed, with the stream from
the irrigator. Should these means fail, it is recommended
to seize the pillars of the coloboma with iris forceps, and
to draw them into position thus. Should the iris still not
remain in place, the wound may be searched diligently
with iris forceps, with the aid of focal-illumination, for
points of capsule possibly lying in it. According to
L. Miillert a tag of capsule may be fixed in an angle of
* The eye is thus safeguarded against accident, in case of sudden
upward movement. The minute and accurate replacement of the
displaced iris with a spatula directed vertically downwards within the
chamber, as sometimes taught, is a measure adopted only for more
reliable and steady patients than it has been my lot frequently to
encounter.
t Kl. Mbl.f. A., xl (1902), Bd. i.
Description of the Operation 143
the wound, and may hold the iris fast there also. The
spatula, in attempts to replace the iris, glides over the
capsule instead of entering the fold of the iris.
Knapp, Forster, and Swanzy* have recommended the
routine search for capsule lying between the lips of the
wound. Iris forceps are passed into the incision and
repeatedly opened and closed throughout its length. Any
portion of capsule seized is slowly drawn out, to be either
snipped off with scissors or torn away, with the assistance
of a second pair of forceps if necessary. Swanzy found
capsule in the wound thus in about 25 per cent, of his
cases. Loss of vitreous need not be feared in the partial
removal of capsule if the speculum be first removed.
But it has been objected that in drawing out one portion of
membrane one may pull another portion into the incision.
Should impacted capsule be keeping the iris also dis-
placed, the release or removal of the entangled shred of
capsule should enable the iris to be fully unfolded.
Further excision of iris at this stage of the operation is to
be avoided if possible. It is often difficult and dangerous
(Chapter IV), and leaves a broad coloboma, unsightly,
and with visual drawbacks. But it is vastly preferable
to leaving iris to heal in the wound.
The old operators first attempted to reduce prolapsed
or incarcerated iris by gentle massage of the cornea
through the upper lid. Contraction of the sphincter may
sometimes be excited by the friction.
Blood-clot lying about the wound adherent to sclerotic
and episcleral tissue is removed with iris forceps or curette,
or wiped away with a sterile moist swab.
The conjunctival flap is then carefully smoothed out by
upward strokes over it with the point of the curette. Or,
if the flap be very short, the point of the cystitome may
* ' Handbook of Diseases of the Eye,' 6th Edition, p. 373.
144 Cataract Extraction
be better used for this stretching-out process, this in-
strument obtaining more purchase upon the membrane.
The margins of the deep wound are thus closely approxi-
mated, except where the cornea is collapsed, preventing
immediate close coaptation of the wound surfaces. In
these cases adjustment of the wound surfaces may be
expected to take place automatically when the chamber
refills.
The speculum is now removed. The assistant gives up
his hold of the instrument to the surgeon, who keeps it
elevated with one hand, while he loosens the screw and
presses the arms together with his other hand. The
assistant then draws the lower lid away from the speculum
and keeps it depressed until the upper arm is slipped from
under the upper lid. Should Desmarres' retractor have
replaced the stop speculum, the lower lid must be kept
depressed until the retractor is removed.
III. In Bombay for many years it has been our almost
invariable custom now, at the close of the operation, to
pass the curette lightly over the whole palpebral con-
junctival surface i.e., over the whole secretory portion
of the mucous membrane to remove mucus a second
time. Sufficient time has elapsed since the cleansing
immediately before operation for a further secretion of
mucus to have occurred commonly in response to the
perchloride stimulus. The curette used in this way often
causes rather a sore feeling, and care must be taken not
to occasion contraction of the orbicularis. I have never
known any accident from this cleansing of the conjunctiva.
To guard against it the lower lid has always been firmly
depressed by the forefinger of the assistant, the finger
lying flat upon the patient's cheek, to be out of the way
of the curette. The lower lid in particular needs to be
Description of the Operation
controlled, because its pressure upon the eyeball would
tend to lever the wound open, whereas spasm of the
upper lid would tend rather to close the wound. Any
mucus detached from the lower fornix and lower tarsal
conjunctiva is washed away by a stream from the irri-
gator. The eyelashes of the upper lid are then seized by
the left forefinger and thumb to raise the lid for the passage
of the curette beneath it, the patient looking downwards
FIG. 70. REMOVAL OF Mucus WITH THE CURETTE.
(Fig. 70). The curve of the curette is forwards, so that
the point of the instrument cannot enter the wound by
any mischance. Two or three sweeps of the instrument
in light contact with the stretched palpebral surface are
sufficient to transfer most or all of the secretion to swabs
held by the assistant.
This measure is a continuation of the cleansing practised
immediately before operation, and is a supplement to the
treatment with strong perchloride. There can be no doubt (see
Chapter IV) that the mucus secreted thus early in our cases
must have often contained pathogenic conjunctival organisms.
IO
146 Cataract Extraction
It seems reasonable, therefore, to remove it as fully as possible.
Yet this removal, so far as I know, is exclusively a Bombay
practice. Others who have used perchloride freely have not
troubled about any supplementary cleansing, and have had
good results. We cannot feel sure, therefore, whether this
measure has in any degree served in its object of aiding to
prevent infection of the wound. Possibly it has been mainly
or entirely superfluous ; yet it has been at least harmless. And
since our figures in regard to infection have been quite excep-
tionally good, it may be that this simple precaution has
contributed its mite towards the complete result. Though
ordinarily microbes imprisoned in mucus may be unable to
gain access to the wound, it may be quite otherwise when the
lips of a purely corneal wound, uncovered by conjunctival
flap, are not in good apposition.
Finally, sterile atropin drops may be instilled if much
cortex or blood-clot has been left in the eye, or if the iris
has been exceptionally mutilated, having perhaps shed a
good deal of pigment ; or if iritis is feared from the con-
dition of the patient, as in advanced Bright's disease ; or,
finally, if there is any question of the possibility of
infective organisms having been carried into the wound
e.g., from the lid margins. Dilatation of the pupil
may be secured now in cases where it will be unob-
tainable after twenty-four hours. Since any tendency
to prolapse of iris is enhanced by the atropin, one would
hesitate to use the drops in eyes with vitreous tension or
when the edges of the wound were not in good ap-
position.
THE DRESSING.
The eyelids are closed gently by the surgeon. If the
patient be told to close his eyes he is apt to do it much
too vigorously. A pad of dry absorbent wool, either boric or
simple sterilized wool, is applied on a few layers of gauze
and fixed by a bandage. A shield is fixed over all.
Description of the Operation 147
Sterilized iodoform is applied about the inner canthus by
some surgeons in cases where there has been lacrymal trouble.
At one time in Bombay we applied it regularly over the
cataract wound. It was doubtful whether it did much good,
and very occasionally a little of it found its way into the
anterior chamber.
Pagenstecher applies von Hoffmann's ichthyol dressing over
the closed lids. Pure ichthyol is smeared over the lids and
covered with gauze soaked in liquid paraffin. Absorbent wool
is laid over this and kept in place by a wire shield in the form
of spectacle frames. The ichthyol probably has some anti-
septic action. Others have similarly employed boric and other
ointments to prevent the drying of discharge upon the eye-
lashes, and to offer a mechanical obstacle to the entry of
micro-organisms into the conjunctival sac.
The object of the ordinary dressing is to maintain the lids
at rest and to protect the eye from light (and from dust ?), and
to absorb watery fluid passing out from between the lids. It
must exert little or no pressure upon the globe, and yet must
not be liable to accidental displacement or easy of displace-
ment by the patient. Haab says* of a too tightly applied
dressing : " The pressure of such a dressing constantly re-
opens the wound, and the patient is very apt to try to over-
come the unpleasant sense of pressure by closing the lid
tightly, and thus makes matters worse. If the bandage is
too tight, the tears are prevented from reaching the palpebral
fissure, because the lids are pressed tightly together, and
in this case, also, the patient adds injury by closing his eyes
still more firmly. The tears collect under the lids, blepharo-
spasm increases more and more, and finally there is severe
pain, and, of course, injurious pressure upon the wound, and
harmful retention of the secretions, both from the wound
and from the conjunctiva." A displaced dressing not only
fails in its object, but is likely to press unevenly upon the
eye.
Though occlusion of both eyes is required for some days
after vitreous accident, and for one day after simple extraction,
it is not so much needed after the combined operation. In
Bombay the other eye was simply covered by a loose strip of
* ' Operative Ophthalmology,' p. 48.
IO 2
148 Cataract Extraction
lint hanging from the brow,* where it was fixed by the
bandage.
To guard against the application of possibly injurious
pressure, the absorbent wool covering should be large enough
to lie over all the bony prominences around the eye, and
should be of the same thickness over them as over the lids ; and
the bandage must be broad. Many surgeons are careful to fill
up the hollows around the eye to immobilize the lids. An
ordinary surgical roller bandage, properly applied, affords
reliable fixation. Firm fixation of a single ' occlusive dressing,'
as distinguished from a ' pressure dressing,' is obtainable only
by turns of the roller tightly drawn around the head and fore-
head, and not covering the eye. Two such turns are sufficient,
passing above the ears, but rather low down behind the head.
And if the bandage be broad, 2| inches, only a single turn
below the ear and over the eye is needed. This is not pulled
tightly over the eye, but is drawn well up under the ear. And
it is tested by inserting a finger under it to see that it does not
lie loosely over the cheek. This single turn does not suffice,
however, to prevent the patient from getting his finger under
the dressing, as he is apt to do when awaking from sleep, if
there be any itching of the lids from drying secretion. This is
to be prevented by the shield. A a-inch bandage lies more
smoothly than a broader one, becoming less folded where it
presses above and below the ear, but it does not distribute the
pressure so well over the margins of the orbit.
The patient's head must lie passive, well supported by the
assistant, during the application of the bandage.
The double bandage covering both eyes in a figure-of-8 is
more easy to apply firmly without pressing upon the eye. For
the turn below the occiput and below both ears cannot slip,
and, with both eyes to be covered, the turns may pass less
obliquely across the face, being drawn well in to the ears, above
and below.
Except in very hot weather, the heat of the dressing is not
irksome. In place of the roller bandage single strips of
material gauze, or knitted or webbed material, more or less
elastic are frequently employed. The ends are fixed by
adhesive plaster or by tapes above and below the ears.
* Owing to the poor nursing arrangements, the patients used to
find their way about the wards unassisted almost from the beginning.
Description of the Operation 149
Russell Murdoch's bandage, made of flannel, is one which
we have used in Bombay with satisfaction.
Or simple strapping may be employed in narrow strips from
the forehead down over the cheek. The use of long strips of
strapping is unpleasant, especially if the eye has to be exposed
more than once a day for the instillation of atropin ; and short
strips are liable to displacement.
A shield is required to protect the eye from injury by
accidental pressure or by insertion of the patient's finger under
the dressing. Among single models may be mentioned Fuchs'
wire lattice-work screen, also the perforated aluminium and
Lloyd Owen's cardboard ' Cartella ' shells. Unless well fixed
by strapping they are scarcely so firm as the double shields.
FIG. 71. RUSSELL MURDOCH'S BANDAGE.
Among the latter may be mentioned Fuchs' double model and
Bronner's wire shade (see Instrument Catalogues) as suitable
for application over the dressing and for use after the dressing
has been discarded.
Haab has used starched bandages.
AFTER-COURSE AND AFTER-TREATMENT.
The patient is carried to bed if the operation has been
performed on a table. He must expect a little soreness o
the eye for a few hours.
It is a usual custom to keep at least the one eye
bandaged for four days or so in uncomplicated cases ;
occasionally longer, whenever the healing of the wound
is delayed. But every day the coverings should be
removed for inspection of the eye and for cleansing of the
lids.
In our work the dressing was frequently found somewhat
discoloured and stiffened after twenty-four hours, and perhaps
i5 Cataract Extraction
in part adherent to the skin of the lids or surrounding parts,
having evidently been soaked more or less with watery fluid
from the eye. There was some lid swelling from the per-
chloride treatment of the conjunctiva, which lasted for a few days
at least. For the first few days the eyelashes and lid borders
generally needed to be cleansed from mucus accumulated
upon them, with bits of lint soaked in i in 5,000 perchloride.
This mucoid discharge was frequently more scanty and more
transient than that from the fellow eye, in which, perhaps, a
chronic conjunctivitis had been aggravated by mere closure of
the eye, without bandaging. It was not, therefore, attributable
to the perchloride irrigation. At these daily cleansings the
conjunctival sac was not washed out at all. Possibly a little
of the lotion employed frequently found its way in between the
lids, for we thought that when boric lotion was used for the
washing, there were more cases of troublesome persistent con-
junctivitis than when the i in 5,000 perchloride was employed.
The cleansing must be done with care, and possible ill effects
from spasm of the orbicularis avoided by keeping the lower lid
pulled well away from the eyeball throughout. Pressure of
the upper lid alone can do little harm, as it keeps the wound
closed, but pressure of the lower lid alone would force the
wound open.
In our cases there was generally at first some bulbar con-
junctival injection as well as considerable ciliary injection.
The former and much of the latter were attributed to the
strong sublimate solution which had been employed. With us
the ciliary congestion lasted about double the ordinary period,
which is said to average eight to ten days for the redness at the
sides and below the cornea, and fourteen days or more for the
congestion localized about the wound. In some of our cases,
however, there was practically no redness of the eye from
beginning to end.
The patient is kept recumbent for twenty-four hours. He is
directed not to lie on the operated side, and not to lie con-
tinuously upon his back, lest flatulent distension of the abdomen
be set up. He may turn from his back to his side, and back
again without help, but he should understand that frequent
turning tends to loosen the bandage. He must be assisted in
rising from the bed and in lying down for a few days. Very
old people and chronic bronchitics may maintain the sitting or
Description of the Operation 151
semi-recumbent attitude from the beginning, if they are suitably
propped up with pillows ; or they may change their position
repeatedly, provided they remain passive in the hands of the
attendants who move them. A sleeping-draught must be
given, if found necessary, for the first night. The patient may
sit up in bed after twenty-four hours, but even after the
combined operation it is perhaps well that he should not leave
his bed for two or three days.
The bowels are not moved as a rule on the first day, having
been sufficiently relieved by the laxative administered before
operation. The patient must avoid straining at stool. Some
people cannot pass urine into a receptacle while in the recum-
bent posture, and may have to be allowed out of bed for this
purpose. Men with enlarged prostates are perhaps more
liable to retention of urine if atropin is being instilled frequently
after operation, and must be watched in this respect.
The patient must talk little, and must only take soft and
fluid food, requiring no mastication, as long as the bandage is
in use. Any tendency to coughing is restrained with morphia,
etc.
The light in the room is kept rather dim. This is preferred
to ordinary daylight by the patients, and is only reasonable
where so many pass through at least the earlier stages of iritis,
while the depressing mental influence of a very dark room is
avoided.
Healing of the Wound. Some of the results of histological
research into the repair of corneal and sclero-corneal wounds
in men and in animals need brief mention.
The usual section at the sclero-corneal junction, like purely
corneal perforating wounds, gapes a little both superficially
and deeply, from elastic retraction of Bowman's and Des-
cemet's membranes. There is also a tendency for the corneal
flap to become displaced a little forward and to overlap or
override the scleral lip of the wound. The suggestions which
have been put forward to explain this displacement include the
pressure of the lids, the action of the extraocular muscles, the
ocular tension, and the normal elasticity of the cornea released
from tension.
The middle layers of the wound surfaces, swollen by imbibition
of fluid, may come into direct apposition, or a narrow space be-
tween them may be bridged across by a plug of fibrinous lymph.
i5 2 Cataract Extraction
In either case retention of aqueous sufficient for the refilling of
the anterior chamber commonly results within a few hours.
The gaps, superficial and deep, between the wound surfaces
fill up in the course of two or three days, or sometimes con-
siderably longer,* by epithelial and endothelial ingrowth.
When this is complete, the second stage of repair is accom-
plished. It is still only a temporary and provisional means of
union, but much firmer than the earlier adhesion, and it is the
only process of repair recognizable until after the usual period
of the patient's stay in hospital. Permanent fibrous union
between the corneal lamellae on the two sides is a slow develop-
ment occupying months. However this may be, closure of
the wound is commonly continuous after the first few hours.
It is only within twenty-four hours that evidence of reopening
of the section after temporary closure is frequently met with,
in the form of prolapse of iris, or very rarely of vitreous, or
emptying of the anterior chamber after it has been refilled.
Later than this the adhesion is apparently only liable to be
broken down by some definite cause, such as sneezing or
coughing, or pressure upon the eye.
Clinically, the gaping of the wound, superficial and general,
may be recognized, and the edges of the wound may be
slightly elevated from imbibition of aqueous and of tears. The
fluid entering the tissues also accounts for a delicate early
diffuse cloudiness spreading for a short distance from the wound,
with a faint dulness of the surface. The cloudiness is ex-
aggerated later for a time by cellular infiltration. The line
of the wound remains permanently visible as a whitish scar.
Sclero-corneal incisions, though still mainly corneal, heal up
somewhat differently. Early cohesion may take place in the
same manner, but the surface epithelium is separated from
the wound by subconjunctival tissue. And the second stage of
repair is accomplished by downgrowth of this subconjunctival
tissue. And where there is an extensive conjunctival flap
covering the greater part of the section it may exercise a great
influence upon the progress of healing. The flap adheres quite
early to the underlying tissue by means of blood-clot and fibrin.
The aqueous, being then retained by the elastic conjunctival
covering, stretches and elevates the flap, and forces the sclero-
corneal surfaces asunder. Temporary breaking down of the
* Thomson Henderson, Oph. Rev., xxvi (1907), 127.
Description of the Operation 153
adhesion, re-emptying the chamber for a few days, is not very
infrequent. If the conjunctival flap be fairly long as well as
extensive, the gaping of the central portion of the underlying
wound may be considerable a millimetre or more across.
Approximation of the surfaces may never be complete, and the
permanent repair of the wound must then depend largely upon
the episcleral tissue overlying and occupying the gap. A ' filter-
ing cicatrix' results, allowing aqueous to pass through to the sub-
conjunctival tissue in the neighbourhood, where it keeps up a
permanent slight oedema.
Clinically, the early distension of the conjunctival flap
is a striking feature. Through the conjunctiva the open
sclero-corneal incision is seen. In some cases the fluid
escaping under the conjunctiva diffuses widely, causing
swelling of the bulbar conjunctiva at the sides and towards
the lower fornix, and producing some slight fulness of the
lids. This filtration oedema may be seen without marked
elevation of the conjunctival flap. It is paler than in-
flammatory swelling, and is further distinguished by its
gravitation to the more dependent situations, and by the
absence of other evidences of inflammatory reaction. The
two forms of swelling may, however, be combined.
This noticeable general filtration osdema subsides in a
few days. The swelling of the conjunctival flap commonly
lasts a few days longer. When it subsides, the separation
of the deep incision may be considerably lessened.
Speaking generally, gaping of the sclero-corneal section
may be taken as evidence that the conjunctival flap is too
large.
In the large majority of cases sufficient approximation
of wound surfaces, with proliferation and condensation of
subconjunctival tissue, has occurred to raise the tension
of the eye to nearly normal at the usual time for the
patient's dismissal from hospital. For this rise in tension
complete approximation is by no means always necessary.
154 Cataract Extraction
On the other hand, a small percentage of our cases were
either kept back on account of low tension, or had to be
sent away with the eye still quite soft. And these were
not always eyes in which visible gaping of the deep wound
persisted (see Chapter V).
A curious feature of the healing of the majority of our
cataract wounds in natives of India was a subconjunctival
pigmentation along the line of the cicatrix. It was some-
times scarcely noticeable, but in other instances very
dark (Fig. 72). It was evidently due to migration of
uveal pigment, for there was always the usual adhesion of
FIG. 72. PIGMENTATION ALONG SCAR LINE.
the base of one or both pillars of the coloboma to the
deep surface of the cicatrix, and with the denser colour-
ing sometimes rather more extensive adhesion.
It was less frequent after simple extraction, owing to
the more general freedom of the base of the iris from the
scar. It occurred without actual inclusion of iris in the
scar. The source of the pigment was shown clearly, also,
by its tint. The minute particles of which the whole was
composed appeared quite black, whereas the neighbouring
conjunctival pigment was brown. The colouration was
at its height two or three months after operation, and
gradually subsided in the course of several succeeding
months.
We had the opportunity of examining many eyes a few
Description of the Operation 155
years after our operations up to nine years. Many of
the operations had been performed with unnecessarily
large conjunctival flaps. There were, consequently, many
cicatrices certainly filtering, and many others doubtful in
this respect.
The chief sign of nitration was oedema of the conjunctiva,
extending for some distance from the scar, and recognizable by
the abnormal size and depth of the pits produced by light
touches with the point of a probe. The cedema was usually
rather more marked about one portion of the scar line than
elsewhere. It could often be increased by finger pressure upon
the globe, applied for half a minute or more through the lower
lid. The central portion of the cicatrix was visible as a broad
uniformly grey line under the conjunctiva, tapering at either
end. The lower limit of the scar was sometimes sharply
defined by a line more intensely white than the neighbouring
sclerotic, representing the margin of the sclero-corneal flap.
There were no dark points in the scar suggestive of fistulae,
and no bulging or unevenness. The ocular tension was normal
or only slightly subnormal, but could be reduced rapidly by
pressure upon the eye.
At the first dressing, twenty-four hours or rather less
after operation, the condition of the interior of the eye
more urgently demands investigation than that of the
wound. A careful examination of the pupillary area and
coloboma and of the iris is made under focal illumination.
The light of a candle or lamp, focussed with a pocket lens,
is thrown upon the parts from the side, so that no direct
rays can reach the fundus and excite reflex closure of the
lids. It is only by such early examination that the
necessary means can be taken to break down early
adhesions between iris and capsule, to remove the iris
from contact with iritating lens debris, and to control
iritis, infective and otherwise. At least in our work, after
the use of strong perchloride lotion, early dilatation of the
156 Cataract Extraction
pupil was considered necessary or advisable in the large
majority of cases that is, in practically all cases in which
the pupil did not react to the light thrown into the eye.
And often the number of atropin instillations made during
the first few days was limited only by the necessity of
avoiding general symptoms (see Chapter V). It is a good
plan to have the drops warmed to avoid causing reflex
closure of the lids.
After the final removal of pad and bandage, the eye
is still kept protected by the wire shield till the patient's
discharge from hospital. Ten days after operation the eye
is examined to see if the patient is fit for discharge, or
requires a ' needling ' for after-cataract. The needling is
then performed if required, and the patient kept in for
a day longer. Otherwise if the case has progressed
favourably it is now practically at an end. The vision is
tested with glasses, and the patient sent out wearing
simple plane smoked glasses as long as any redness of the
eye persists. Correcting lenses should not be used, as a
rule, for a couple of months* after operation ; this ensures
that no writing or reading shall be attempted. A few of
our cases were kept back if there were beds available
cases in which the tension was still very low, or in which
there was some suspicion of slight iritis. And of course
cases presenting definite complications had to be kept
back.
On focal illumination adhesion of the base of one or
both pillars of the coloboma to the back of the cornea
at the line of incision can be made out in the large
majority of cases. The capsule should be seen in a plane
more posteriorly. Quite occasionally more extensive
* Most of our hospital patients were not seen again. They were
provided with cheap spectacles, spherical lenses, but told not to wear
them till the two months had expired.
Description of the Operation 157
adhesion of the base of the iris will be found, though
the healing of the wound may have progressed uninter-
ruptedly. Thereby more or less shallowing of the chamber
above is produced, and tremor of the iris prevented. The
iris, when free from adhesion both to the line of the wound
and to the capsule, generally hangs so loosely that it is
shaken by every movement of the eye.
A few simple directions to the patient are advisable
on discharge, that he may refrain from stooping and from
all powerful exertion. And it is well to keep all patients
under observation, if possible, who are allowed to leave
hospital with considerable ciliary injection, or with some
slight traces of iritis.
Post-Operative Astigmatism. In testing the vision at -the
time of discharge from hospital the proportion of patients
requiring a convex cylindrical lens with axis horizontal or
nearly so, in addition to the usual spherical lens, varies con-
siderably with the method of operation practised, and with
several factors as yet imperfectly studied. This astigmatism
has been shown to be due not only to vertical flattening of the
cornea, but also to an increase in the horizontal curvature.*
In some cases the degree of astigmatism found a fortnight or
so after operation persists unaltered, or even increased later. In
others it either diminishes somewhat or entirely disappears in
the course of a few months. Reduction in the amount of the
corneal flattening may safely be ascribed to gradual adjust-
ment of the wound surfaces, displaced by forward springing
and overriding of the corneal flap. In sclero-corneal sections
the downgrowth of episcleral tissue interposes a wedge between
the wound surfaces, keeping them apart. Hence the permanent
element in the abnormal curvature is commonly greater in
sclero-corneal than in purely corneal incisions. The astigmatism
from a corneal section is apt to be greater the nearer the sec-
tion to the centre of the cornea. Jackson f found that in only
15 per cent, of cases was the permanent amount of astigmatism
* Treutler, Zeit. f. A., June, 1900.
t Oph. Review, xii (1893), 349.
158 Cataract Extraction
reached within two months, while in 20 per cent, regressive
changes continued for more than three months.
Rollet,* reporting on 150 cases, found that in from two to
five months after operation 25 per cent, of the corneas were
free from asymmetry, while the remainder had a mean astig-
matism of 2 -57 D. A year or more after operation there
was either complete disappearance of the astigmatism or the
development of a small degree at right angles to the original.
Clark f (Columbus, Ohio) reports an interesting observation
of a case in which increase of corneal curvature was due to a
band of pupillary membrane, maintaining the convexity of one
meridian of the cornea like the string of a bow. Division of
the band reduced the curvature by 1-25 D. This observation
suggests that a factor in the production of the early overriding
of the corneal flap may be the vertical tension of the mem-
branous diaphragm, composed of lens capsule and zonule,
acting upon the posterior lip of the wound. The axis of the
correcting lens is nearly always parallel to the base line of the
section, but the astigmatism is sometimes irregular.
For some years I have taken such opportunities as have
presented themselves in private practice of noting the degree
and progress of the astigmatism in my own cases. The amount
at the time of ordering spectacles, generally about two months
after operation, has varied from nil to as much as seven
dioptres. I have been struck by the small amount of change
which has taken place after the first examination about a
fortnight after operation. This has usually persisted with
little appreciable alteration for years. The absence of any
notable tendency to diminution of the astigmatism must be
counted a definite drawback to the use of a large conjunctival
flap. Still, compared with the question of the safety of the
eye, abnormal corneal curvature is a very minor considera-
tion. Some eyes with the larger degrees of astigmatism have
with correction attained excellent central vision. And it has
been remarked that it is to the general advantage of the
patients to accept a low grade of average vision rather than to
considerably improve the average visual results at the cost of a
fractional percentage of total loss. In a few of our cases the
* Rev. Gentrale ifOph., Juin, 1904. Ref. The Ophthalmoscope,
ii (1904), 523-
f Ann. of Ophth., viii (1899), 504.
Description of the Operation 159
eyes examined months or years after the prescribing of glasses
have shown even a slight increase in the degree of astigmatism.
Our results show that progressive contraction of the sclero-
corneal gap often formed under a large conjunctival flap is not
to be anticipated. Cicatrization apparently takes place solely
by the consolidation of the overlying tissue and by filling up of
the gap by downgrowth of this tissue. (Possibly narrowing
of the interspace might have been brought about by a pressure
bandage, begun a week or so after operation.)
The visual restilt attained at the time of discharge from
hospital is often comparatively poor in spite of a clear pupil
(perhaps cleared by needling), and of correction of astigmatism,
and there is steady improvement in the course of a few months.
Some of the early defects may at times be ascribed to the fine
lines on the posterior surface of the cornea described in
Chapter V. Where the cataract has existed for a long time, as
is often the case in India, there may be amblyopia from disuse.
Moulton* recorded the progress of improvement in two marked
cases of this amblyopia. In cases of congenital or infantile
cataract operated upon in youth or early adult life the result is
very poor. Some of our patients could only see moving bodies
afterwards.
Coloured Vision. Erythropsia is an occasional complaint
of aphakic patients after exposure to bright light, especially,
perhaps, in cases where a broad iridectomy has been made.
We saw almost nothing of it in Bombay, probably because the
wards were rather dark, and the patients were all supplied
with cheap dark glasses and shades on dismissal. It is caused
mainly by the ultra-violet rays, for which the lens has a high
absorptive power.
Cyanopsia has been comparatively seldom recorded. This is
possibly because it is a very transient condition. Elliot, in
Madras, found that slightly more than half of his patients had
blue vision for some period of their stay in hospital. f Enslin
has also drawn attention to this affection after cataract ex-
traction. Maddox suggests that as most cataractous nuclei
have a yellowish or amber tint, the sudden removal of this
coloured medium is sufficient to flood the retina with the
complemental colour.
* Oph. Record, April, 1903.
f The Ophthalmoscope, iv (1906), 15.
CHAPTER III
EXPULSIVE HEMORRHAGE. VITREOUS
ACCIDENTS
IN the foregoing pages numerous difficulties and accidents
have been set forth, distributed according to the stage of
the operation which they complicate. There are still two
grave complications which belong to no particular step of
the operation, and which may occur even later during the
healing period. These complications, expulsive haemorrhage
and prolapse or loss of vitreous, are therefore to be con-
sidered now. The trouble with vitreous is generally a
consequence of one of the mistakes or difficulties already
dealt with.
EXPULSIVE HEMORRHAGE.
By this term is understood bleeding from the fundus suffi-
cient to expel part or the whole of the contents of the globe
through the wound. It is also known as ' essential ' and ' retro-
choroidal ' haemorrhage. It is, fortunately, a rare accident.
Formerly, in nearly 3,000 extractions I had only met with it
twice, but now, with the total only about 5,000, I have to
record seven typical and two incompletely expulsive cases.
De Wecker reported eight haemorrhages in 3,000 operations,
Sattler * only four cases in over 3,000 operations.
The bleeding, also seen after iridectomy for glaucoma, has
been shown by anatomical investigation to come from choroidal
veins. The blood, collecting first between the sclerotic and the
choroid, ruptures the latter. The accident most frequently occurs
* A.f. O., xlvi (1898), 235.
160
Expulsive Haemorrhage 161
during operation or immediately after it, but it may happen at
any time during the first twenty-four hours after operation,
and has been known as late as ten days afterwards.* In the
first case the corneal flap is slowly pressed forward, vitreous
presents in the wound and, after rupture of the zonule, escapes.
Blood soon follows, and often after the expulsion of the whole
or greater part of the vitreous, detached portions of retina and
choroid may be seen. Occasionally, however, the appearance
of blood in the wound is the first indication of trouble. When
the haemorrhage takes place later, we find the dressings soaked
with blood, the lids pressed forward, and protruding from the
widely gaping wound a large clot of blood. The eye filled
with clot feels hard, and perception of light is lost. The onset
may be marked by acute pain, or there may be merely a feeling
of tension or heat, or no particular feeling of discomfort at all.
There may be vomiting, and epileptic seizure has been recorded
(Berry). '
The bleeding sometimes stops early. At other times there
may be continued or repeated oozing for days, in spite of a
pressure bandage. The globe afterwards shrinks. In former
times panophthalmitis sometimes developed.
In some cases disease of choroidal blood-vessels has been
found dilatation, degeneration, and infiltration of the walls of
the veins, also sclerotic changes in the arteries. But in other
eyes no evidences of disease have been found in the blood-vessels.
The accident is recognized as perhaps the chief danger in
extracting the lens from a glaucomatous eye (one of our cases
was thus accounted for). Venous congestion from vomiting,
coughing, or straining has been blamed as a partial cause, also
strong pressure upon the eye during operation. Noyes and da
Gama Pinto reported the occurrence of the accident in highly
myopic eyes, probably from disease of the choroid (see also our
case mentioned in the footnote to p. 74). Haemophilia was
mentioned in one case by da Gama Pinto. Often no explana-
tion of the complication can be found.! And possibly the old
idea that the bleeding was a result of loss of vitreous may
* White Cooper, quoted by Terrien, ' Chirurgie de Poeil,' p. 172.
t Sattler thought that the accident was rarer in the old days before
cocain was used. But it has been suggested that some of the cases
were then reported differently, being attributed to vomiting due to the
anaesthetic.
II
1 62 Cataract Extraction
sometimes be partially correct.* In patients who have had
both eyes operated upon the disaster has usually been observed
only in one eye.
One very occasionally sees inexplicable escape of vitreous,
apparently spontaneous, during operation so suggestive of the
onset of deep haemorrhage. But no blood appears, and the
eyes do perfectly well afterwards, and one may fail to find any
choroidal detachment or other sign of fundus haemorrhage.
Possibly, however, the presence of after-cataract may at times
account for this negative finding.
There are also rare cases of less profuse haemorrhage, in-
completely ' expulsive,' in which some sight may be retained.
In one of our cases the corneal flap was slowly pressed forward
at the close of the operation. Then followed rupture of zonule
and large loss of vitreous, but no blood appeared in the wound.
A month later the patient could count fingers at 2 feet with
this eye, but later the vision fell to moving bodies only, and the
eyeball was shrinking. Again, in a Czermak's lower subcon-
junctival operation haemorrhage occurred large enough to
open the wound and raise the overlying conjunctiva, but there
was no expulsion of vitreous. The pupil became closed,
though the iris remained bright. An irido-capsulotomy, nearly
a month later, failed to do good. The opening became occupied
by blood, apparently from the vitreous. Later the eye was
softening and the field of projection of light was contracting.
A case of haemorrhage complicating an iridectomy operation
for chronic glaucoma in our practice is also of interest here.
It was profuse enough to expel the lens with a quantity of
vitreous and to distend the wound. But the patient a month
later could count fingers at 9 inches. Before operation he
could count them at 2 feet. Such cases link the more profuse
and uncontrollable haemorrhages with the small fundus haemor-
rhages sometimes produced by operation in advanced glaucoma,
and with those responsible for the condition ' malignant glau-
coma.'
* For example, in one of our cases a large loss of vitreous followed
an attempt to dislodge a bit of cortex by external pressure, but the
flow of vitreous appeared to be at an end when the lids were closed.
Half an hour later the patient was vomiting, and had considerable
pain, and some little time afterwards the dressing was found soaked
in blood.
Expulsive Haemorrhage 163
H. Becker* reported a case of arterial haemorrhage, ap-
parently not expulsive, which began during operation and
resisted treatment (including evisceration and packing and
cauterization of the central artery) for four weeks.
Treatment. Ordinarily a pressure bandage is applied,
after excision of any portions of choroid or retina lying in the
wound. If the bleeding does not quickly cease, a hypodermic
injection of 20 minims of adrenalin chloride solution (Parke
Davis's, i in 1,000) may be given, and 15 grains of calcium
chloride administered every hour for some hours. This proved
sufficient in all our cases, but various other measures have
been found advisable or necessary at times. Ice has been
applied and morphia injections given, and the upright position
assumed. Trousseau advised the application of a sclero-
corneal suture. Enucleation has been frequently performed.
Formerly this was done more often than now, partly with the
object of avoiding panophthalmitis. Evisceration and packing
with gauze or gelatin has been done also.
Prophylaxis. If it be decided to extract a cataract from the
fellow eye after one eye has been lost from expulsive haemor-
rhage, both general and local precautions are indicated.
1. Preliminary general treatment must be directed to lessen
any circulatory disturbances and to lower the blood-pressure.
Tersonf recommends as preparation a suitable diet, little to
drink, purgation, iodides, and tinctura veratri viridis, also
chloral at night.
Abadie suggests egotin injection, and for twenty-four hours
from the time of operation compression of the carotid.
2. A preliminary iridectomy is indicated, though in spite of
this haemorrhage has occurred at the subsequent extraction.
Instead of the ordinary extraction, discission and linear extrac-
tion have been performed,! discission of a fully ripe cataract
giving rise to little trouble in the eye. The cataract incision
must be made slowly, in order that the ocular tension may not
be diminished suddenly. And perfect rest must be maintained
afterwards.
* Ref. A.f; A., September, 1905.
t Arch. dOphth., xiv (1894), no.
| Peirone, A.f. A., xxxviii (1899), 163.
II 2
164 Cataract Extraction
VITREOUS ACCIDENTS.
The escape of vitreous humour from the eye has already
received frequent mention. It predicates a perforation or
rupture of the supporting diaphragm formed of suspensory
ligament and lens capsule, also of the hyaloid membrane.
In addition, an expelling force is needed. This is generally
external pressure, by instrument, finger, or lids, or less
obviously by action of the extrinsic muscles upon the eye ;
but occasionally the pressure is from within, from elasticity
of the sclerotic, contraction of the tensor choroidese (?), or
intraocular haemorrhage.
Prolapse and incarceration of vitreous in the wound,
distinct from the actual flowing away of the humour, are
minor grades of vitreous accident, but not necessarily of
diminished gravity as regards the result. So far as one
can judge they depend upon rupture of zonule or capsule
alone, the hyaloid membrane remaining intact. They
are comparatively infrequent except as brief preliminaries
to expulsion. The whole length of the incision may be
forced open by a narrow and low protrusion of vitreous
showing no immediate tendency either to recede or to
enlarge. More commonly the protrusion steadily increases
in height and width, still further separating the wound
margins, up to a certain point when it suddenly collapses
more or less and vitreous flows away. The rupture of an
invisible containing membrane is the obvious explanation
of the occurrence. Should a simple prolapse remain
stationary the same partial or complete collapse, with flow
of vitreous, may be brought about by puncture with a knife
or by partial excision of the prominence with scissors.
Occasionally the vitreous may present at the wound with-
out actually entering it ; the corneal flap is pressed for-
ward, causing the wound to gape a little.
Vitreous Accidents 165
The appearance of vitreous in the incision is in many
cases preceded by a characteristic deepening of the anterior
chamber, from vitreous entering through the pupil or
through the coloboma. Very occasionally the humour
may pass into the chamber thus without reaching the
wound. In other cases the anterior chamber remains
empty, and the iris is forced forward into the wound. If
an iridectomy has not been made, the bulging iris retains
the vitreous until the pupil dilates so widely that the
whole breadth of the upper portion of iris lies exposed in
the section, allowing the humour to pass out in front of it.
The deepened chamber seems more likely to be met with
when the zonule ruptures below, while the vitreous seems
more likely to press the iris forward when the rupture
occurs close to the wound above.
Vitreous expulsion most often accompanies or follows
immediately the delivery of the lens. The escape may,
however, take place as soon as there is a large enough
opening made in the eyeball, or it may begin slowly with-
out obvious cause just after the operation is finished.
Rarely it may occur later during the healing process
(Chapter V).
Since a flow of vitreous may possibly continue or recur
after the eyelids have been closed and the dressing applied,
estimates of the quantity lost can only be tentative. In
any case they are very rough. Smith's losses at Jullundur
are said to have consisted usually of only a small ' bead '
of humour. In my experience quite small losses are the
exception. The amount may vary up to about two-thirds
of the total humour. Where the vitreous is of very fluid
consistence some of it may pass through the wound with-
out being noticed. The only evidence may be a slight
gumminess of the fluid in the conjunctival sac. At times,
therefore, one may feel uncertain as to whether a small
1 66 Cataract Extraction
gush of vitreous has taken place or not. Not very un-
commonly in large losses, the portion which comes first is
of more or less reduced consistence, and it is followed by
firmer normal material. In some cases the flow may prove
to be in no degree controllable until a considerable
quantity of humour has been lost. These eyes include
some in which no other evidence of ' vitreous tension ' has
been observed. On the other hand, from slack and rigid
eyeballs the humour has to be actually pressed out, and
ceases to escape as soon as external pressure is removed.
Causes. In ordinary cataract extraction the complica-
tion may be due to fault of the operator or assistant, or of
the patient, or of neither. The cause is often quite
obvious. Or again, one may feel at a loss to hazard even
a conjecture as to the offending conditions or mechanism.
Of pre-existing conditions, the only one quite unassail-
able as constituting usually a sufficient excuse for the
accident (though even here the accident is not always
inevitable) is dislocation of the lens. Also there are cases
of diseased eyes where dislocation, due to weak suspensory
ligament and perhaps fluid vitreous, occurs during the
making of the incision, however gently it be made. But
the tremor of a Morgagnian, or formerly Morgagnian,
cataract is not to be accepted as conclusive evidence of
conditions more than feebly predisposing to accident.
Exceptional gentleness and correct procedure are com-
monly effective in preventing complication in these cases.
In similar manner, by prompt recognition, 'vitreous
tension ' is generally deprived of its peculiar danger.
And the special tendency to rupture of zonule in eyes
with much retracted conjunctival fornices applies only to
extraction by ordinary section, and not to the subcon-
junctival operations. In eyes apparently sound apart
from the cataract, occasional difficulty in determining
Vitreous Accidents 167
the real origin of vitreous complication may possibly be
explained sometimes by the suggestion that the main
cause is separated from the result by a definite interval of
time. Damage done to zonule during the earlier stages
of operation may not be made known until pressure is
applied for the expulsion of the lens or of cortical remains.
Or predisposition to accident may have been introduced
by too deep a counter-puncture and too peripheral a
section, depriving the zonule of the support usually
afforded by the peripheral strip of cornea and by the
sclerotic.
The loss of the support of the iris after a coloboma
has been made has also been claimed as slightly facili-
tating rupture of the zonule. And very prominent eyes
e.g., in exophthalmos and high myopia are more liable
to vitreous accident in that the lids contracting upon
the globe obtain a greater purchase upon it.
Among the more obvious and immediate excitants
distributed through the pages of Chapter II may be
recapitulated : a dragging incision ; too firm or too heavy
fixation ; slipping of speculum ; drag or pressure of cysti-
tome or of capsule forceps ; sudden upward movement of
the eye with an instrument in the anterior chamber, or
with curette resting above the wound, or with the upper
lid insufficiently elevated ; incautious pressure in expelling
lens or cortex ; difficulties in connexion with the toughened
capsule of overripe cataracts ; also painful or startling
occurrences calculated to excite spasm of the orbicularis,
such as a prick with the point of the knife near the inner
canthus, or spurt of fluid upon the face from the irri-
gator.
There are puzzling spontaneous expulsions of vitreous
about the close of the operation already referred to.
Those which I have seen have not been in eyes with
1 68 Cataract Extraction
noticeable vitreous tension. They at once suggest the
onset of expulsive haemorrhage, but the haemorrhage does
not take place, and the eyes commonly see well after-
wards. In Bombay we have somewhat neglected our
opportunities of examining these eyes for choroidal
detachment later, such as would suggest that the vitreous
expulsion had been caused by limited retro-choroidal
haemorrhage. Spasm of the tensor oculi muscle has been
mentioned as a possible cause by Nicati.
Prevention. From the very varied means of production
of the complication it is obvious that endeavours to reduce
its frequency must be comprehensive.
1. Among the more essential precautionary measures is
the proper control of nervous patients. Excitable patients
must be quieted by bromide or other sedative, by com-
bining adrenalin with the cocain instilled, and by the
surgeon's influence during operation. A trained assistant
is important to take charge of the stop-speculum, which
must be removed promptly if the patient shows signs of
losing control over his orbicularis muscle. If the patient
fails to pass the prescribed tests beforehand, a subcon-
junctival operation should be performed.
2. The latter method should be adopted also when
conditions present in the eye predispose to vitreous
accident (Chapter IV).
3. In particular gentleness must characterize the surgeon's
procedure throughout. The remarks made in Chapter II
must be borne in mind regarding dragging incision, over-
firm fixation, cautious capsulotomy, and especially slow
expression of the lens and careful dealing with cortex.
4. Watchfulness and caution are mainly matters of
experience, to promptly detect and remove direct causes of
accident and excitants of lid spasm, and to guard against
injury by sudden movements of the globe. The situation
Vitreous Accidents 169
must be saved if necessary by bringing the operation to a
close without completing the ' toilet ' of the eye.
An additional, but an unfair, means of reducing one's
percentage of accident would be the rejection of com-
plicated cataracts and dislocated lenses.
Our vitreous losses in Bombay in 1,262 flap extractions
performed during 1905 and 1906 totalled thirty-eight i.e.,
3 per cent. (Cases are not included in which the loss was
preliminary to expulsive haemorrhage.) Of the thirty-eight,
sixteen escapes may be classed as avoidable, seven excusable,
and fifteen unavoidable.
For the sixteen avoidable accidents I accept the responsibility.
Eight of the losses were caused by the patients squeezing their
lids forcibly together. But this might have been prevented in
many cases by securing more complete anaesthesia with adre-
nalin and cocain, and by other precautions. Six of the accidents
were due to ill-performed operations by downward section,
three by ordinary flap incision, three by Czermak's scissor
method. I was at the time inexperienced in both of these
methods. Another loss was ascribed to the use of a rather
blunt knife, and another to accidental puncture of the posterior
capsule (in a case of traumatic cataract).
The seven excusable accidents were all in connexion with
toughened capsules of overripe cataracts. Against these may
be set other extractions, intracapsular and otherwise, where
from extreme overripeness, dislocation, and so on, loss of
vitreous was anticipated, but was avoided.
The fifteen unavoidable cases included no less than eight
spontaneous escapes, and seven others accounted for variously,
by existing dislocation of the lens (three cases), ectopia ientis
(one), occluded pupil with fluid vitreous (one), and atrophic
zonule (two cases ; in one the vitreous escaped during the
making of the section, and in the other the lens became
dislocated during the cutting).
Thus the losses might with extreme care have been possibly
reduced by about one-third of the total. The actual figures,
however, are not of much value for application elsewhere. So
much depends upon the class of patients, and the proportion
of diseased eyes and overripe cataracts. It may be safely laid
1 7 Cataract Extraction
down that in countries where cataract is commonest the
proportion of complicated cataracts will be lowest. On the
other hand, in India the cataracts are very much more often
allowed to become overripe than in Europe and America.
Elliot* (Madras) had only 27 per cent, of vitreous losses in
2,000 consecutive extractions. Maynard i (Calcutta) reported
63 per cent, of losses in an earlier series of 1,000 operations,
4-3 per cent, in a later similar series.
Management of Cases. When vitreous escape is due
to spasm of the lids, usually our first concern is to remove
the speculum before further harm can be done. But it is
often necessary to adjust the margins of the incision.
This may sometimes be done with the speculum still
in position, otherwise with the lids controlled by the
assistant's fingers or with Desmarres' retractor. Where a
large loss has been occasioned by external pressure alone
there is more or less collapse of the globe. The corneal
lip of the incision generally falls back behind the scleral
lip ; or it may override the latter considerably. In the
former case the conjunctival flap must be drawn up over
the peripheral lip. Some surgeons have filled the anterior
chamber with saline solution, to obtain better adjustment
of the wound margins, but it is unnecessary. In tenser
eyeballs the wound may still remain occupied by a
projecting mass of firm vitreous, just as when prolapse alone
occurs without loss. It is advisable to cut away some of
this projecting material with scissors. This does not lead
to immediate coaptation of the wound margins, but in my
experience it secures their readjustment within twenty-
four hours. The snipping away of a simple prolapse is
imperative, This must be done as quickly as possible,
and the patient is not asked to turn his eye strongly
downwards, lest additional expulsion of vitreous be thus
* Personal communication.
t Ind. Med. Gazette, xli (1906), 315.
Vitreous Accidents i? 1
brought about (through the pull of the recti muscles
tending to open the wound, and their pressure tending to
expel vitreous).
Should a wide prolapse of iris lie in the wound also,
much of this may be excised at the same time, but usually
without the aid of iris forceps. The globe cannot be
fixed with forceps, and if not kept quiet by the patient it
may be impossible to remove the iris. Should the vitreous
have escaped before an iridectomy has been made, and
should the iris have been pressed back within the globe by
the humour passing in front of it, the iris should not
be interfered with.* There is little or no risk of subse-
quent prolapse. The upper portion of the iris may have
already receded partly or completely behind the scleral
margin.
A narrow incarceration or mere presentation of vitreous
causing the wound to gape but slightly is left in the hope
that it will recede.
Both eyes are bandaged carefully, without pressure upon
the operated one. The greatest care is necessary at the
earlier dressings not to cause a recurrence of vitreous
escape. The eyelids need be scarcely separated, and the
lower lid must be kept well away from the eye. After
several days, if the wound is still not closed and the eye is
no longer quite soft, the application of a pressure bandage
is indicated.
Consequences. In most cases there is next day no
longer any evidence of the mischance ; the healing goes on
normally and the consequences are nil. Very occasionally
the wound remains open with vitreous impacted in it. If
the wound margins are only a little separated, their
approximation generally takes place under a pressure
* The use of a sharp hook has been recommended for drawing out
the iris for excision.
1 72 Cataract Extraction
bandage. But sometimes this does not happen, and in
the case of a wide incarceration is not to be expected. The
exposed vitreous soon becomes opaque from infiltration,
and later acquires firmness from the formation of fibrous
tissue in it. Thus cicatrization progresses with the
corneal flap considerably displaced. A high degree of
astigmatism persists. The anterior chamber may fail to
reform for a long time, and opacity of the posterior layers
of the cornea ' contact keratitis ' may develop. And
opaque bands may spread from the impacted tissue into
the vitreous, further interfering with vision, and tending
to draw the retina forward and to cause detachment.
The exposure of the vitreous, and later, the ectatic scar
which develops, must open the way more or less per-
manently for possible infection of the eye. Even when
the wound is found well adjusted at the first dressing,
it may have been kept open by vitreous for some hours
after the operation. It is only fair to attribute to this
source some of the infective inflammations which follow
early or late. For experience in discission operations has
shown that numbers of eyes have been lost by suppuration
through impaction of minute threads of vitreous in needle
punctures. Bacterial invasion of the eye may be further
aided by the healing of iris in the wound, prolapsed
or incarcerated. Even where an iridectomy has been
performed impaction of iris frequently occurs at the two
ends of the incision. One is afraid to attempt excision of
the displaced iris on account of the risk of causing
renewed loss of vitreous.
It is said that, apart from the risk of secondary infection,
the prognosis of cases with vitreous healing in the wound
is bad, and that many of the cases end in atrophy of the
globe.*
* Czermak, ' Die Augen. Op.,' S. 943.
Vitreous Accidents 173
Impaction of firm vitreous in the wound is seldom seen after
loss during operation if the projecting mass has been rather
freely cut away. I had gained an impression from Bombay
work that incarceration during the healing process was to be
found only in cases where vitreous had not actually escaped,
and where, therefore, the hyaloid membrane might be still
intact. Elliot (Madras) has kindly given me his experience
on this point. He had fifty-eight vitreous escapes in 2,000
extractions. In eight of these cases the section gaped for
variable periods afterwards. Among these cases one pupil
became occluded, and there were two other very poor visual
results. Besides these accidents, there were six other cases in
which impaction occurred at the time of operation or later,
though there was no vitreous escape. These eyes all obtained
good vision, and a finally closed section is mentioned in ali
but one case, in which a hypopyon formed.
Many cases in which the wound heals up normally show
an evidence of anchoring of vitreous to the scar. Possibly
in these cases fine threads or films of vitreous tissue
become incorporated in the scar. The evidence consists
in a striking and characteristic enlargement, distortion, and
displacement of the pupil, without impaction of the iris or
adhesion of the iris to the wound. It is mostly seen after
large losses, but I have seen medium and minor grades of
the abnormality where no vitreous accident of any kind
had been noticed at the time of operation. Probably in
at least some of these cases expulsion of vitreous may
have taken place after the application of the bandage.
In the typical condition as seen after large losses the
appearance is as though an enormous iridectomy had been
made. It is the same whether an iridectomy has been
actually performed or not. The upper half of the iris
has disappeared, retracted behind the scleral margin. It
can be seen, however, by focal illumination, narrowed,
immobile, and irresponsive to eserin.
The pupillary margin of the lower half of the iris arches
174 Cataract Extraction
across, only slightly curved, about or above the middle of
the cornea, to disappear at either end behind the sclera
(Fig. 73). It reacts but little or not at all to light.
In the minor grades of abnormality the retraction of
the iris is less complete, and the widening of the pupil
laterally is not extreme. The upper narrowed strip of
FIG. 73. DISTORTED PUPIL.
iris lies behind the cornea. Even here the division
between the two portions of iris may be quite sharp, though
I do not know if it is always so.
In some cases, at least, the plane of the atrophic iris
FIG. 74. DISTORTED PUPIL.
is distinctly posterior to the scar line. But in old cases
where the upper part of the iris has practically disappeared,
the condition may perhaps closely approximate to that
Fig- 75. DISTORTED PUPIL.
brought about by adhesion of capsule and of iris to the
scar.
Though the retraction of iris may be well marked at the
first examination twenty-four hours after operation, the
portion of iris then involved may be only small. It may
increase gradually later, with progressive widening and
Vitreous Accidents 175
drawing up of the pupil. And the narrowed iris in the
course of months may become still narrower and markedly
atrophic, and probably may disappear altogether.
Fig. 74 (a) shows a condition seen eleven days after operation
on the discharge of the patient from hospital. Two months
later this condition had changed to that shown in Fig. 74 (b).
The remains of iris above were almost unrecognizable merely
a narrow, pale greyish band, with its lower margin dark
towards either end. Fig. 75 (a) shows a condition of pupil
found on the first day after an extraction by Czermak's lower
section. There had been no presentation or loss of vitreous,
but there had been evidently rupture of the zonule above, for
the upper edge of the capsule was to be seen later in the dis-
torted pupil. At the time of discharge from hospital the
distortion and enlargement of the pupil had increased, as
shown in Fig. 75 (b).
Though Pope and Elliot (both of Madras) have referred
to this distortion of pupil, the only description of it, so far
as I know, has been in my ' Practical Details of Cataract
Extraction.'
The fixation of the vitreous to the scar is supposed to
tend towards later detachment of the retina. But detach-
ment may follow also without this adhesion. This is the
result which we fear most after large vitreous loss. But
often it does not take place after very large escape, even
from myopic eyes. The connexion between vitreous loss
and retinal detachment is undoubted, but we need much
more exact knowledge of the subject than we now possess.
Sometimes after vitreous expulsion the tension of the eye
is late in being re-established. And after the largest
losses, especially repeated losses, the eyes may become
rapidly atrophic. One fears a bad result from vitreous
accident in the not infrequent cases in which long floating
threads of opacity are found in the vitreous at the time of
discharge.
176 Cataract Extraction
In a recent Bombay case in which there was detachment of
the retina and low tension after a vitreous escape, the clear area
of the coloboma above an opaque patch of capsule occupying
the pupil became slowly covered by a grey exudative film,
though there was no ciliary injection or other evidence of
inflammation. The edges of the wound were in good
apposition.
Opinions are widely divided as to the gravity of the
dangers from loss of vitreous. Smith of Jullundur, the
world's biggest operator, maintains that small losses are
harmless, and states that nearly all of his escapes are quite
small. Major Birdwood, I. M.S.,* after a large acquaint-
ance with vitreous accident, says : " Provided the capsule
(of the lens) is unruptured no evil effects whatever seem
to follow the escape of vitreous even when in fair quantity."
These opinions, however, are not shared by surgeons in
Europe and America, who are able to follow up their cases.
And even in India a very different picture has been drawn
from the records of the Calcutta Ophthalmic Hospital. t
Among 122 operations complicated by vitreous expulsion
there were 28 failures presumably failures recognized before
discharge from hospital. In 9 cases there was atrophy of the
globe. The other failures were all apparently infective 10
by iritis, 8 by corneal sloughing, and 4 by panophthalmitis.
Twenty-two of the 122 losses were large, amounting to more
than a fourth of the humour. And there were only 5 failures
among these 22 cases. So that it was held that the question
of the quantity lost had very little influence upon the result.
I have seen early shrinking of the globe rarely, and
simple detachment of the retina rather more frequently,
either before the patient's discharge or a few months later ;
but I have no figures bearing upon the relative frequency
of these results. I have thought that after escape of
* Ind. Med. Gazette, xli (1906), 201.
f L. M. Mookerjee, Trans. Ind. Med. Congress, 1894.
Vitreous Accidents 177
vitreous in our practice infective losses were more fre-
quent.
For instance, in a series of 578 extractions, there were
3 severe inflammations leading to atrophy. Two of the
3 cases occurred after loss of vitreous. It may be noted also
that among 9 large vitreous losses reported by Smith * there
were 3 suppurations. In the matter of infection the quantity
lost can have little bearing. Probably Smith's relative im-
munity from infective losses is attributable to his preliminary
douching of the conjunctiva with i in 2,000 perchloride.
* Ind. Med. Gazette, xl (1905), 327.
12
CHAPTER IV
VARIATIONS IN PROCEDURE, AND
THEIR VALUE
General preliminary and preparatory details Fixation The section
Simple extraction Peripheral iridectomy Preliminary iridec-
tomy Other modes of opening the capsule Intraocular irriga-
tion The open treatment of the wound Extraction of the lens
together with its capsule Asepsis Results.
GENERAL PRELIMINARY AND PREPARATORY
DETAILS.
The Value of the Mouth-Mask or Screen. It is well realized
nowadays that salivary infection of wounds is a danger seri-
ously to be guarded against. But an extensive face covering
in the form of a veil is scarcely called for, since the expired
air in breathing is harmless. In Smith's Jullundur work the
screen is superfluous, since neither he nor his assistant find
it necessary to speak to the patient during operation ; but
in ordinary work many of the patients need repeated verbal
directions. I have little doubt that some of our earlier Bombay
infections were from this source. We thought, immediately
after the use of the screens was begun, that there was a
decided and continued improvement in the average appearance
of the eyes after operation. We thought there were fewer
muddy pupils and irises seen requiring early treatment.
Axenfeld* has remarked that infection in eye operations is
almost exclusively by the pneumococcus, which is rare in the
healthy conjunctiva, but common in the saliva.
Some surgeons lay stress upon the cleansing of their own
and of their assistants' hands, passing them through the regula-
tion brushing with soap and water, steeping in alcohol and in
* Klin. M.f. A., xli (1903), 2, 474.
178
Variations in Procedure, and their Value 179
i in 1,000 sublimate. And they wear sterilized blouses and
caps. De Schweinitz sprays the nasopharynx three times daily
with a solution of permanganate of potassium, i in 5,000, as a
preparation for cataract extraction.
The casual references made in Chapter II to the
Cleansing of the Lids and surroundings, and especially
of the lid margins, will be regarded by many as quite
inadequate. They represent the general practice in
Bombay and, I believe, in India generally a practice
based less upon conviction than upon an insufficient
supply of reliable assistants and attendants. We frankly
took up the position of making no attempt to sterilize
these surfaces, or even to clean them thoroughly. We
recognized these surfaces and the eyelashes as possibly
foul, and undertook the responsibility of preventing con-
tact between the lid borders and lashes with the portions
of instruments which entered the wound. Particular care
in this respect was exercised in making the incision, as
already insisted upon. But under more favourable cir-
cumstances it would seem wise to devote more attention
to the lid margins at least, even admitting that complete
sterilization cannot be attained. This is suggested by the
bare possibility that the surgeon may fail to notice
accidental contact of the blade of the knife with the lashes
or skin before the incision is completed. Considerable
importance has been laid also upon the lid margins as one
of the main sources of supply of conjunctival bacteria
(see also the section on ' Asepsis '). Hence, thorough
cleansing of the skin may tend to lessen the risks of
secondary infection of the wound. At the same time,
care must be taken lest more harm than good should
follow too energetic efforts, by exciting inflammation.
A common practice is to cleanse the skin of the lids and
neighbouring parts thoroughly, either on the preceding
12 2
180 Cataract Extraction
day or on the morning of operation, and then to cover
the parts with a compress moistened with antiseptic fluid,
until immediately before operation. At this time a final
cleansing is practised. The initial washing is first with
soap and hot water, then alcohol, and then, perhaps, subli-
mate lotion, i in 2,000, care being taken that none of these
irritants reach the conjunctiva. The compress is soaked
in I in 5,000 sublimate, and covered with guttapercha
tissue.
There is no objection to covering up the eye thus for
an hour or two before operation, but applied as a ' test
dressing ' from the preceding day, the compress continued
up to the operating period is objectionable. If continued
for more than a night the normal period of closure in
sleep the immobility of the lids and the warmth of the
dressing favour the growth of micro-organisms in the con-
junctival sac, and often excite slight temporary hyper-
aemia. A few hours should be given for this to subside.
The prolonged application of weak perchloride solution to
the skin excites an acute discharging dermatitis in a few
people. It is urged against all ' test dressings ' that they
are apt to disturb the patient's sleep, so much needed the
night before operation.
Epilation of the cilia, of the whole of both lids, or of the
upper lid only, has been practised by a few surgeons. It
is, of course, a painful procedure, and may cause inflamma-
tion. On these accounts it is more usual to cut the lashes
short. But even this is not required except at the outer
portion of the upper lid beyond the point where the arm
of the speculum crosses the lid border.
Here it is necessary if the blade of the knife is to be guarded
from contact with the eyelashes in making the incision. But
there is no difficulty in preventing the portions of instruments
which enter the wound from touching the lashes of other
Variations in Procedure, and their Value 181
portions of the lids. If there were any such difficulty, it could
be avoided by the use of specula with plates or bars, such as
Lang's or Koster's.
It is recognized that the cilia and the lid margins cannot
be made certainly sterile by ordinary washing with soap
and lotions. Benzine introduced by Pflugk* and used by
Kuhnt, Mayweg, and others, has been recommended as a
cleansing agent, t It is non-irritant, provided its action is
confined to the skin surface. The swabs dipped in it are
squeezed nearly dry. De Wecker applied i per cent,
cyanide solution to the lashes. Panas, True (Montpellier)
and Louis Dor (Lyons) have used a solution of biniodide
of mercury in oil for the lid margins. (Panas' solution
is 4 in 1,000.) Hess, after washing with I in 2,000 sub-
limate solution, applies sublimate vaseline, i in 1,000.
The cleansing of the lid borders is facilitated by
cutting short, and still more by pulling out, the lashes.
Also, after operation, the lids cannot be glued together by
secretion, and the latter is easily washed away.
Expression of the contents of Meibomian glands as a part
of the routine preparation of the patient is, so far as I am
aware, exclusively a Bombay practice. It was forced upon
us by our free use of intraocular irrigation. Any operator
who separates the lids with a speculum, and uses the
ordinary irrigator for washing out cortex, must at times
have noticed the Meibomian secretion floating upon the
fluid in the conjunctival sac; and once having seen the
material which can be expressed from sluggish glands, he
will continue in a routine effort to remove possibly in-
fective material. This emptying of the glands appears to
be essential if the lid borders are to be maintained clean
* A.f. A., xlv (1902), 176.
t The benzine may act slightly as a disinfectant, but its main action
is as a powerful solvent of fats.
1 82 Cataract Extraction
throughout a cataract operation. It seems especially
necessary in operations where the lower lid border is
utilized for applying pressure upon the eye for the expul-
sion of the lens and of cortical remains.
Some operators prefer to cover the greater part of the
patient's face with sterilized gauze, leaving only the eye
and its immediate neighbourhood exposed.
The eyebrow, regarded as unsterilizable, has been
shaved by a few surgeons, e.g., Haab, Czermak, lest bac-
teria should be transferred from the hair to the surgeon's
hand, and this indirectly to the instruments. Also lest
organisms should be carried down by perspiration in
summer to the lid margins (Haab).
General Anaesthesia. Chloroform is practically never
needed in cataract extraction in adults. If a patient, insane or
otherwise, be so deficient in self-control that Czermak's opera-
tion by lower subconjunctival section cannot be performed, he
will not be a fit subject for operation, because of the care
needed to prevent accident during the healing period. And in
the case of painful glaucomatous eyes temporary measures can
be employed to reduce tension till the eyes are fit for opera-
tion. The only occasions on which one might be compelled to
use general anaesthesia, would be when a patient became
uncontrollable during operation. But of late years I have not
met with such.
Apart from the question of risk to life, chloroform is
objectionable, because of the danger of prolapse of iris or loss
of vitreous occurring afterwards from vomiting. More time
is taken up by the operation, and unless the patient be kept
completely under the influence of the anaesthetic, inconvenience
is occasioned by the eyeball rolling upwards.
In operating upon children by linear extraction chloroform
may be needed, but the quantity given may be much reduced
if cocain be instilled into the eye, as usual, also.
General anaesthesia by subcutaneous injection of scopo-
lamine and morphine has been recommended by Suker* and
* Medicine, January, 1906.
Variations in Procedure, and their Value 183
Segelken.* One-fiftieth of a grain of scopolamine hydro-
bromate (Merck) and half a grain of morphine sulphate are
dissolved in three drachms of distilled water. One Pravaz
syringe full of this solution is injected three hours before opera-
tion, and a second similar dose given one and a half hour
later. A few drops of cocain solution are instilled before
operating. Although the patient is apparently comatose, he
can turn the eye in any direction when asked to do so. The
solution ' Skopomorphin ' can be obtained sterilized in tubes
from J. D. Riedel, Berlin.
The Cleansing of the Conjunctiva.
The value of perchloride irrigation of the conjunctiva
before operation, and its mode of action, are discussed at
the end of this chapter, under ' Asepsis.' The fairly general
affection evinced by eye surgeons for sublimate lotion
is based upon wide clinical experience. This solution has
been much more extensively tested than any other antiseptic
fluid, in spite of the irritation set up by it. And the
explanation is that its usefulness depends mainly upon its
action on the conjunctival tissues. Laboratory research
showed years ago that there was little prospect of success
in the search for an effective but unirritating conjunctival
antiseptic. And according to present evidence, it would
be a mistake to attempt to replace the perchloride by
cyanide of mercury solution, or by other antiseptic fluids,
which, with a given bactericidal power, produce less
irritation.
The drawback to the use of the perchloride is the
inflammatory reaction set up by it. But our Bombay
experience shows how, by adjustment to individual needs,
the reaction can be kept within bounds. Any unusual
degree of conjunctivitis excited is in itself but a slight
temporary inconvenience, of no real consequence whatever.
* Klin. Monats. f. A., Juli, 1907.
184 Cataract Extraction
It is gratifying to the operator that the eye should remain
free from noticeable reaction, but it is necessary to
distinguish between personal gratification and actual
benefit to the patient. It is, of course, better to irritate a
hundred eyes than to lose one by suppuration. It might
be anticipated that this traumatic inflammation might
occasionally tend to favour secondary infection of imper-
fectly healed wounds. For such reactions are known
to encourage the multiplication of pathogenic cocci in the
conjunctival sac. But no clinical evidence is forthcoming
of wounds being thus influenced. Excessive reaction,
however, may do harm by simple spread to the deeper
tissues of the eye. Where much lid swelling is occasioned
by the conjunctival application, it is reasonable to suppose
that some slight injection of iris and ciliary body may be
set up from the surface irritation, such as may be observed
commonly with any slight corneal lesion. And this,
acting together with other causes of iritic reaction, may
assist in the development of iritis. Practically the extent
of this drawback, as seen clinically, consists in the need
for more atropin after operation than would otherwise be
used. Another point frequently scored against perchloride
is that by injuring the tissues it renders them less able to
cope with any pyogenic organisms. But since the lotion
does not gain access to the wound and is only applied to
the conjunctiva beforehand, the objection does not apply.
Where no pathogenic organisms are present even simple
mechanical cleansing, if at all vigorously carried out, may
be objected to as causing a slight unnecessary reaction.
The ideal procedure would be the determination of the
presence or absence of pathogenic organisms, and such
preliminary treatment of the conjunctiva as proved
necessary to remove these inhabitants. Some attempt
has been made in this direction, e.g., by Freeland Fergus.
Variations in Procedure, and their Value 185
Simple cultures upon Loffler's serum, supplemented oc-
casionally by subcultures, supply fairly definite information.
One would prefer not to operate, as we found we were doing
in Bombay, in the presence of pneumococci or streptococci,
orange or citron staphylococci, or diplo-bacilli, or even of
numerous white staphylococci. Freeland Fergus* is of
opinion that the Staph. albus does not cause suppurations,
or even iritis or irido-cyclitis, but if present in considerable
quantity, almost invariably gives rise to conjunctivitis after
operation.
Had there been means and opportunity in Bombay, however,
for carrying out bacteriological examinations at a sufficient
interval before operating, the knowledge obtained would have
been an embarrassment, and would have lessened the useful-
ness of the hospital. We would have feared to operate in
many cases even with the help of perchloride, and would have
kept patients attending for outdoor treatment until many of
them would have fallen into the hands of the couching quacks.
Bacteriological examination would be appealed to more
commonly did surgeons feel perfect confidence in the result.
One fears to place implicit trust in a negative result, which
may possibly, by some rare chance, be due to faulty technique.
There is also the feeling that a few dangerous microbes may
escape detection, lying in folds or recesses. Probably, however,
such scattered organisms are of little account, for it is recog-
nized that a certain dosage is required for the effective lodgment
of pyogenic organisms in a wound. However this may be, it
was curious that the one complication, presumably infective,
which occurred among our fifty cases bacteriologically ex-
amined (see later) was in an eye in which the test gave no
warning of danger, i
* Brit. Med.Journ., March, 1905.
t It was one of our rare cases of occlusion of the pupil from iritis.
But the iritis was not very severe ; there was neither much injection
of the eye nor much exudation. The closure of the pupil came as a
surprise, and was apparently largely due to the treatment being at
first very mild. From the conjunctiva after perchloride irrigation
only one colony of white staphylococci was grown, while the tube
inoculated before irrigation furnished eight colonies of white staphylo-
cocci and two small moist pits suggestive of early diplo-bacillary
colonies, which, however, did not develop.
1 86 Cataract Extraction
Separation and Control of the Lids.
The advantages of the stop-speculum are somewhat
more evident in dealing with deeply set eyes than with
others, for the risk of vitreous accident from contraction of
the orbicularis is least in these cases, and wide separation
of the lids is most needed. The danger of vitreous
expulsion, in so far as it is due to the speculum properly
elevated, is explained by the fact that the peripheral fibres
of the orbicularis muscle are alone able to press upon the
eyeball. The elevation of the tarsal portions of the lids
leaves the front of the globe unsupported, and the corneal
flap can be thus forced forwards. Hence it has become
customary to insist upon some provision for very rapid
removal as one of the essentials in the design of a
satisfactory speculum. There is no such provision in the
screw adjustment, which is the only stop mechanism with
which I have had extensive experience ; and I have not
found the want of it noticeably embarrassing. When
harm is done by spasm of the orbicularis, it is nearly
always at the first moment of the contraction. The
muscle is commonly relaxed again at a sharp word of
command from the surgeon, and the instrument is readily
withdrawn before further contraction can take place.
Automatic removal, brought about by the actual con-
traction of the lids, as in Miiller's speculum, is the only
mode of removal rapid enough to guard the vitreous
effectually. And the sudden closure of the lids permitted
may do harm should any instrument be in the wound
at the time or should the iris be in the grip of the iris
forceps, or should the wound be gaping widely, with
the lens lying in it. Again, violent contraction of the
orbicularis is frequently foreshadowed by preliminary
twitches or blinkings, which serve as a warning for
Variations in Procedure, and their Value 187
removal of the speculum, and substitution of other means
for separating the lids. Our figures (p. 169) show how
infrequent vitreous accident from spasm of the lids may
be, in working with the ordinary screw speculum under
the general precautions indicated in Chapter III.
With Desmarres' retractor in the hands of an experi-
enced assistant, powerful spasm of the orbicularis may be
effectually resisted without endangering the vitreous,
except, perhaps, in the case of unusually prominent eyes.
Yet it is extraordinary sometimes how the muscle is able
to exert pressure upon the globe, with the retractor firmly
pressed against the roof of the orbit. With the stem bent
as shown in Fig. 41 the instrument can be used more
effectively to control the action of the orbicularis muscle,
but it is not so easily withdrawn when the muscle is
contracting.
In Chapter II separation of the lids by the assistant's
fingers is considered only as a substitute for the use of the
speculum after the section has been completed. But a few
surgeons employ it in making the incision, e.g., Sir Ander-
son Critchett. When working without an assistant, this
operator elevates the upper lid with the ring finger
of the hand holding the fixation forceps.* Trousseauf
(Paris) employs his own finger and thumb for separation
of the lids and for fixation of the eye. The chief
objection to control of the lids by the fingers alone, apart
from its comparative ineffectiveness, is an inadequate
protection against infective risks.
* The Ophthalmoscope, iv (1906), 112. Critchett says: "The
sensitive natural speculum possesses this great advantage, that it can
recognize the beginning of a spasmodic effort on the part of the
patient, and can at once give the necessary relaxation, and as the
section is nearing its completion, the gradual withdrawal of the finger
allows the lids to close gently and without effort."
f La Clinique Ophtal., November 25, 1905.
1 88 Cataract Extraction
When the lids have to be released on powerful spasm
occurring, the edge of the corneal flap, possibly with the con-
junctival flap lying over it, deep surface foremost, sweeps
upwards in contact with the conjunctiva of the upper lid. And
should closure of the lids occur with the lens half out of the
wound, the corneal flap may be carried down by the bacterio-
logically unclean border of the upper lid, and thus possibly
the zonule ruptured, vitreous lost, and the interior of the eye
widely exposed to any bacteria present in the conjunctival
sac. Should this accident occur, the lower lid must be firmly
depressed by the assistant, while the upper lid is elevated by
pulling on the lashes, or, if necessary, by the insertion of
Desmarres' elevator, and the flap replaced by the curette.
Angelucci raises the upper lid by means of the fixation
forceps gripping the tendon of the superior rectus.
FIXATION.
Some operators who complete as much as possible of the
section in the first inward stroke of the knife, fix the globe
with forceps at the inner side of the cornea, to resist the thrust
of the knife. The forceps applied here may be of some slight
service in defining the site of the counter-puncture. In our
work with a gentler use of the knife, fixation is more needed
below to resist the upward pull in the sawing movements of the
blade.
Angelucci's Method of Fixation. Fixation of the globe
by gripping the insertion of a rectus muscle (the internal) with
forceps through the conjunctiva was practised by Macnamara.
Angelucci * is warmly supported by Gutmann f in claiming
special benefits derived from his method of fixing the eye
by grasping the tendon of the superior rectus muscle. He
performs simple extraction through an upper section compris-
ing little more than one-third of the corneal circumference, and
incises the lens capsule with the point of the knife as it passes
across the chamber. The fixation forceps serve not only to
fix the globe, but also to elevate the upper lid. They should
* Arch, di Offal., vi (1899), 260.
f Bericht der xxx Versamm. der ophth. Ges. in Heidelberg, 1902,
S. 239.
Variations in Procedure, and their Value 189
have ends 3 millimetres broad, and teeth not very pointed.
Angelucci dispenses with an assistant, and does not depress
the lower lid. The upper lid is first well elevated by the
thumb of the right hand, while the forceps, held in the left
hand, and pressing deeply, seize the conjunctiva and the under-
lying tendon 4 to 5 millimetres from the corneal margin. This
hold is maintained while the various steps of the operation are
performed with the right hand.
It is stated that the fixation so close to the section entirely
immobilizes the eye, and the making of the section is conse-
quently very easy. The forceps serve for counter-pressure in
expelling the lens in the ordinary way with Daviel's spoon.
The pressure required is only light, and therefore there is little
risk of vitreous accident, and rarely any injury to the iris or
any prolapse. The return of the iris within the chamber is
facilitated by the forward pull of the forceps on the scleral
margin of the wound. In senile enophthalmos and in ble-
pharophimosis the forward pull of the forceps is an advantage.
It would seem that the hold on the muscle must be frequently
painful, and therefore likely to excite spasm of the lids.
THE SECTION.
Variation in the style of cutting is optional, thus :
Many surgeons attempt always to complete the section
in one double movement of the knife, in and out. This
may frequently be accomplished with a fairly broad and
sharp knife. Czermak used a blade 3 to 3*5 millimetres
broad. Critchett and Kuhnt have employed the knives
already described.
It is by no means always possible, however, to finish
the section thus simply and rapidly without using more
force than one may consider advisable. This is particu-
larly so whenever a long sweep* of the knife is impracti-
* A slightly longer movement of the blade is practicable if the eye
be turned a little outward, or if the same effect be got by keeping the
eye fixed and turning the head a little to the other side.
190 Cataract Extraction
cable in sunken eyes, therefore, and in those with
contracted palpebral aperture.
When it can be effected easily, the incision by this one
to-and-fro stroke presents two claims upon our considera-
tion : (i) It makes a wound with perfectly smooth level
surfaces. And such wounds are much more likely to unite
rapidly and firmly than others somewhat jagged and
uneven. This is important in operations where the
conjunctival flap is dispensed with, or where only a small
apical flap is made. And more especially so if at the
same time no iridectomy is made, since early union is
relied upon to prevent prolapse of the iris. (2) An
advantage much more appreciated in simple than in
combined extraction is that some aqueous is retained in
the chamber during the greater, part of the cutting.
Thus injury to the iris by the knife is prevented, and this
is an additional safeguard against subsequent prolapse.
There are two drawbacks to this mode of cutting :
(i) The higher degree of force that one is tempted to
exert to complete the incision with a knife which is
beginning to lose its edge must endanger a weak zonule.
And this ligament may be further endangered by any
slight twist of the broad blade which may be required in
following the edge of the cornea upwards, causing the
back of the blade to press upon the lens and iris. (2) This
mode of cutting does not afford facilities for shaping any
conjunctival covering except at the summit of the wound,
for so much of the incision is accomplished in the mere
puncture and counter-puncture by a very broad Graefe's
knife. And the fashioning of anything approaching a
complete conjunctival flap depends so much upon the
slight alterations in the plane of the blade which are
practicable during sawing movements, that it is found that
the narrower the blade the more nearly can one succeed
Variations in Procedure, and their Value 191
in the difficult outlining of any particular design of con-
junctival appendage.
On the other hand, the narrower the blade the more
often will the iris be cut or scraped by it, owing to escape
of aqueous before the edge of the knife has passed well up
in front of the iris. This in spite of the fact that slight
alterations in the plane of the narrow blade may often be
made without appreciable loss of aqueous.*
Thus, in our work, wanting always a moderately
complete conjunctival covering, and, though frequently
attempting the simple operation, more frequently ending
with the combined, we found the blade of medium width,
2 millimetres exactly, most satisfactory. It was not too
broad for the cutting of a satisfactory conjunctival flap,
and was yet broad enough to obviate frequent injury to
the iris.
A narrow blade is more easily guided across a very
shallow anterior chamber, pressing less against the lens
and iris.
If one attempt to accomplish the whole or greater
portion of the section in one movement of a medium
or rather narrow blade, the push of the knife is somewhat
apt to force out aqueous and iris through the wound at
the inner side below the knife.
The Conjunctival Flap serves several purposes :
i. Its chief function is as a protection against infection
of the eye. Serving as a covering for the wound, it must
bar the entry of micro-organisms from the conjunctival
sac after the operation. And for this purpose, the more
* The slightest twist of a broad blade at once empties the chamber
of aqueous. In our earlier practice we found the iris more often
injured by broad-bladed knives. But this was due to want of care in
placing the blade correctly before beginning the incision. One of the
chief objections to the old broad Beer's knife was the difficulty in
altering its plane during the making of the section.
192 Cataract Extraction
complete the covering, presumably the more effective
should it be, especially in eyes where vitreous tends to
press the corneal flap forward. It is doubtful, however,
whether in ordinary cases a protective covering is in any
degree necessary or advisable, except about the middle of
the wound at the summit of the arch. It is here that
any gaping of the wound tends to be widest.* And it is
here, also, that micro-organisms are most likely to be
worked into the wound from the overlying palpebral con-
junctiva by movements of the eyeball, since uncontrolled
movements after operation, just as during operation, are
presumably mostly in the vertical direction. And probably
the making of even a small localized flap may be considered
indirectly to guard against secondary infection to some
extent by ensuring that a portion of the incision traverses
vascular scleral tissue.
It is not unreasonable to suppose further that the
protective influence, as regards infection, which we
attribute to the conjunctival flap, is exerted partly during
the actual operation.
The mere covering then appears to be of little value, unless,
possibly, to screen the eye from the operator's saliva in speaking.
But the cutting of the flap provides a strip of raw sterile
surface, enlarged by retraction of the elastic membrane, over
which instruments pass in entering the eye. Thus the instru-
ments are not likely to carry in conjunctival organisms. If
the conjunctival flap be left in place, instruments inserted
beneath it have to pass between two active raw surfaces, likely
to rub off loose bacteria from the instruments, and well able to
dispose of them subsequently.
2. The very rapid adhesion of a conjunctival flap to
the underlying tissue must undoubtedly tend to prevent
* It is understood that reopening of the incision towards either end
from prolapse of iris is at once remedied by excision of the prolapse.
Variations in Procedure, and their Value 193
prolapse of iris. But this statement needs qualifying
greatly. Since a cataract incision largely covered by
conjunctival flap must be at least partly sclero-corneal,
this peripheral situation of the section, as compared with
one at or in front of the limbus, is calculated to more than
counterbalance any benefit derivable from the conjunctival
covering. For another reason, any value attributable to
the conjunctival appendage as a preventive of prolapse is
restricted mainly to the smaller conjunctival flaps (see
below).
3. The use of the flap makes the complication, delayed
union of the wound, as shown by non-retention of aqueous,
a rare one and almost a negligible one. Should the
complication occur, it will not persist for long, and will
not require treatment, and there is no fear of down-growth
of surface epithelium into the anterior chamber, with
its subsequent liability to induce probably incurable
glaucoma.
4. We attributed our almost complete exemption from
secondary glaucoma in Bombay cataract work mainly to
our very general use of an extensive conjunctival flap. A
permanently filtering cicatrix rendering rise of tension
practically impossible appears to be the constant and
inevitable result of any recognizable separation of the
sclero-corneal incision under the conjunctival covering.
5. A quite minor advantage of the conjunctival ap-
pendage is in the use that may be made of it to draw open
the wound during operation, for the iridectomy and in the
expulsion of the lens.
Drawbacks. (i) During operation it may be a little in
the way when the iris is being cut, but the chief trouble
from it then is (2) the haemorrhage into the anterior
chamber, which is to be expected more or less with any
extensive flap unless adrenalin solution has been in-
13
194 Cataract Extraction
stilled. This blood is not only a nuisance at the time,
interfering with the capsulotomy and with the removal of
cortex, but also afterwards. A little of it may become
organized, causing permanent after-cataract and synechise.
The bleeding is to be more carefully guarded against in
intracapsular extraction, since here the blood cannot
well be washed away. Still, these are not very serious
matters. Also may be mentioned as a slight drawback
(3) the difficulty experienced in outlining the flap exactly
as one wishes. (4) After operation the separation of the
deep wound, which takes place under a too complete
conjunctival covering, presents very decided disadvantages
to set against the advantage already claimed (namely, the
value of this separation as a safeguard against secondary
glaucoma). They are (a) the permanent astigmatism
attributable to it, occasionally considerable in amount ;
(6) some slight fear of accident to such of these eyes as
pass through a prolonged low-tension period ; and (c) the
very occasional late, gradual incarceration or prolapse of
iris in a wound gaping under the conjunctival flap, seen
by us especially after combined extraction. This occur-
rence is, however, too infrequent, even with a very extensive
conjunctival flap, to greatly qualify the statement above
made on the use of the flap as a preventive of prolapse.
Moreover, this late prolapse, always small, is removable
without any particular risk or difficulty. And all of these
drawbacks apply only to a covering left considerably
larger than usually necessary. They can be avoided by
trimming the flap, except where vitreous presenting in
the wound renders this inadvisable. (5) Very rarely the
flap fails in its purpose through becoming folded down
over the cornea.
The question of the Size of the wound is not one of
importance nowadays. With the application of such
Variations in Procedure, and their Value 195
antiseptic and aseptic precautions as are now in vogue, it
is found that with a flap not exceeding a semicircle the
tissues are sufficiently well nourished to guard against
the possibilities of sloughing or suppuration of the flap.
The form of the section may also be taken as finally
settled for routine extraction.
The most suitable Site of the incision with relation to
the corneal circumference, however, is still not finally
settled.
The reduced liability to suppuration of sclero-corneal
wounds as compared with purely corneal ones was seen
in the improved results obtained in pre-antiseptic days
with Jacobson's and von Graefe's incisions. The super-
ficial vascular, scleral and conjunctival tissues serve to
protect the underlying cornea from bacterial invasion.
The resistance of the limbus and of the cornea imme-
diately underlying it is also well recognized in destructive
suppurative processes. (Though the protected marginal
zone of cornea generally includes a rim of tissue within
the normal limbus, this appears to be due to rapid in-
growth of the limbus blood-vessels, rather than to an
influence exerted beyond the terminations of the blood-
vessels. The rim of cornea saved is found covered at the
time with new vessels. Our knowledge of acute suppura-
tions of the cornea, therefore, does not warrant us in
expecting the same protection to be afforded by the
limbus covering, in the case of a section at the edge of the
clear cornea, as when both lips of the incision lie a little
further back.) The comparative safety of sclero-corneal
wounds is probably explained, not only by their vascu-
larity which enables them to dispose of bacteria lying in
them and also leads to quicker healing but also by the
usual absence of the superficial groove which is formed by
retraction of Bowman's membrane in purely corneal
132
196 Cataract Extraction
sections. More important than this is the protection of
the conjunctival flap.
A minor advantage of a peripheral puncture and
counter-puncture is the lengthening of the base line of
the flap, enabling the lens to escape more easily. But
this is more than counterbalanced by an increased
liability to cutting and scraping of the iris by the knife,
and by frequent trouble with haemorrhage during opera-
tion. (The tendency to bleeding, however, is a very
minor drawback, since it can be prevented by the use of
adrenalin beforehand.) A more definite disadvantage is
the increased risk of subsequent prolapse.
By a section placed more anteriorly, in clear cornea,
trouble with the iris is more commonly avoidable both
accidental section and prolapse. Hence the advantage of
such a section in the simple operation. And there can be
no trouble from bleeding. But few surgeons care to place
any portion of the incision definitely within the boundary
of clear cornea, on account of the infective risks. Also
the post-operative astigmatism tends to be greater the
nearer the incision to the centre of the cornea (though
the average amount from a purely corneal section is
probably less than that from a sclero-corneal section
gaping under a large conjunctival flap). And any ad-
hesion of iris or capsule to the line of the wound appears
the more likely to lead to secondary glaucoma the further
forward the incision is made.
Smith of Jullundur appears to derive some advantage
from an upper corneal section ending well below the
corneal circumference, in that he is able to deliver the
lens more easily without requiring the patient to look
down.
The fairly general selection of the site at the margin
of clear cornea has been in the hope of retaining the
Variations in Procedure, and their Value 197
benefits of the purely corneal section, and at the same
time securing some, if not all, of the safety pertaining to
more peripheral incisions. This question of safety from
infective risks overshadows all others. If it can be shown
that infective complications may be as completely ex-
cluded as by the sclero-corneal incision, the placing of the
puncture and counter-puncture in the boundary of clear
cornea is more than justified. For it is still quite easy to
outline a conjunctival flap above. In some eyes this
necessitates turning the edge of the knife somewhat back-
wards in completing the section, but in other eyes (see
p. 64) the knife in cutting up parallel to the iris becomes
placed behind the conjunctiva above. But it has yet to
be shown that infection can be certainly excluded with
such a section. In Bombay we have been able to exclude
suppurations entirely with our sclero-corneal section, both
those beginning in the cornea and those beginning as
severe irido-cyclitis. It is to be noted that we did not
entirely escape irido-cyclitis ending in sympathetic loss of
the fellow eye. We had reason to think, however, that
finally this possibility had been practically excluded. And
there is no, doubt the cases observed were due largely to
neglect after operation. The question is of importance
here, because in old days it was found that the reduction
of corneal wound suppurations by the adoption of
von Graefe's peripheral linear section was counter-
balanced by an increase of losses from deep infective
inflammations ending sometimes in sympathetic oph-
thalmia. But there is little doubt that these losses were
mainly, if not entirely, attributable to the frequent incar-
cerations of iris in the very peripheral wounds.
The Downward Section was practically the only one
available for the early operations without anaesthesia.
198 Cataract Extraction
Neither speculum nor fixation forceps was needed, and the
whole operation was less painful and less trying to the
patient. The lens and cortical remains were compara-
tively easily expressed, and the manipulation of the various
instruments could be carried out conveniently without
much exposure of the eyeball.
The ordinary lower section, however, has serious draw-
backs. The risk of infection is increased by the danger
of accidental contact of the wound with the lower lid
margin in movements of the eye during operation, and by
the position of the wound opposite the lid space after-
wards. According to our Bombay experience there is a
greater tendency to loss of vitreous, from two causes. The
wound in this situation is (i) more easily forced open by
contraction of the lids, and (2) also liable to be pulled
open by the drag of the lower fornix, fixed by the speculum,
when the globe rolls far upwards. (The lower fornix,
normally less extensive than the upper, was also in our
cases frequently more or less retracted by scarring).
These dangers, however, can be guarded against by ex-
tracting the lens subconjunctivally, and by substituting
retractor and finger depression for the speculum. But
still the great drawback of all lower sections remains
viz., the placing of the coloboma below whenever an
iridectomy has to be made, whether of deljberate intent,
or on account of trouble during the operation, or of
prolapse afterwards. It was on this account that the
upward section became the routine practice for all ordinary
cases. It has been held that all the manipulations,
including the delivery of the lens, are more difficult by
the upper section. But this is not so, provided the patient
looks steadily downwards. On the contrary, to one used
to the upper section, the delivery of the lens is often less
easy through the lower opening. The forceps cannot be
Variations in Procedure, and their Value 199
used as mentioned on p. 115, and it is more difficult to cut
a satisfactory conjunctiva! flap below the cornea with the
knife. It is a question whether at least a narrow con-
junctival bridge should not always be left undivided in
operating below, and peripheral iridectomy has special
claims (see later).
It has been held that the upper section exposes the
interior of the eye more to possibilities of infection, in that
not only blood, but also fluids from the surface of the
globe, possibly microbe-containing, more easily find their
way into the anterior chamber. On the other hand,
should irrigation of the chamber be practised for the
removal of cortex, blood, etc., the situation of the wound
above is undoubtedly preferable. For it is scarcely
possible to irrigate without forming a pool of fluid in the
conjunctival sac sufficiently large to cover a lower section,
thus connecting the interior of the eye by moving currents
of fluid with a possibly foul lower fornix.
Some form of downward section is almost forced on one
in the case of patients who cannot be depended upon to
look steadily downwards. It is also indicated when a
coloboma already exists below, either congenital or other-
wise ; also for lenses dislocated into the anterior chamber ;
and is performed by some operators where the upward
section is difficult in deeply sunken eyes, or in eyes with
narrow palpebral aperture. Also, by Czermak's method,
for dislocated lenses.
Outer Sections. Section of the outer portion of the cornea,
though largely practised for the ' linear extraction ' of soft
cataracts, has never become an established procedure for the
removal of lenses with hard nuclei. It has been performed,
however, by a few operators. Daviel gave a trial to a
triangular section outwards. Galezowski (1871) performed
von Graefe's scleral linear extraction outwards with a bent knife.
Macnamara (1871), Castorani (1874) and Andrew (1883), all
200 Cataract Extraction
made a linear section at the temporal margin of the cornea
with a broad keratome (Castorani later with Beer's knife) and
removed the lens in its capsule with a spoon.
Bourgeois* (Rheims) has reported four perfectly successful
simple extractions by an external lateral section specially
adapted for the application of sutures. It is designed for
occasional use only viz., in most of the cases where the appli-
cation of sutures is indicated (p. 214), also in very prominent
eyes, and where the palpebral aperture is small, and in totally
deaf patients.
He uses a double knife f consisting of two bent "broad
needles " lying parallel to one another in the same plane,
separated by a space of i millimetre. Their handles are
locked together by a simple mechanism, which admits of their
being easily separated.
Cocain having been freely instilled and Panas* speculum
inserted, the globe is fixed at the inner side by the assistant.
The puncture is made at the limbus, one blade on either side
of the horizontal corneal meridian. The knife is held in the
right hand, and this determines the position of the operator for
either eye in the usual way. At the moment of puncture the
surgeon fixes the eye with his left hand, giving up the forceps
again to the assistant immediately afterwards. As soon as the
blades have penetrated well into the anterior chamber they are
unlocked. And while the lower blade is held in position with
one hand, the other one is made to cut upwards along the
corneal margin nearly to the vertical meridian. It is then
withdrawn, and a similar downward incision made with the
lower blade. Thus two equal half sections are made, separated
by a bridge of undivided cornea, i millimetre broad.
The sutures are now inserted, first one at the middle of the
lower half section, and then one in the corresponding position
above. In each case the corneal lip of the wound is pierced
and the curved needle drawn completely through, before the
scleral lip is perforated. The loops of thread crossing the
wound are left long, and turned out of the way, upward and
downward, over pads of sterilized gauze.
The corneal bridge is then divided with a blunt-pointed
knife. The lens is extracted in the ordinary way after opening
* Ann. d'Ocul., cxxv (1901), 10.
f Made by M. Major, 91 Boulevard Saint- Germain.
Variations in Procedure, and their Value 201
the capsule, or it may be removed in its capsule with a small
spoon. To facilitate this latter, Bourgeois suggests division of
the pupillary zone of the iris, where necessary, with scissors.
The threads are then drawn tight by their scleral ends and
tied. They are left in situ for five or six days. A third suture
might be placed at the middle of the wound, if thought neces-
sary, to prevent prolapse of iris.
Double Flap Sections. -Schulek* in 1895, and Plehntin
1901, published accounts of two very similar double-flap sections,
designed with the idea of preventing prolapse of iris. The
former used a very narrow Graefe's knife, the latter a special
trapeziform instrument. After cutting upwards in the limbus
FIG. 76. SCHULEK'S INCISION.
for a portion of the distance for an ordinary upper flap, the
section is continued at an angle downwards and forwards to
completion. Thus, in addition to a larger lower flap directed
upwards, there is formed a smaller overlapping tongue of cornea
projecting downwards from above. The lower flap fits into
the groove behind the upper, and is kept in place by it. In
Schulek's hands the method did not prove effective against
prolapse ; his proportion was 10 per cent.
L. Milller % has designed a section which, by its devious
course and by fixation with sutures, provides for very firm and
exact closure of the wound. It is intended to be used only in
cases where the application of sutures is indicated (p. 214).
The first step is the formation of a small superficial corneal
flap with its base upwards at the limbus. Its lateral measure-
* Ungar. Beitr. z. A., i (1895), 2 S4-
t Zeitsch.f. A., v (1901), 259.
+ KL Mbl.f. A., xli (1903), 11.
2O2 Cataract Extraction
ment is 5 millimetres, its vertical extent 2 millimetres. It is
made by thrusting a very narrow Graefe's knife across in the
substance of the cornea, with the cutting edge downwards, and
without going deep enough to enter the anterior chamber.
After cutting downwards for 2 millimetres, the edge of the
blade is turned directly forwards. Thus the small flap, (a) (b)
(c) (d) and (i) (k) (g), is not thinned at its extremity, but is cut
rectangularly.
Two sutures are now inserted through the angles of the flap
at (c) and (d) into the neighbouring cornea, but the loops are
left loose.
The section is then completed by an upward incision with a
a b
FIG. 77. L. MULLER'S INCISION.
Graefe's knife, as in making an ordinary 3-millimetre corneal
flap section. [Puncture and counter-puncture at (e) and (/),
summit of the flap at (k) (i).] It must end, therefore, exactly
at the base of the small superficial flap, and care must be
taken not to cut into the base of the small flap at all.
The sutures are tied at the close of the operation, and are
not required for longer than one or two days, owing to the
considerable area of the opposed surfaces of the wound.
Subconjunctival Extraction.
Where there appears to be any particular advantage to
be gained by it, the lens may be delivered beneath the
conjunctiva, previously undermined, and thence through
an opening which does not correspond with the sclero-
corneal section. There are two methods which have been
largely practised by a few operators as routine procedure
Variations in Procedure, and their Value 203
for the general run of cases. The ' conjunctival bridge '
or ' adherent conjunctival flap ' operation, first performed
with downward section by Desmarres in 1851, was ex-
ploited largely with upward section in 1899 by Pansier
and Vacher (Orleans), independently of each other. The
method is as in the cutting of a large conjunctival flap,
but the knife is passed onwards under the conjunctiva for
i to 1*5 cubic millimetres, and the making of the flap is
not completed, a bridge as broad as possible, 5 to 8 milli-
metres, being left undivided. From this simple measure
Czermak's ' conjunctival pouch ' operation developed,
affording an even more effective covering to the deep
wound. The first step was the preliminary undermining
of the conjunctiva with scissors before making the section.
And finally, the sclero-corneal section itself was made
mainly with scissors subconjunctivally.
The main value of the subconjunctival operations
obtains during the healing period. The more complete
the covering of the sclero-corneal wound, the more per-
fectly is secondary infection excluded. By Czermak's
method the protection appears complete. As a safeguard,
however, against primary infection i.e., infection intro-
duced during the operation the advantage of the sub-
conjunctival methods of extraction is not so definite. The
deep wound is certainly guarded from accidental contact
with palpebral conjunctiva and lid margins (and from
fouling by the operator's saliva should he not wear a
mask), but otherwise the possibilities as regards the entry
of micro-organisms do not appear greatly altered.
The conjunctival covering is not able to retract like a
completely divided flap, and so there is not the subsequent
separation of the deep wound which forms one of the
drawbacks to a large flap, and its rapid union with the
underlying tissue serves to prevent reopening of the wound
204 Cataract Extraction
and prolapse of iris. Czermak found the eye practically
safe from iris prolapse after the first few hours following
operation. Vacher reported a series of 120 extractions,
mostly simple, free from prolapse. In our Bombay
experience of Czermak's operation we had almost no
prolapse, though the pupil was sometimes left somewhat
distorted and displaced. Against this, however, must be
set the frequency with which we had to perform combined
extraction (see below). Should prolapse occur, it does not
open a way for infection of the eye, owing to the pro-
trusion being subconjunctival.
It is a small advantage that the eyes thus operated upon
need less after-care than ordinary, also it is claimed that
there is less astigmatism caused.
The tense conjunctival covering is of service during the
operation in certain cases (p. 211), in reducing the risk of
vitreous accident.
The drawbacks to any subconjunctival operation are
chiefly :
i. Undoubtedly an enhanced difficulty at times in
delivering the lens safely, and in evacuating lens remnants.
The difficulty is, perhaps, greater the more the con-
junctiva is anchored, as it is in the 'pouch' method, and
where the ' bridge ' is very broad. Hence frequently
injury to the iris necessitating iridectomy, and a tempta-
tion to increase the pressure in expulsion, to such a degree
as to risk rupture of the zonule.
The iridectomy is of consequence only in the downward-
placed operations. In our earlier operations with con-
junctival pouch doubtless owing largely to faulty
technique we had to do combined extraction in about
half the cases, and only quite at the end did we reduce the
proportion of combined operations much below one-third.
In no Czermak's operations an iridectomy was made no
Variations in Procedure, and their Value 205
less than 46 times, and once excision of prolapse was
undertaken afterwards. The coloboma* situated down-
wards and outwards, constitutes a grave defect in a patient
who requires very acute vision afterwards.
2. The number of vitreous accidents attributable to diffi-
cult expulsion of the lens is likely, unless great patience be
exercised in the expulsion, to obscure the advantage of the
operation in this respect in the special cases above referred
to. In Bombay our proportion of vitreous losses was
slightly higher in these operations than in ordinary extrac-
tions.
3. The tendency to stripping of cortex in the delivery
of the lens through a wound not widely open renders sub-
conjunctival extraction quite unsuited for cataracts at all
unripe.
4. In spite of adrenalin, hcemorrhage into the anterior
chamber may occasionally cover lens and iris. A small
quantity of blood may be readily expressed. But per-
sistent bleeding t from rigid blood-vessels may fill the
chamber and the conjunctival pocket (in Czermak's opera-
tion) with clot, rendering the completion of the operation
* In most of our Indian patients the iridectomy downwards could
not be considered a very serious drawback. In some instances the
excision of iris \vas to facilitate the delivery of the lens or of lens
remnants ; in others to prevent prolapse of the iris, more or less
injured in the expulsion of the lens. In most of these latter cases the
complete coloboma might probably have been replaced by a small
peripheral opening, with little or no effect upon vision. Such a small
iridectomy might be made downwards or downwards and inwards
through a small conjunctival slit.
t In one of our cases, already mentioned on p. 162, there was
bleeding about the close of the operation to produce a considerable
swelling under the conjunctiva with separation of the lips of the deep
wound and bending forward of the lower part of the cornea. There
was no pain, and no loss of perception of light. But the pupil became
closed with clot and lymph, and though the iris was perfectly clear,
needlings failed to provide an open pupil, and the tension of the eye
remained low.
2o5 Cataract Extraction
very difficult, and making it impossible to deal satis-
factorily with the iris.
5. The slight prolongation of the operative procedure is
scarcely noticeable in the narrow bridge operation, but is
definite where undermining of the conjunctiva by scissors
is undertaken. This is of no importance in downward
sections, but appears to limit the application of Czermak's
upward section very considerably, owing to the increased
strain placed upon the patient's self-control in continuously
looking downward.
Czermak's Downward Section with Subconjunctival
Pouch.
Adrenalin must be combined with the cocain or used
before it, and during this operation the cornea needs
moistening from time to time with sterile salt solution.
The operator stands in the usual position for the right
eye, beside the patient for the left eye. The patient turns
the eye somewhat upward, and the globe is fixed with
forceps close to the inner side of the cornea, immediately
above its horizontal meridian. With a broad (3-milli-
metre) Graefe's knife a sclero-corneal puncture is made
close to the limbus at the outer end of the horizontal
corneal meridian, with the cutting edge of the knife down-
wards, as if to cut a semicircular flap with the knife. The
puncture is made subconjunctivally after engaging the
conjunctiva at a little distance (2 millimetres) from the
cornea on the point of the knife and sliding it inwards.
The capsulotomy may, if preferred, be made with the
point of the knife, and the instrument is then withdrawn.
Or the capsular opening may be made later in the usual
way.
The opening in the conjunctiva is then extended with
Variations in Procedure, and their Value 207
scissors obliquely down and out, nearly to the lower
fornix. The inner border of this slit is now raised with
forceps and the scissors introduced, to undermine by a few
snips the lower ocular conjunctiva from the limbus down-
FIG. 78. CZERMAK'S LOWER SECTION.
The Puncture.
(From 'Die Augenilrztlichen Operationen.')
wards. Thus is formed a subconjunctival pocket, as far
as a vertical line falling from the inner end of the
horizontal corneal meridian. Czermak holds it important
to loosen the membrane quite up to the limbus, to enable
FIG. 79. CZERMAK'S LOWER SECTION.
The Cutting.
(From 'Die Augeniirztlichen Operationen.')
the sclero-corneal section to be placed immediately behind
the limbus, thus to reduce the chances of prolapse and
incarceration of iris. At the same time care must be
taken to avoid perforating the conjunctiva with the
scissor points.
208 Cataract Extraction
The sclero-corneal section is now completed with
scissors. Czermak uses Louis' scissors, with fine and
thin blades, curved on the flat, and with round points.
One blade is I to 1*5 millimetres longer than the other.
Therefore two pairs of these scissors are required, one for
the right eye and one for the left. The long blade is
introduced into the anterior chamber through the puncture,
and the other blade passed under the conjunctiva. With
three or four snips a subconjunctival incision may be
made as far as the nasal end of the horizontal meridian of
the cornea. In cutting, the scissors are held obliquely to
the scleral surface, so that the curvature of the blades may
correspond with that of the corneal margin, and a light
forward pull upon the eye is maintained by the deep
blade. The little finger of the cutting hand is supported
on the assistant's hand, except at the beginning of the
incision in the right eye, when it rests against the patient's
temple.
The lens is delivered in the ordinary manner of simple
extraction by pressure above and counter-pressure below.
The spatula or curette below is introduced under the
conjunctiva. The lens is pressed into the subconjunctival
pocket, and thence outwards. Any cortical remains are
dealt with in the same way, or removed by irrigation.
The iris frequently becomes prolapsed, and in any case
needs to be replaced with the spatula if the pupil is not
round.
A fine suture may now be used to close the conjunctival
opening (I have never sutured it), and finally eserin is
instilled.
To remove the danger of primary infection during the
operation as completely as possible, Czermak was careful not
to introduce any instrument into the eye nor to raise the lip of
the conjunctival opening without first mopping up any trace of
Variations in Procedure, and their Value 209
fluid which might be lying in the lower fornix. The mouth of
the pocket was opened with fine forceps at the time of intro-
duction of any instrument, in order that the latter might not
come unnecessarily in contact with the conjunctival surface.
A small modification of the section is to make not only the
puncture, but also the counter-puncture with the knife, and so
to get over the difficulty which is experienced in cutting with
the scissors at the nasal end of the incision if the patient
does not look upwards. The perforation of the conjunctiva,
however, leaves the sclero-corneal wound not quite fully
covered.
In our Bombay operations by this method I nearly always
punctured a little above the horizontal meridian of the cornea,
with the knife pointing upwards and inwards, and so made the
flap downwards and a little outwards instead of directly down-
wards. This, of course, reduces the difficulty in cutting with the
scissors at the inner side. Even so, with a patient who is
unable to fix his eye at all upwards, it is well to counter -
puncture with the knife. If this counter-puncture be made
slowly about ^ millimetre behind the corneal margin, and
especially if the blade be twisted slightly at the time, leakage
of aqueous under the conjunctiva may balloon it forwards out
of reach of the point of the knife, so preventing any perforation
of the conjunctiva. It saves trouble, also, to cut the greater
portion of the temporal half of the deep wound by sawing
movements with the knife. The section, as far as the vertical
meridian of the cornea, may be readily made thus with an
empty anterior chamber and without injury to the iris or to
the conjunctiva, if the simple precaution be taken to do all the
actual cutting in the withdrawal movements of the knife (none
during the inward movements of the blade). In one case I
made the whole of the section, including the counter-puncture,
subconjunctivally with the knife.
Our difficulties in expression were lightened as soon as we
realized that it was better to remove the stop-speculum and to
substitute Desmarres' retractor for the upper lid and finger
depression for the lower lid, before attempting to expel the lens.
This loosens the conjunctiva considerably.
Finding it easier to express (by means of the tenotomy hook)
with the right hand and to apply counter-pressure (by the
curette) with the left hand, I had to change position always
14
2io Cataract Extraction
from the patient's head to his side, or vice versa, after making
the section.
Our troubles in the earlier cases were sometimes due to
making the section rather small. I used only Stevens' curved
strabismus scissors one pair for cutting and loosening the
conjunctiva, and a second pair for the deep section. (Being
rather stiff in opening, they had usually to be withdrawn from
the wound between the snips.) In cutting, the scissors were
steadied against the left forefinger. The scissor blades nearly
always got soiled by contact with the lid margins, but not close
to their points.
The deep wound may become exposed in part owing to
perforation of the conjunctiva. This may happen either in
undermining the membrane close to the limbus, or during the
making of the section if any downward movement of the eye
should then take place, or if the scissor blades be not held at
the correct angle of obliquity.
In one or two of our cases the base of the iris was nipped by
the scissors. The weakening or perforation of the base of the
iris increased the difficulty of forcing the lens through the pupil,
and so perhaps accounted for a few of our iridectomies.
Among the minor drawbacks and complications of the
operation may be mentioned also :
Like all downward sections, the wound is badly situated for
irrigation of the anterior chamber, for it is impossible to use
the ordinary irrigator without forming a pool of fluid in the
conjunct! val sac covering the wound. The surface of the
conjunctiva must, therefore, be well douched before any fluid
is allowed to enter the wound.
After operation, transient patchy opacity of the centre of the
cornea in its posterior layers, extending frequently by streaks
to the wound line, afforded evidence of bruising of the centre
of the cornea during the expression of the lens. Its flaky
appearance gave a close resemblance to bits of lens cortex left
in the anterior chamber. Finally, at the time of discharge
the fine posterior lines mentioned under ' Corneal Opacity,'
Chapter V, were frequently found, especially following early
cloudy opacity, extending more or less over the central area
of the cornea.
At the time of discharge a number of eyes were found still
very soft, though there was no visible separation of the deep
Variations in Procedure, and their Value 2 1 1
wound. The sclero-corneal wound surfaces made by the
scissors appear, therefore, frequently slow in uniting. We
kept one of these patients in hospital for three weeks after
operation, and still the tension was very low.
Indications. A. Where a complete covering appears
advisable or imperative to keep out infection.
1. In Bombay the operation was mostly performed from
fear of infection from an unhealthy conjunctiva, discharging
slightly. Danger from any slight inflammation about the
lids might be similarly guarded against. If the fellow eye
had been lost by suppuration following cataract extraction,
the subconjunctival method would seem to be indicated.
2. Very unhealthy patients need all the protection they
can get, on the supposition that their tissues cannot be
expected to cope with even very few and but feebly patho-
genic micro-organisms. This applies particularly to
albuminurics with marked anaemia and some oedema about
the ankles.
3. In rare cases where prolapse or loss of vitreous seems
likely to occur, preventing immediate closure of the wound,
it is well that the wound shall be covered as completely as
possible. This applies for a lens dislocated into the
anterior chamber. For such a lens the operation is also
indicated, on account of the position of the wound, and the
mode of making of it with scissors. These claims hold in
spite of the possible drawback of having to make a
coloboma in the iris downwards. But I think Czermak
was wrong in advising this method for partially dislocated
and tremulous lenses, because in such eyes the utmost
gentleness and freedom of manipulation are demanded in
extracting the lens.
B. To reduce the risk of vitreous loss during operation.
Nervous, frightened patients, who jerk their eyes about
on small provocation, and are thus very liable to accident
142
212 Cataract Extraction
under the ordinary operation, behave remarkably well
during Czermak's operation. This is largely owing to the
degree of anaesthesia induced by the combination of
adrenalin and cocain. Their quietude is further assured,
in that they are not worried with instructions to keep their
eyes strongly rotated in any direction.
Further, the wound cannot well be forced open by
spasmodic closure of the lids, nor can it be pulled open by
extreme vertical movements of the globe. This advantage
is greatest in exophthalmos and where the fornices are
much retracted by scarring. In tremor capitis and marked
nystagmus this operation is the safer.
C. Czermak's operation may well become almost the only
downward section practised, as it is distinctly superior to
the ordinary lower section. In Bombay we used the
method in stupid patients who were unable to look
steadily downwards after a little training, and we were
thus saved much worry. In very deaf patients the same
would apply. In other conditions which call for the
lower operation, such as the presence of a coloboma below,
congenital or manufactured, Czermak's method is suitable.
It may, however, be impracticable, owing to adherent
leucoma or anterior synechia, or in rare cases of scarring
of the ocular conjunctiva, from injury or otherwise. In
patients in a state of dementia the method appears
advisable on grounds both B and C, also on account of
the lightened after-care.
D. A very occasional indication for the scissor section
is where during the ordinary operation the anterior
chamber becomes emptied accidentally soon after the
puncture has been made. The puncture being above the
horizontal corneal meridian, Czermak would have com-
pleted the operation upwards with iridectomy. But unless
iridectomy seems likely to be called for, a section down-
Variations in Procedure, and their Value 2 1 3
wards and outwards is applicable, especially in patients
who cannot be expected to maintain prolonged downward
fixation.
Czermak also made a similar upward section in eyes where
iridectomy was likely to be needed. The piece of iris was
removed through a minute vertical conjunctiva!' puncture.*
As already mentioned, the great objection to this operation is
that the long period of downward fixation required would
appear to place a considerable strain upon the patient's self-
control. In this important respect it presents a great contrast
with the downward scissor section, which is comparatively
easy of performance, and does not need the co-operation of the
patient at all.
When a tense covering is desired for an upward section, as
in an eye, glaucomatous or otherwise, where vitreous tension
probably exists, or where there is persistent cough, dyspnoea,
or straining in micturition, the necessary conjunctival bridge
can be fashioned sufficiently well and quickly with the knife.
Should a very complete covering be desired, the site of the
puncture may be covered by sliding the conjunctiva, and that
of the counter-puncture by bringing the point of the knife out a
fraction of a millimetre further away from the corneal margin
than usual (p. 79). Thus, the ' bridge ' will probably usually
replace the ' pouch ' above the cornea. Below the cornea a
conjunctival bridge may still occasionally be made where for
any reason the scissor section of the sclera and cornea is
inapplicable.
Kuhnt has employed a double-pedicled band of conjunctiva
for covering the cataract incision, outlined and undermined
beforehand. The two attached ends are situated laterally. It
has been used as a prophylactic against infection in unruly
patients and in those suffering from emphysema, bronchiectasis,
ozaena, chronic rhinitis, etc.
Wound Suture. Suturing the wound, first used in cataract
extraction by Williams f (Boston) in 1867, has been tried by
various operators. The sutures, at first applied at the close of
* Liebreich's iris forceps were used, in order not to stretch the small
conjunctival opening.
t Congres de Londres : Compte rendu, 1873, p. 174.
214 Cataract Extraction
the operation, were inserted by Czermak immediately after
making the section. Suarez de Mendoza* made an incision
at the limbus only two-thirds or three-quarters through the
cornea from the anterior surface, and then applied the sutures
before opening the anterior chamber. Bourgeois, using a
special double-bladed knife, is able to leave a minute central
bridge of tissue undivided till after the threads are inserted.
L. Miiller, in a complicated incision, inserts the sutures before
the anterior chamber is opened. Kaltf and others applied
them before beginning the section. They have been employed
either (i) as a routine procedure, to guard against prolapse of
iris more particularly ; or (2) in selected cases only, where
there was reason to fear loss of vitreous or displacement of
the corneal flap or expulsive haemorrhage ; or (3) later, in the
healing period, to bring together wound margins separated by
extensive prolapse of iris or vitreous, or by anteflexion of the
cornea. I have had personal experience of the corneal suture
only in certain glaucoma operations. As applied to the
ordinary upper cataract incision it is altogether too difficult
and complicated a measure, placing too great a strain upon
the patient for general use. Its application to a lower or outer
section is simpler and easier. But it has to compete, as
regards both usefulness and safety, with other measures, more
particularly subconjunctival extraction.
As a preventive of prolapse a single suture has not proved
always successful. Kalt had four prolapses in fifty operations,
Czermak two prolapses in ten cases, Schweigger six prolapses
in twenty-seven operations. As a safeguard against secondary
infection, the sutures, though not going through the whole
thickness of the cornea, and therefore not entering the anterior
chamber, are perhaps not altogether free from suspicion.
But sutures should perhaps serve best to keep the wound
firmly closed after operation. They may thus prevent vitreous
prolapse in patients of feeble intelligence, or when delirium is
feared (e.g., in drunkards), or in very old people who cannot be
kept recumbent, or after operation for luxated or subluxated
or tremulous lenses, or in glaucomatous eyes and eyes with
vitreous tension, or where there is severe bronchitis, asthma,
etc., or where the fellow eye has been lost by expulsive
* Arch. d'OphL, ix (1889), 444-
f A.f. A., xxx (1895), 15-
Variations in Procedure, and their Value 2 1 5
haemorrhage. Apparently vitreous presenting in the open
wound at the close of the operation may sometimes be made to
recede without any of it being lost by the tightening of the
sutures. Kuhnt has spoken well of suturing in special cases.
During operation, however, there is no help to be got from
sutures as there is sometimes from the subconjunctival method
of operating eg., in the case of unruly patients in whom
blepharospasm and movements of the globe are to be feared.
The simplest way of obtaining double traction across the
wound is to pass the fine, sharp, and curved needle and thread
horizontally about 3 millimetres in the cornea and back again
in the sclerotic. The loop of thread lying across the proposed
line of incision left long during the making of the section and
the completion of the operation, and kept as clean as possible
by resting on a sterile pad of wool forms one band across the
wound when tightened up, and the ends of the thread tied
together form the second.
FIG. 80. WOUND SUTURE.
Sutures have been applied, also, to the conjunctival flap by
Williams (Boston), Kuhnt, Maddox, and others. Williams in
eleven cases had one prolapse.* Komoto (Japan) has fixed a
long conjunctival flap by means of a suture passed through the
tendon of the superior rectus.
Ellett f (Memphis), to guard against infection in a case of
intractable chronic conjunctivitis, separated the conjunctiva
around the whole of the cornea before operation, as for enuclea-
tion. Afterwards he drew the edges of the conjunctiva together
over the cornea with sutures horizontally placed. The stitches
were removed after four days. Three days later the conjunc-
tiva had retracted to its normal position. The case did well,
though the conjunctival discharge persisted.
* Boston Med. and Surg. Journal, April 16, 1896.
f Ophth. Record, 1903.
216 Cataract Extraction
SIMPLE EXTRACTION.
No question in eye surgery has been more discussed
than the merits and defects of the two methods of
operating, with and without iridectomy. Opinions have
varied much, and apart from preconceived ideas practice
has been influenced by the conditions of operating, the
quality of the nursing, and the skill and experience of the
surgeon and of his assistant.
Not only has each method of operating the combined
and the simple claimed strong partisans, but the opinions
of individual operators have veered from one extreme to
the other with their varying experience. One's attitude
in the matter is doubtless largely controlled by tempera-
ment. Most beginners rightly practice the combined
method exclusively, and many experienced operators have
been content to continue throughout with the more certain
attainment of thoroughly useful results. Whereas others,
desiring the best attainable, have not been deterred by
occasional accidents from aiming at the ideal. Most
surgeons nowadays recognize that this unsettled question,
like practically all others in cataract work, is one for the
exercise of eclectic principles. Each of the two opera-
tions may claim an indisputable field of applicability, but
the boundary line between them must ever be a very loose
one. The question is no longer, Which is the better
method ? But rather, In which cases should the simple
operation be attempted ? Selection of cases is needed for
simple extraction, since some only are suitable, whereas
all senile operable cataracts are alike fit for the combined
operation.
Differences of opinion hinge largely on the varying
appreciation of the value of the round mobile pupil
obtained, when all goes well, by simple extraction. Most
Variations in Procedure, and their Value 2 1 7
of the patients are too old to care much about the dis-
figurement of the coloboma of the combined operation.
This may, indeed, be scarcely noticeable in dark eyes, or
may be covered by the upper lid if the palpebral aperture
be rather narrow. It has never been shown that the
visual acuteness of the eye, as corrected by glasses, is at
all impaired by the addition of the coloboma to the
pupillary area, and by the accompanying enlargement
and sluggishness of the pupil. Increased frequency and
degree of some minor visual defects must be admitted as
due to iridectomy, but mainly to a wide iridectomy.
Exposure to strong sunlight has in some cases caused
much disablement from dazzling, even though the visual
acuteness was good. It has also been responsible for
retinal exhaustion and erythropsia. Another disadvantage
of a wide coloboma acknowledged by von Graefe, is
defective orientation from poor peripheral vision. On the
whole, the gain from a small active pupil is too slight to
justify any large risks or sacrifices.
The penalties incurred by the simple method are seen in
the complications met with prolapse of iris and trouble
with lens cortex. The weak point of the operation is
universally admitted to be the tendency to iris prolapse
with all its attendant evils, iritis, irido-cyclitis, sympa-
thetic ophthalmia, cystoid scar, staphyloma, and astig-
matism. A prolapse rate of 5 to 10 per cent, is a serious
matter, considering that the protrusion of simple extrac-
tion is often too large to be completely excised. In spite of
treatment, incarceration of the iris in the scar may be left
with its permanent drawbacks and dangers. In the com-
bined operation entanglement of the iris in the wound is
much more regularly preventable. And the inclusions,
besides being less frequent, are smaller ; they are -mere
incarcerations and small prolapses. It seems strange that
218 Cataract Extraction
these small entanglements (of divided iris) have been
blamed more* as excitants of destructive irido-cyclitis
and sympathetic ophthalmia than have the larger pro-
trusions (of the unwounded, uninjured iris) of the simple
method.
Is it not simply that incarcerations are often left un-
treated, to give rise to infection, while prolapses more
insistently demand excision ? Our Bombay experience,
indeed, led us to regard the small entanglements of
combined extraction as distinctly less prone to excite iritis
and irido-cyclitis than the large prolapses of the rival
method. And it was thought that this difference was due
to the fact that the small inclusions were more often com-
pletely covered by the conjunctival flap than the larger
ones. And our operative experience in the treatment of
glaucoma warranted us in anticipating a very considerable
permanent protection from this conjunctival covering.
The operation without iridectomy is almost free from risk
of impaction of capsule in the wound, an accident possibly
quite as harmful as impaction of the iris. But this is a
comparatively rare complication in a properly performed
extraction with iridectomy.
Judging from our Bombay experience, too much has
been made of the liability of impactions and adhesions of
iris and of capsule to give rise to glaucoma t after the
combined operation. In this respect we found little cause
to fear either obvious incarcerations of iris, or the adhesions
of one or both pillars of the coloboma to the line of the
wound, almost constantly met with. The drawing forward
of the iris by these frequent minute adhesions to the peri-
pherally situated scar must be generally almost inappreci-
able. Though the combined operation is the more fre-
* E.g., by de Wecker, Ann. d'Ocul., xciv (1885), 29.
f See Chapter V.
Variations in Procedure, and their Value 2 1 9
quently followed by glaucoma, this can be reckoned but a
comparatively small drawback compared with the dis-
advantage of iris prolapse after simple extraction. For
secondary glaucoma is always uncommon ; in Bombay,
so far as we could tell, it was quite rare, for the reason
already given.
In extraction without iridectomy cortex is more often
left in the eye, especially behind the upper part of the iris,
in spite, perhaps, of more regular use of irrigation and
more prolonged manipulation. It has been held* that
this does not apply in patients over fifty-five years of age,
when the layer of soft cortex in the lens is thin and comes
away readily with the nucleus. But this has not been my
experience. Hence sometimes tedious and prolonged after-
treatment, controlling iritis, or waiting for the absorption of
lens matter. Hence also rather more frequent needling
required for after-cataract. Also it must not be forgotten
that the more frequent need for fairly prolonged irrigation
during operation may be counted as a definite drawback in
itself. As regards retained cortex and after-cataract, it may
be stated that after simple extraction there is more chance
of the pupillary area being entirely occupied temporarily by
opaque tissue than there would be if the possible visual
area were enlarged by the addition of a coloboma. But
after needling, the advantage more often lies on the other
side. An entirely black pupil is more probable the smaller
its area. With a large coloboma the vision may be a
little reduced by diffusion of light through grey patches
beside the clear area.
Owing to the risk of these complications, iris prolapse
and cortex remaining behind, the results of simple extrac-
tion are admittedly less certain than of the combined
operation. Though the percentage results may work out
* Cf. Czermak, ' Die Augenarztlichen Operationen,' S. 973.
22O Cataract Extraction
as well for the former as for the latter, the comparison
must take into account the selection of cases. The cases
least favourable for operation are relegated to the com-
bined list. The result of such comparison, favourable as
it may be to the combined operation, does not, however,
necessarily indicate an all-round superiority of the latter.
It merely emphasizes the need of careful selection.
Various other advantages and disadvantages, of minor import-
ance or ill substantiated, have been urged for and against each
method. The simple operation is held to be the quicker of the
two ; by some operators the easier, and by opponents more
difficult. It is claimed that the operation is simplified by the
omission of one step which, by the way, is not infrequently a
slightly painful* one. The feeling of the majority viz., that
simple extraction undoubtedly often proves the less simple in
performance is echoed in the general instruction to beginners
to confine themselves to the combined method. The difficulty
experienced in delivering a firm sharp-edged lens without
stretching and bruising the iris, cannot always be avoided by
making the regulation incision, including three-sevenths to one
half of the corneal circumference. Also there is the trouble with
cortex already mentioned.
The larger incision demanded by the simple method cannot
nowadays be considered a drawback, except in so far as it
predisposes to accidental reopening of the wound and conse-
quent prolapse of iris, sufficiently noted above.
It has been counted as one of the advantages of combined
extraction, that it permits of the section including an extensive
conjunct! val flap, but with care the same section may be used
for simple extraction (p. 225). The simple method certainly
at times necessitates slightly less instrumentation, and thereby
possibly less chance of introducing infection. But the relative
incidence of infective inflammations has been connected almost
entirely with the scar results already discussed.
Loss of vitreous has been said to follow the simple operation
less often than the combined. Drake-Brockman,f comparing
* Bleeding from the cut iris has been mentioned also as a draw-
back to the combined method. See, however, p. 98.
t The Ophthalmoscope, v (1906), 123.
Variations in Procedure, and their Value 2 2 1
the two methods in equal numbers of cases from his own
practice, 293 of each operation, gave percentages of i'O2
and 5-8 vitreous losses. Marshall's Moorfields figures" from
1889-93, showed only a small difference 2-99 per cent, and
3-75 per cent.
The risk of prolapse of iris renders simple extraction seldom
applicable for private work in a patient's house unless one is
prepared to visit the case next day with an assistant, prepared
to excise iris, if necessary. On this account I have scarcely
ever adopted the method in private operations. (Czermak's sub-
conjunctival operation is almost free from this objection.)
The Selection of Cases. The cataract must be ripe,
or its removal will be incomplete. It must not be very
overripe,! with opaque capsule to be extracted. I And
tremulous and subluxated lenses, also cataracts in eyes
with presumptive (in high myopia) or certain disease of
vitreous, all demanding the easiest possible delivery of the
lens, are excluded. Also usually ' black ' cataracts hyper-
sclerotic lenses too large to pass easily through the
pupil. (In general, the older the patient the more often
may iridectomy be needed on account of the large size of
the lens.)
An iridectomy may be necessitated by a small and rigid
pupil, or, for optical reasons, by central corneal opacity.
For both optical and mechanical reasons by synechiae,
anterior or posterior, it being necessary to provide space
* R. L. O. H. Rep., xiv, 56.
t Morgagnian cataracts, though overripe, are very suitable for
simple extraction if they happen to possess transparent or nearly
transparent capsules, as they not infrequently do.
% The Punjab operators, Mulroney and Smith, extracted lenses in
their capsules without iridectomy. But Smith now performs these
operations preferably with iridectomy.
The rigidity of pupil may have been noticed by very imperfect
dilatation in the dark room, and later under the influence of cocain.
Otherwise it may not be noticed till an attempt is made to expel the
lens, when it may be one of the troubles which transform an intended
simple extraction into a combined one.
222 Cataract Extraction
for the passage of the lens. Glaucoma, primary or
secondary, necessitates a wide coloboma. Though this is
commonly made beforehand, it need not be always. so
(Chapter VI), especially in India, where the patients will
not usually wait for the two separate operations. Also
iridectomy must generally be performed in eyes with very
shallow anterior chamber.*
The conjunctiva, and still more the lacrymal passages,
must be healthy, so that if prolapse should occur the iris
may not be exposed to the attack of pathogenic organisms.
The patient must be quiet and sensible, behaving well
under the usual tests for lid control and globe fixation.
There must be no clonic spasm of the lids, and no general
condition present likely to interfere with the healing of the
wound. Among such may be mentioned a chronic cough,
dyspnoea from any cause, straining at micturition or at
stool, also a feeble intellect, epilepsy, extreme old age and
extreme obesity. Also there should be no special reason
to fear iritis afterwards, as in diabetes or albuminuria.
If the sight of the fellow eye has been lost, the combined
operation is nearly always indicated. Outside conditions
should be satisfactory e.g., the surgeon sufficiently ex-
perienced (Pagenstecher),t and the nursing good, and
there must be no occasion for general anaesthesia.
* These eyes are mostly debarred from the simple operation by the
fact that the cataract is seldom quite ripe. There is generally some
transparent cortex present. Should this, however, not be the case,
simple extraction may be attempted if preferred. That is to say, the
larger section of the simple method may be made. Iridectomy then
may, or may not, prove necessary on account of injury to the iris
by the knife, or through trouble with the copious soft cortex present,
or possibly on account of vitreous tension. Should this latter
condition chance to be present, the larger wound will prove a distinct
disadvantage. My personal preference is for the combined operation,
with smaller incision, in all eyes with marked shallowing of the
chamber.
f Kl. M.J. A., xxxii (1894), 339.
Variations in Procedure, and their Value 223
An operation begun as a simple extraction not infre-
quently becomes a combined one. This happens most
often from over-stretching or bruising of the sphincter of
the pupil ; also from scraping or wounding of the iris by
the knife, or nipping with capsule forceps. Seldom on
account of vitreous tension or vitreous prolapse or escape.
Sometimes because the lens refuses to rotate forward easily
into the pupil (still more should it have become partly dis-
located during the opening of the capsule), or because of
cortex remaining impacted behind the iris. Or, again, the
change may be due to the patient proving unexpectedly
deficient in self-control.
It is only rarely that one's intention becomes altered in
the reverse way i.e., that an operation meant to be a
combined one is ended without iridectomy. This happens
when a considerable early prolapse of vitreous renders
iridectomy unnecessary by displacing the iris backwards.
A few years ago the number of simple extractions performed
at the C. J. Hospital, Bombay, was about half that of the'
combined operations (The Practical Details of Cataract Extrac-
tion, second edition, p. 63). The small proportion was
explained by the number of unripe cataracts operated upon,
also by the frequently unsatisfactory state of the conjunctiva,
and by frequent injury to the iris through using slightly
blunted knives, and by the want of proper nursing. Later the
proportion fell considerably lower. But quite at the end of my
time in Bombay, when the advantages of adrenalin had been
realized, simple extractions were becoming more frequent than
combined.
The Performance of simple extraction is in principle
merely the operation already fully described, minus one
important step. In practice differences have to be em-
phasized at each stage of the operation.
It is a question whether adrenalin should not be used
regularly with cocain in the eye before simple extraction.
224 Cataract Extraction
This was our practice in Bombay latterly, having been
begun and having proved satisfactory in subconjunctival
extractions by Czermak's method. Under the combined
influence of the adrenalin and cocain the pupil was found
enlarged at the time of operation. The degree of dilatation
was at times only moderate, at other times considerable.
The pupil was generally not quite round and also somewhat
displaced, perhaps most often downwards. The enlarge-
ment of the pupil seemed to us particularly helpful, in that
it persisted fairly well after the anterior chamber had been
opened. The passage of the lens through the pupil with-
out injury to the iris was appreciably facilitated, thus
lessening the risk of subsequent prolapse. The value of
the adrenalin lasted after the operation. Eserin solution,
4 grains to the ounce, being instilled once or twice (with
an interval of one minute) at the close of the operation, its
action upon the pupil was enhanced by the localizing
influence of the adrenalin. It thus sufficed to overcome
the dilatation, and almost invariably next day a quite small
pupil was found, guarding against prolapse of the iris.
The liability to this complication was also, perhaps, some-
what reduced by the mental quietude of the patient
during and after operation, attributable to the more
complete anaesthesia.
The section must be of full size, including three-sevenths
to one-half of the corneal margin, without regard to the
nature and size of the cataract. The base of the flap
must thus be brought low down, nearly or quite level with
the centre of the pupil, in order that free immediate
rotation of the lens upon its horizontal axis may be
provided for, without preliminary upward sliding of the
lens. It is more important also that the knife shall be
quite sharp, and the first inward thrust should perhaps be
made rather more quickly than in the combined operation,
Variations in Procedure, and their Value 225
so that the edge of the knife shall in general reach almost
the summit of the anterior chamber in the one movement.
It is important that the greater part of the section shall be
completed with some aqueous still in the anterior chamber,
and that the final sawing action of the knife shall be as
restricted as possible. Otherwise the iris must be rubbed
and injured by the blade, and this tends greatly to the sub-
sequent occurrence of prolapse.
There is a general feeling that the section should not lie
at all behind the superficial sclero-corneal junction, but
this admits of dispute. Allowing that proximity of the
wound to the base of the iris increases the tendency to
prolapse, yet it by no means follows that a sclero-corneal
incision should always be accompanied or preceded by an
iridectomy. I have always retained the same site for
simple as for combined extraction. Much of the tendency
to prolapse through a large sclero-corneal wound may be
overcome by the early adhesion of a fairly complete con-
junctival flap. And we have in general been more careful
to provide an effective conjunctival covering than in com-
bined extraction. Perhaps a more effectual additional safe-
guard is the combination of eserin and adrenalin instillation.
And perhaps with this posterior incision one must be
more ready to perform iridectomy at the close of the
operation, should the pupil be at all distorted and dis-
placed. In Bombay we would have given up simple
extraction altogether if its performance, by altering the
site of the incision, had necessitated giving up or con-
siderably reducing the conjunctival flap. The conjunctival
covering was considered a necessity, and the retention of
the intact iris rather a luxury.
Should the iris have been much scraped by the knife, or
should a small piece of it have been unintentionally excised, it
is better, as a rule, to complete the iridectomy at once before
15
226 Cataract Extraction
delivering the lens. Otherwise the margin of the lens, instead
of coming forward to the pupil, tends to engage in the weakened
area of iris. The intact pupillary band holds the lens back
until the band becomes much stretched or broken.
Should iris prolapse immediately after the section has been
made, it is replaced by the curette. If a round pupil is not
secured at once, it is perhaps well to perform iridectomy.
In performing the capsulotomy long incisions are not
quite so readily made as when there is a coloboma, hence
they more generally need to be multiple. The use of
capsule forceps is described later.
Delivery of the Lens and of Cortical Remains.-* Steady
continuous pressure is applied with the hook or spoon
directly backwards about the junction of the middle
and lower fourths of the cornea, while counter-pressure is
made with the curette placed horizontally above the wound.
The hook is held in the right hand and the curette* in the
left hand. The primary object is to tilt the upper edge of
the lens forward into the pupil. The corneal flap, if its
base be sufficiently low, at once swings forward, and with
it the lens and upper part of the iris. At the same time
some little upward movement of the lens and of its cover-
ing iris takes place. The iris stretches, but less so than
the pupil, which widens mostly laterally as the lens
equator slowly revolves forward to occupy it. As soon as
the upper margin of the lens is visible at the upper border
of the pupil a slight increase of the pressure of the hook
backwards and upwards suffices to bring the lens forward
into the chamber and into the gaping wound. The back-
ward pressure of the curette assists in drawing the iris
back over the upper margin of the lens. As soon as this
* For use upon the right eye the curette held in the left hand must
be fully curved, otherwise it cannot be laid flat above the wound. If
the curette be made of German silver, the curve may be readily altered
as desired.
Variations in Procedure, and their Value 227
upper part of the iris has receded behind the presenting
lens, the steady pressure upon the cornea may often be
advantageously replaced by repeated short, light, upward
pushing strokes over the lower part of the cornea.
These strokes are very effective applied below the lower
margin of a firm discoid lens. The lens should thus pass
upwards without carrying the iris into the wound, so that
when the lens is delivered the wound may close unoccupied
by iris. Cataracts with firm cortex, however, and flattened
.anterior surface and sharp equator, do not come forward
easily into the pupil, and upon continued pressure readily
slip upwards and carry the iris into the wound. The same
trouble frequently occurs with too small a section, i.e.,
with a section suited for most combined extractions. If
the pressure be continued, the sharp edge of the lens
stretches the iris considerably, scraping off uveal pigment
and weakening the sphincter muscle, before finally enter-
ing the pupil,* so that it is better to relinquish for the
moment the attempt to express the lens. The curette
having been removed and the wound allowed to close, the
lens is pushed downwards into position by the convexity
of the hook (or spoon) applied to the upper part of the
cornea. A second attempt to swing the lens equator for-
ward into the pupil may be then more successful. In
general, quicker expression is aimed at than in combined
extraction, since only fairly ripe cataracts are operated
upon without iridectomy. A rather rapid passage of the
lens through the pupil obviates unnecessarily prolonged
stretching of the sphincter, and so tends to reduce the
risk of subsequent prolapse.
In cataracts with much soft cortex, the nuclei and the
* The iris might be drawn back over the presenting edge of the
lens by the curette moved downwards into contact with the iris, were
it not for the danger of transferring conjunctival organisms thus into
the wound.
152
228 Cataract Extraction
greater part of the broken-up cortex slip forward easily
through the pupil without undue stretching of the iris.
But some lens substance remains, especially behind the
upper part of the iris, to be dislodged by external pressure
alternated with irrigation, as described in the combined
operation. Cortex behind the upper iris may often be
displaced downwards into the pupillary area by pressure
with the hook or other instrument upon the cornea just
below the wound, while pressure is also maintained with the
curette upon the sclerotic above. Also, while irrigating, a
touch with the point of the nozzle upon the iris is often
useful in expelling lens matter lodged behind the iris. It
is only to be expected that the douche must prove less
effective in removing cortex when the iris is intact than
when there is a coloboma ; and if a strong current be
directed into the posterior chamber (except with the double-
current syringe) the iris is apt to be carried by it into
the wound. After clearing away all the visible lens sub-
stance it may be taken, as a general rule, that a wholly black
pupil is a sufficient guarantee that any peripheral cortex
still remaining hidden behind the iris is in such small
quantity that it may be safely left. One often prefers to
leave a small quantity of refractory soft cortex rather than
to perform an iridectomy to aid in its removal. But an
iridectomy must sometimes be made on this account.
Replacement of Iris. There is reason for satisfaction
when the pupil spontaneously resumes its normal shape,
size, and position, after the evacuation of the lens matter.
More often the pupil is more or less displaced upwards
and perhaps distorted and enlarged. A light touch with
curette or spatula introduced into the chamber may
effectually replace the iris. Or light massage upon the
centre of the cornea with the back of the curette or of a
tortoiseshell spoon may induce sufficient contraction of
Variations in Procedure, and their Value 229
the sphincter muscle. Occasionally it may be permissible
to draw the iris into position with iris forceps passed into
the chamber, though I have never practised this means of
replacement.
De Wecker and others have recommended irrigation
especially as a means of replacing iris at the close of the
operation instead of using the curette or repositor, when-
ever the pupil is displaced and distorted, still more when
the iris lies incarcerated or prolapsed in the wound. He
and Hofmann introduced eserin solution, % to 3- per cent.,
into the anterior chamber with this object. Elliot*
(Madras) describes replacement thus :
" The current is directed first under the lower margin of the
iris, then on the lips of the wound from above, and finally, if
necessary, over the anterior surface of the iris, the nozzle being
inserted in the chamber. . . . Where iris is retained in the wound
by cheesy cortex impacted behind the scleral lip of the wound,
the lens matter is dislodged by a stream of fluid directed back-
wards, or even backwards and upwards. If this fails, a portion
of the lens capsule, seen hanging down into the chamber, is
seized with iris forceps and drawn towards the centre of the
pupil. The upper cul-de-sac of capsule is thus everted and
emptied of its contents into the chamber."
The pupil, in spite of these efforts, may still remain dis-
placed a little upwards and either vertically elongated,
perhaps pear-shaped, with the apex upwards, or simply
enlarged. This shows an injured iris and a consequent
liability to prolapse. The same may be shown simply by
a quite inert sphincter muscle. The pupil can perhaps be
pushed into the normal shape and position without much
dilatation, but there is no tendency to spontaneous
resumption and no active retention of this normal
form, the pupil simply remaining in any shape imparted
to it.
* Ind. Med. Gazette, xii (1906), 203.
230 Cataract Extraction
In our work we attributed many of our injured irises and
consequent prolapses to the use of knives with slightly dulled
edges. Hence rather slow incision, sufficient of it not being
completed before all the aqueous had escaped, bringing the iris
into contact with the blade. We noticed also that this injury
of the iris with the knife occurred more often in the left eye,
owing to the laboured incision made with the less expert left
hand. Another cause, unrecognized in our earlier practice,
was the making of too small a section, embracing two-fifths
or less of the corneal circumference. Hence the lens had to
move upwards a little behind the iris before it could rotate
fully.
The more marked defects necessitate immediate iridec-
tomy ; the slighter grades may often be overcome by the in-
stillation of eserin, especially if adrenalin has been used
before the operation. A simple instillation of eserin, 4 grains
to the ounce, is perhaps advisable as a routine practice after
all simple extractions. But when there is any particular
occasion to fear prolapse three instillations should be made
at intervals of a minute, several drops being used each
time to flush out the conjunctival sac. The comparative
ineffectiveness of a single instillation, and the need for its
repetition thus immediately after operation, are due to the
washing away of the solution by tears and probably by
aqueous. If the closed lids are watched after the instilla-
tion, fluid slightly tinted by the eserin may often be seen
to ooze out and to flow away from the outer canthus.
Though eserin is by no means so sure a preventive of
prolapse as iridectomy, yet one may decide to give it a
trial, because iridectomy at the close of a cataract opera-
tion is neither easy of performance nor a very safe*
* Yet de Wecker [Ann. d'Ocul.^ xciv (1885), 41] recommended the
routine performance of iridectomy at this stage, because of the
difficulty sometimes experienced in determining earlier whether the
consistence and size of the lens were such as to necessitate an excision
of iris.
Variations in Procedure, and their Value 231
proceeding. The patient may have now * lost his nerve '
and be unable to keep the eye still, and fixation with
forceps is practicable even less than before the lens was
removed. The lens when present affords some support to
the suspensory ligament and posterior capsule. Thus the
performance of the iridectomy may possibly lead to a loss
of vitreous.
Some operators e.g., Haab and Pagenstecher prefer
to perform iridectomy whenever the iris does not return
readily into position after delivery of the lens. It has
been remarked that if a flaccid iris be met with in
operating upon one eye of a patient, it will also be found
in the fellow eye.
It is not essential that the iridectomy shall be complete.
A simple ' buttonhole ' is probably quite effective (see
below), leaving the pupillary zone of iris untouched. But
this partial excision is more difficult to accomplish, par-
ticularly because the portion of iris concerned is generally
narrowed by the upward displacement of the pupil. It
may be attempted, though sometimes the attempt will
result in a complete coloboma.
Rather greater care being demanded in the after-treat-
ment of simple extraction, both eyes are kept covered for
a day. After this it is usually sufficient to keep one eye
bandaged only. The patient must be kept as quiet as
possible, and he should be made to sleep well the first
night.
Among other means which have been found useful for
the prevention of prolapse may be mentioned :
1. Sedatives and soporifics morphia injections, bro-
mides, etc., before operation.
2. Suture of the wound or of the conjunctival flap ;
232 Cataract Extraction
the subconjunctival operations ; also covering the wound
with a bridge of conjunctiva (Kuhnt).
Von Millingen suggested corneal contact glasses applied
for the day following operation.
PERIPHERAL IRIDECTOMY AND IRIDOTOMY.
Bell Taylor* practised cataract extraction through an open-
ing in the iris at its base, in order to leave the pupil quite
untouched, and so to guard against prolapse and impaction of
the iris in the wound. He made a small peripheral iridectomy,
and then enlarged the opening by a transverse cut on each side
with fine scissors. The chief drawbacks to the method were
the rather complicated procedure, difficulty in delivering the
lens through the opening, and distortion of the pupil after-
wards, from the wide separation of the root of the iris.
I made use of a basal opening in the iris, in ten cases of
Morgagnian cataract only, for the expulsion of the nucleus.
Though only a comparatively small opening was needed, vary-
ing with the size of the nucleus, the making of it generally
required two snips with the scissors, the iris having to be
drawn out of the wound twice for this purpose. The method
was abandoned because it introduced an impediment to the
subsequent dilatation of the pupil by the loss of the dilator
fibres of the iris over a fairly wide area, and dilatation of the
pupil was somewhat frequently called for in these cases on
account of muddiness of the pupil and iris. The cases were
too few in number to enable one to judge whether this early
exudation was attributable to bruising of the iris, with some
interference with the circulation in the bridge of tissue left.
This bridge, in particular, tended to become bound down early
by adhesions. A minor advantage of this operation for
Morgagnian cataract lay in the fact that only a very small
section was needed, just as for ordinary combined extraction of
these lenses.
Bajardif makes a considerable peripheral incision in the iris,
through which he expels the whole of the lens cortex. The base
* The Lancet, 1871, vol. ii, pp. 634 and 802.
t La Clinica Oculistica, Aprile-Luglio, 1905.
Variations in Procedure, and their Value 233
of the iris is punctured by de Wecker's blunt-pointed scissors
immediately after the corneal section has been made, and the
opening is enlarged after the nucleus of the lens has been
delivered through the pupil. Pfliiger* and Hess have made a
small basal iridectomy merely to prevent prolapse, after deliver-
ing the lens and cortex through the pupil. Whether this
practice be confined or not to cases where attempted simple
extraction has led to weakening of the sphincter and distortion
of the pupil (see above), the small peripheral opening appears
preferable to the complete coloboma of ordinary combined ex-
traction. A sufficient ' sluice gate ' is provided for the passage
of fluid from the posterior chamber, and there are not the
drawbacks of the wider basal iridectomy already mentioned.
The shape of the pupil is unaffected. The small opening is
frequently covered by the upper lid. And the pupillary bridge
of iris, if it retains or quickly regains its tone, may aid in
preventing prolapse.
Beckles Chandler,! operating with a basal iridectomy, got
four prolapses in 312 extractions; two of the accidents were
due to direct violence.
Elliot | (Madras) gave peripheral excision of iris a trial,
practised before delivery of the lens. As is well known, delivery
of the lens through the pupil is rendered difficult by the
presence of such an artificial opening in the iris. Elliot found
the removal of cortex by irrigation much less easy than with a
complete coloboma.
Schweigger, practising a downward section, has utilized a
basal iridotomy to prevent prolapse. After introducing tropo-
cocain into the anterior chamber to obtain complete anaesthesia,
he pulls the iris forward with fine forceps and makes an
extensive peripheral incision with a broad needle. Eserin is
then instilled, to widen the opening by contraction of the pupil.
The incision generally closes completely later.
Verhoeff|| (Boston), extends the principle of the key-hole
iridectomy into a combined iridectomy and iridotomy. After
making a small peripheral buttonhole, he incises the iris from
* XII Congr. Intern, de Med. ci Moscou (1898).
t Arch, of Ophth., xxxiii (1904), i.
% Ind. Med. Gazette, xli (1906), 203.
Arch, of Ophth., xxvii (1898), 255.
|| Ref. Arch, of Ophlh., xxxv (1906), 453.
234 Cataract Extraction
the opening to the pupil with scissors. " The excision of iris
tissue is made where it will be most effective in preventing iris
prolapse, and at the same time do the least damage from an
optical standpoint. . . ." "The lens is removed with the same
ease as in the combined operation, and cortical matter is readily
expressed."
A vertical iritomy, or ' sphincterotomy,' is made by Mano-
lescu, Pascheff, and Mark Stevenson (Akron). Pascheff*
does this with an "iridotome," consisting essentially of a hook
to engage the sphincter within the chamber, and a small knife
sliding upon the hook.
PRELIMINARY IRIDECTOMY.
Preliminary or preparatory iridectomy, a few weeks t
before extraction of the lens, was practised first by von
Graefe. The double operation was found to be somewhat
safer than any form of single operation, and only the
inconvenience of the prolonged or repeated treatment
restricted its application. This inconvenience, especially
now that a secondary operation for after-cataract is so
frequently performed, is certainly weighty. The value of
the method, as compared with the ordinary combined
operation, depended upon a reduction in the number of
infections,! and of prolapses and incarcerations of iris
observed after operation.
In practice it is not true that the double operation
introduces two chances of infecting the eye. For the
iridectomy operation, even in pre-antiseptic days, was
almost free from infective risk, and now is practically
* Wochens.f. Ther. w. Hygiene des Anges, Marz 9, 1905.
f The interval between iridectomy and extraction has varied from
a few days to eight weeks.
% The Moorfields records from 1889-93, however, do not show any
marked difference in the proportion of suppurations 1-58 per cent,
after extraction with preliminary iridectomy; 172 per cent, after the
combined operation ; 178 per cent, after simple extraction (Marshall,
R. L. 0. H. Rep., xiv, 56).
Variations in Procedure, and their Value 235
entirely so. The succeeding extraction proved to be less
dangerous than an ordinary combined operation, owing
probably to the shortening and simplification of the
operation. Involvement of the iris in the wound after the
operation has been certainly rare.
A minor advantage claimed is that the extraction is not
so likely to be complicated by bleeding, provided sufficient
time has elapsed for the scar of the iridectomy wound to
become only feebly vascular (and provided the second
incision follows the same line as the first. In England,
however, the iridectomy incision is usually placed an-
teriorly to the cataract section). The preliminary opera-
tion is also said to have a valuable educational effect upon
the patient, and to enable the operator to judge of the
behaviour to be expected during the major operation.
Improvement in technique and a better understanding
of the origin of infective troubles and of prolapse of iris
have practically abolished the need for this division of the
operation for ordinary ripe cataracts. In some compli-
cated cataracts, however, the iridectomy as a separate
operation may be desirable to show the condition of the
lens or to reduce tension. It is performed also in cases
where one eye has been lost from profuse haemorrhage
following cataract extraction. And in dealing with unripe
cataracts preliminary iridectomy has to-day a considerable
vogue as part of Forster's ripening procedure. As already
mentioned, a few operators practise the iridectomy alone,
without massage of the lens, as a ripening measure.
Hirschberg* laid down preliminary iridectomy as necessary
where there was high tension, lest, as pointed out by Arlt,
extraction should give rise to expulsive haemorrhage ; and also
in eyes after sympathetic ophthalmia. He considered it
advantageous for annular or multiple broad posterior synechiae ;
also where there was only the one eye, or where any mental or
* D. Zeitschr.f.pr. Med., 1874, S. 31.
236 Cataract Extraction
general condition appeared likely to interfere with rest after-
wards ; and, finally, for Forster's ripening.
Kuhnt practises preparatory iridectomy where there is
diabetes, gout, or chronic rheumatism, posterior synechiae,
recent cyclitis, anaesthesia of cornea or suspected glaucoma,
and in persons of anxious temperament; Critchett, when trouble
from much soft cortex is anticipated ; True, in indocile subjects.
OTHER MODES OF OPENING THE CAPSULE.
Peripheral Capsulotomy. The opening of the capsule
in the upper periphery stands in direct contrast to the removal
of a portion of the capsule. It leaves the whole of the pupillary
area occupied by the two layers of capsule.
It was introduced by Gayet* to avoid the drawbacks
experienced from tags of capsule left in the pupillary area. He
practised combined extraction, and divided the capsule at the
equator of the lens after causing the latter to tilt forward into
the wound by exerting backward pressure at or below the
middle of the cornea.
Quioct recommended a broad iridectomy, and divided the
capsule with a Graefe's knife along the whole length of the
wound. He considered the procedure applicable to lenses with
softened cortex, and especially to Morgagnian cataracts. From
these latter the nucleus escapes much more readily through an
upper opening than through a central one.
Knapp still uses "peripheric splitting" systematically for all
forms of cataract, and without iridectomy.
He thus describes J the procedure : " The operator gives the
knife back to the assistant, and takes from him a cystitome,
which he introduces into the anterior chamber, with the knee
forward, from the temporal side, near the conjunctival flap,
which latter he is careful not to drag into the eye. He then
advances the instrument so that the tip goes underneath the
upper part of the iris, turns it, and with the tooth makes the
incision into the upper part of the capsule, parallel with the
corneal section, about 6 or 7 millimetres in extent. As soon
as the capsule is opened the lens makes a visible forward
* Gaz. hebd., Nr. 35, 1873.
t These de Paris, 1879.
J Norris and Oliver's ' System,' iii, 798.
Variations in Procedure t and their Value 237
motion ; then the cystitome is withdrawn again with the knee
forward, so that the point does not injure the iris."
The particular advantage is that there are no shreds of
capsule to unite with the lacerated pupillary margin, and so
the pupil remains free from posterior synechiae. The lens
escapes easily, and entanglement of tags of capsule in the
wound cannot take place, though, if an iridectomy be made,
there may be adhesion between the capsular and corneal
incisions. Cortical remains become enclosed by early union of
the capsular incision. Thus irritation of the iris is avoided,
but the cortex is only slowly and imperfectly absorbed. The
drawback to the method, which has prevented its general
adoption, is the necessity for an after-operation in a very large
proportion of cases to give permanently clear vision. Rarely,
the entrance of blood* into the capsule may give trouble, owing
to slow resorption.
Opening of the Capsule at the time of the Corneal
Section (Keratokystitomie of Gayet). It is a very old
practice to incise the capsule with the point of the knife as it
passes across the anterior chamber. Gayet f first utilized the
method on a large scale. Many others have reported favour-
ably and unfavourably upon it, and it is still employed to a
small extent. Gayet dipped the point of the knife a little way
under the capsule at the middle of the pupil to either raise a
flap of the membrane or simply to tear it. Some operators
have preferred to extend the puncture vertically. But much
movement of the blade tends to slight distortion of the wound
surfaces and to premature escape of aqueous and its conse-
quences. Some surgeons have been satisfied with a small
puncture, withdrawing the blade sufficiently to free the point,
and trusting to the pressure of the lens during delivery to
enlarge the opening. The opening is apt to be insufficient
except in somewhat unripe cataracts, for in fully ripe and
slightly overripes cataracts the capsule may prove to be
toughened, though not noticeably opaque. Knapp held the
method inapplicable for thickened capsules, also where the
pupil was small or the anterior chamber shallow.
There appears to be some slight risk of pressing the lens
* Chisholm, Report on the Eye and Ear Infirmary, Baltimore,
1879-
f Ann. d'Ocul., xcv (1886), 227.
238 Cataract Extraction
backwards in penetrating a thickened capsule, or even of dis-
locating the lens forward into the anterior chamber (Pfliiger)
after transfixing the membrane.
To compensate for these disadvantages there is only the
simplification of the operation the combination of two stages
into one and the elimination of an instrument.
Preliminary Capsulotomy. The opening of the capsule
by means of a fine (Bowman's) needle before making the
section has been adopted by a few operators. It has formed
the routine practice in the Madras hospital.
Haab has occasionally employed the method in juvenile
cataracts. It is claimed that useful information is thus
obtained as to the size of the nucleus and the consistence of
the cortex ; also that the capsular opening is made more
exactly, since the operator can see better what he is doing, and
the point of the needle cannot be hidden by blood, as it may be
after the section is made. Also the pupil is wider (dilated with
atropin) than after the emptying of the anterior chamber. The
needle is inserted at the limbus to obviate escape of aqueous.
Should any fluid escape, it suffices to wait a few minutes for its
re-accumulation .
The Extraction of Anterior Capsule.
Until 1874, when Forster began the systematic removal
of a portion of the transparent anterior capsule, the pro-
cedure had been almost entirely confined to opaque
thickened capsules. It is now preferred to all forms of
capsulotomy, whenever applicable, by numbers of ex-
perienced operators. It certainly fulfils the indications
(p. 100) better. It is practised both with and without
iridectomy. The coloboma is a convenience in that it
eliminates the risk of nipping the iris together with the
capsule, and permits of forceps being used with numerous
teeth to afford an extended grip of the membrane. But
apparently the smaller hold taken with the iris intact
very frequently suffices for the tearing away of the greater
part of the anterior capsule. The rupture tends to take
Variations in Procedure, and their Value 239
place near the equator, because the capsule is thinner there
than about the pole of the lens.
The patient must look downwards, and the globe is
fixed below. Any blood present in the anterior chamber
is expressed or washed out as fully as possible. The
forceps are introduced at the summit of the wound with
the blades closed and directed straight downwards. They
are passed down almost to the lower border of the pupil and
then slowly opened so that the blades reach to the lateral
borders of the pupil. The pupil may be a little widened
horizontally by the forceps to allow of a larger hold of the
capsule being taken. The ends are then pressed back-
wards lightly on to the lens and closed.
The next movement of the closed forceps, presumably
gripping a fold of capsule, is downwards. The capsule is
thus torn above, generally near the equator of the lens,
and in simple extraction one can see that the iris is free.
Then with slow side-to-side movement the instrument is
withdrawn. In combined extraction, if the capsule be not
first torn above, it is liable to be drawn into the wound
and to tear beyond the wound, leaving a tongue of the
membrane impacted.
Should the forceps have failed to seize the capsule, or
should the iris have been nipped, the manoeuvre of opening
and closing the instrument is repeated with the ends
directed at an increased angle to the lens. Increasing the
angle necessitates some pushing forward of the corneal flap,
opening the wound more.
It is difficult to grasp the tense capsule of a swollen
lens. In cataracts with soft or fluid cortex the teeth often
glide over the surface instead of gripping it, or they may
pierce the capsule and tear it irregularly. The forceps may
then come away at once, bringing with them little or no
capsule. Or, especially in the case of a Morgagnian
240 Cataract Extraction
cataract with thickened capsule, they may tear away a
portion of the membrane ; but only after a pull sufficient
to rupture the suspensory ligament below. It is con-
sidered expedient to open all tense capsules first with the
cystitome or sharp hook. But here we tend to needless
elaboration, since the use of the cystitome or hook alone
may amply suffice. Terson* (pere) makes a small opening
with a cystitome below in all opaque capsules before using
the forceps, much as described on p. 112. It is in general
unwise to prolong the stage of the operation unnecessarily,
lest the patient's stock of self-command be thus early ex-
hausted. Provided the capsule is not definitely thickened
and opaque, the use of the forceps succeeds best in
lenses with firm cortex, that is, when the lens is flattened
and reduced in bulk from the normal. With an opaque
capsule there is some risk of tearing both zonule and
capsule simultaneously, or zonule alone, unless the cysti-
tome be used first.
If the pupil be small and rigid, the use of capsule forceps
is contra-indicated, unless with a wide iridectomy. The
patient must be reliable and quiet, and the fixity of the
eye must be assured before one should venture upon pro-
longed retention of an instrument pointing directly down-
wards far within the chamber.
Forster and de Wecker have found that the piece of
capsule removed has frequently measured 6 or 7 milli-
metres across, and has therefore included nearly the whole
of the anterior capsule, which measures only about 9 milli-
metres. Thus the freest exit is secured for the lens.
Also the chances of capsular shreds becoming entangled in
the wound, and of adhesions forming between the margins
of the capsular and pupillary openings, are reduced to a
minimum. These, however, can be counted only as minor
* Ann. d'Ocu/., cxxxix (1903), 420.
Variations in Procedure, and their Value 241
benefits, for both of these complications can be usually
avoided without removing capsule. And a few fine pos-
terior synechiae are not of great consequence. The main
advantage of partial capsular extraction may be summed
up in the fact that it largely reduces the number of need-
lings required for after-cataract. Enclosure of lenticular
remains is practically impossible, and later capsular pro-
liferations and foldings can seldom take place. Treacher
Collins* reported that in a series of a hundred extractions
using the capsular forceps, only four eyes required sub-
sequent needling. He found that 25 per cent, of his cases
got full vision (f) with only the single operation.
Considering that early discission for the purely capsular
forms of after-cataract has now become an extremely safe
measure, and affords a more certain promise of per-
manently clear vision, the gain from the use of capsule
forceps does not appear very great. It is more particularly
in cases where the capsule is opaque and inelastic at the
time of operation that simple division is likely to be in-
sufficient. But here the use of capsule forceps alone
becomes dangerous, since the toughened capsule may
prove more resistant than the surrounding zonule.
How do the advantages weigh against the risks ? There
is a real, though small, danger of loss of vitreous from
depression of the lens in seizing the capsule, or through
movement of the globe with the forceps in the eye, or
from the displacement of the lens by the drag upon a
tough capsule. The question, like so many others in
cataract work, is not one of absolute right or wrong, but is
rather one of the selection of suitable cases. Perhaps the
risk attaching to the use of the forceps may be quite
eliminated by utilizing them only upon steady eyes and
suitable cataracts.
* Brit. Med. Journ., 1905, ii, p. 433.
16
242 Cataract Extraction
My personal experience of the method is a small one, dating
some years back. With either Terson's forceps or Rochon-
Duvigneaud's modification I tore away anterior capsule in ten
operations, and tried, but failed, to seize the capsule on eight
other occasions. In all but one of these eight eyes the
cataract was of the swollen, liquefying variety, and the capsule,
therefore, presumably tenser than normal. In one case I
certainly depressed the lens a little, and got an escape of
vitreous, and in one other eye the lens appeared to have been
a little displaced by the forceps, but no vitreous was lost. I
did not dare to use the instrument except in very quiet
patients, and with transparent capsule. It appeared to me to
be a clumsy, troublesome, and dangerous instrument compared
with the cystitome, and I did not feel impelled to persevere
with it.
De Wecker uses forceps only in docile patients, Sattler
unless the capsule is tense, Lagrange unless the capsule is too
dense. Kuhnt uses forceps or cystitome " according to cir-
cumstances."
Birnbacher* outlines a piece of capsule with a special knife
to avoid leaving loose shreds behind.
Puncture of Posterior Capsule. Puncture of the
posterior capsule after extracting the lens and completing the
toilet of the eye appears to be occasionally indicated. Where
it is obvious that discission is needed for some central opacity
of the posterior capsule, it saves trouble to perform it at once,
instead of as a supplementary operation a fortnight later. But
the patient must be steady and there must be no trace of
vitreous tension, for one has no right to risk loss of vitreous.
I have practised it rarely, using the cystitome, but not always
without vitreous accident. The forward pressure of the
vitreous distends the small opening, but evidently does not
always continue to do so, for Schweigger sometimes found no
trace of the opening later. The procedure was advocated
especially by Hasner.f It was practised earlier, not only to
anticipate trouble from after-cataract, but also to raise the
cornea by the displacement of vitreous for the adjustment of
the wound margins in cases of rigid sclerotic and corneal
* Cbl.f.pr. A., 1894, S. 70.
t Prager Med. Wochenschr., 1864.
Variations in Procedure, and their Value 243
collapse. Sometimes a fairly extensive vertical incision was
made in the capsule.
It is best done with the lids separated merely by finger
traction. Hasner used a cataract needle for tearing the
capsule. Pressure upon the globe with the bandage must be
carefully avoided afterwards.
INTRAOCULAR IRRIGATION.
The removal of lens cortex by intraocular irrigation
appears to have been first practised by Guerin and
Sommer* toward the latter end of the eighteenth century.
Water was injected, plain or with additions. Forlenze
(1799) used a graduated syringe with flattened nozzle.
Maunoir simply allowed fluid to enter through the wound
from the conjunctival sac. The procedure was not gener-
ally adopted. It fell into disuse, and was forgotten until
started anew by McKeown in i884.t His report was
quickly followed by others from Inouye (Tokio), Panas,
Vacher, and Wickerkiewicz in 1885 and later. The method
gained many adherents, especially in France. McKeown
endeavoured particularly to facilitate operation upon
unripe and partial cataracts; with this object he injected
fluid within the lens capsule by a sharp-pointed needle
before attempting expulsion. One of the oldest uses of
the introduction of fluid into the eye, still taken advantage
of, I was to restore the curvature of a collapsed cornea or
collapsed eyeball, whether after vitreous loss or not.
Vacher and Panas hoped by the use of antiseptic solutions
to destroy infective organisms in the wound and in the
chambers. As already mentioned, de Wecker, Hofmann,
* See Magnus, A.f. O., xxxiv (1888), 2, 167.
f Report at the Brit. Med. Association Meeting at Belfast.
J By Knapp, Lippincott and Pooley in America, by Elliot in
Madras, and doubtless by many others.
l6 2
244 Cataract Extraction
and Elliot have insisted upon the value of irrigation for
replacing the iris in position.
A number of solutions have been employed, including
distilled water, normal saline, chlorine water, solutions of
boric acid, perchloride, iodide and cyanide of mercury,
alcohol, trichloride of iodine, etc. Nuel and Cornil* and
Mellingert came to the conclusion that the only fluids
applicable among a considerable number tested were
sterilized normal saline and concentrated boric acid solu-
tion. Others were liable to cause permanent opacity of
the cornea by destruction of its endothelial lining. Irriga-
tion is at present practised a good deal in India. Many
prominent surgeons, however e.g., Fuchs and Pagen-
stecher regard it as either dangerous or superfluous. In
Bombay we had ten years' experience of it, extending
probably to about four thousand operations. For years
the douche was employed as freely as the needs of the
cases suggested, without thought of possible evil conse-
quences. During this period we were able practically to
exclude panophthalmitis as a complication. But milder
infections occurred, shown by iritis and irido-cyclitis of
varying degrees of intensity. And in trying to get rid of
these complications during the last few years we were
forced, by a process of exclusion, to the opinion that
irrigation was responsible for at least some of them.
Latterly better results were obtained under a much more
restricted use of the method. There were fewer muddy
pupils found the day after operation, and attacks of iritis
and irido-cyclitis became rarer and milder (see ' Asepsis').
In our experience, then, the infective risks of intraocular
irrigation are real but small, the accidents not being of
the gravest. By proper management and by restriction of
* Arch. d'Opht., x (1890), 319.
t A.f. O., xxxvii (1891), 4, 159.
Variations in Procedure, and their Value 245
the application of the method, as shown in Chapter II, it
may be employed without incurring any appreciable risk
at all. In this connexion, however, our treatment of the
conjunctiva with strong perchloride must be borne in
mind. Possibly without this conjunctival douching
infective accidents attributable to the intraocular irriga-
tion might have proved more serious.
I have never hesitated to wash out blood early in the
operation to facilitate the capsulotomy. There is not the
same probability of some of the fluid being left in the eye
at this stage of the operation, as later, after expulsion of
the lens.
The fear of infecting the wound from the conjunctiva,
just as by over-free instrumentation, has deterred many
from trying the method, while the occurrence of un-
explained accidents* has induced others to give up the
method after trial. Captain Gidney, I.M.S.,t relates two
instances of panophthalmitis where the evidence against
irrigation was strong. He, irrigating presumably after
removal of the speculum, or with the speculum not
elevated by the assistant, suggests that the patient's head
should be not only tilted to the side but should be well
elevated, with chin depressed, to keep the wound above the
level of the conjunctival fluid. He alludes also to a
minor drawback which the method presents to surgeons
who have to operate without trained assistance. Unless
they take the trouble personally to ensure that the fluid
and apparatus are properly sterilized, there must be reason
to fear the introduction of infective material into an eye
directly from these sources sources which are placed
beyond consideration in fully staffed and equipped hospitals.
* McKeown had one suppuration and two cases of uveitis in 146
extractions. Lippincott two suppurations and one occluded pupil in
100 operations.
t Ind. Med. Gazette, xlii (1907), 450.
246 Cataract Extraction
A hard-worked surgeon can scarcely be expected to find
time for such details unless very decided benefit is to be
derived from them.
In another way it has been held (Chibret, Czermak),
that irrigation may work indirectly against infection of the
eye. It may lessen the opportunities for the multiplica-
tion of organisms within the globe, by ensuring the more
complete removal of debris upon which the organisms
might thrive. But one must be careful not to lay too
much stress upon this point. The irrigation may be directly
responsible for an early non-infective reactive exudation
of lymph, in which bacteria might establish themselves.
Maynard says:* "Twenty-four hours after an extraction
with irrigation the anterior chamber sometimes looks as if
filled with commencing lymph. This all clears away by
the second or third day." We have thought, too, that some
of our muddy pupils and irises, seen on the day following
operation, were ascribable to over-free douching. Possibly
this reaction is preventable. It may be due to the use of
fluid at an unsuitable temperature. Using the one flask
for a number of operations, our solution often became
cooled too much. (In a colder climate much more care
would have been needed to keep the temperature of the
fluid nearly correct). Wanless (Miraj, India) thought that
prolonged syringeing gave rise to striped keratitis in some
of his cases.
Other accidents due to irrigation are of comparatively little
importance because of their rarity. It is obviously possible to
do considerable damage with the cannula in the eye. Yet I
have only once seen loss of vitreous apparently attributable to
irrigation. The accident immediately followed the use of the
douche, but I believe the zonule had been ruptured previously.
On one other occasion the tip of the cannula was thrust
. * ' Manual of Ophthalmic Operations,' Calcutta (1908), p. 66.
Variations in Procedure, and their Value 247
through the posterior capsule by sudden movement of the
globe, but no vitreous prolapsed. Dr. J. H. Claiborne
(America) reported that he once saw extensive irido-dialysis
caused. " Irrigation had been performed with but slight
pressure with a curette." In Bombay we once had a very
unfortunate experience. Fluid containing a little sublimate
was used on two successive days. Twenty-two cataracts were
extracted, and irrigation was practised in varying quantity in
nearly all of the cases. Seventeen of the corneas were made
permanently opaque in varying degree. The vision was
reduced to perception of moving bodies in a few cases, and at
least three of the eyes developed secondary glaucoma. The
accident was due to the tubes having been put into the flasks
filled with the sublimate solution in which they were sterilized.
There is no question that irrigation was on the whole of
great use to us, removing cortex more, completely, easily,
and quickly than would have been possible otherwise, and
enabling us to extract unripe cataracts upon which we
would otherwise not have ventured to operate. It enabled
us also to utilize a complete conjunctival flap without
serious inconvenience, in the days before we instilled
adrenalin solution. The wound margins were left cleaner,
and this must have helped to promote rapid union.
The use of the douche is contra-indicated in cases of
threatened or actual escape or prolapse of vitreous, and
therefore in intracapsular extraction of the lens. Though
it is employed to fill the anterior chamber in collapse of
the cornea and in collapse of the globe, whether after
vitreous loss or not, it is probably unnecessary for this
purpose, at least in operations with a conjunctival flap.
THE OPEN TREATMENT OF THE WOUND.
Numerous objections have been urged against the occlusive
dressing : (i) It has a tendency to induce, or to exaggerate
already existing, conjunctival injection and secretion. The
heat of the dressing and the stagnation of the fluid in the con-
248 Cataract Extraction
junctival sac, due to the stoppage of the blinking movements
of the lids, promote the development and retention of micro-
organisms. The ' physiological toilet ' of the eye is interfered
with. (2) The bandage is liable to displacement by restless-
ness during sleep, and it may then do harm by pressing
unevenly upon the globe. (3) The pressure of a bandage too
tightly applied may cause prolapse of iris (see also p. 147).
(4) Frequent inspection of the lids is rendered impracticable.
(5) The double covering has been responsible at times for the
development of mental depression or delirium.
But these disadvantages may be largely eliminated by care
in covering the eye, and by limiting the period of application
of the dressing. And there is the benefit of immobility of the
eye while the double bandage is in place. Praun* and
Czermakt have especially recommended what is sometimes
known as the ' modified open ' or the ' German ' method by
' hollow dressing.' The eyes are covered only by a double
Fuchs' shield, well padded at the margins to fit closely, and
covered by black cloth to exclude light and dust. Thus com-
pletely shaded, the lids are commonly kept closed and the eyes
immovable, almost as continuously as if fixed by a dressing.
Czermak got less reopening of the wound than with an
occlusive dressing. Fuchs applies a dressing under the mask,
held by a single strip of linen fixed with soap plaster. Wicker-
kiewicz,| following Wolffberg, simply covers the eye with
strong brown silk paper, cut to the required shape, and pasted
to the skin over the orbital margin with ordinary gum arabic.
For similar occlusion without dressing, Doyne employs a
cast of dentist's wax, moulded beforehand. The mask extends
beyond the orbital margins. After the cast has set it is removed,
and its central portion that which covers the eye cut away.
It is then replaced, and the defect made good with soft, heated
wax, which does not adhere to that which has already set.
This loose central portion overlaps the other. After it has set
it is thinned, by scraping, to remove it from contact with the
eyelids, and perforated for ventilation. The wax must be
hard or it may not withstand the heat of the face sufficiently.
In our Bombay work a large absorbent dressing was neces-
* Cbl.f.pr. A., Marz, 1898. f Ibid., Mai, 1898.
J Kl. Monats.f. A., xlii (1904), 2, 222.
Method shown at Oxford, July, 1907.
Variations in Procedure, and their Value 249
sary at least for a day, to receive the fluid poured out from the
conjunctiva, irritated by the strong perchloride lotion. Where
there is this watery discharge the dressing is needed, both for
the sake of cleanliness and to obviate wiping and rubbing by
the patient, and to prevent excoriation of the skin. Otherwise,
there seems to be little advantage in retaining the occlusive
dressing longer than twenty-four hours. Observation tends to
narrow the period of origin of most of the serious complications
to the few hours immediately following operation. And the
advantages of immobilization after this period are appreciable
only in the case of unreasonable and unintelligent patients. In
many of these, however, the unoperated eye must be left
uncovered from the beginning.
Some surgeons have used the wire shield alone from the
beginning, others transparent celluloid shells fixed by adhesive
strapping along their margins and by tapes. These are
decidedly preferable to the completely open treatment of
Hjort,* affording no protection of any kind against light or
injury.
Czermak found closure of the lids by a strip of court plaster
necessary (i) when the lid space was so wide as to expose
the (upper) section ; (2) when the section had been made
below, and was, therefore, necessarily exposed between the
lids ; and (3) after loss of vitreous. A pressure bandage was
considered advisable where intraocular haemorrhage was feared,
as in glaucoma.
For various reasons cataract patients have been treated
from the beginning as out-patients, walking to their homes a
few hours after operation. In up-country practice in India
this may be at times necessary. Darier finds that such cases
do practically as well as indoor patients.
REMOVAL OF THE LENS TOGETHER WITH
ITS CAPSULE.
From the earliest days of cataract extraction operators
have made occasional involuntary acquaintance with the
delivery of the lens in its unbroken capsule. It happened
* First published in the Cbl. f. pr. A., Mai, 1897. See also
Mohilla's results, Cbl. f. pr. A., December, 1899.
250 Cataract Extraction
in two ways. Either it was a pure accident in which the
surgeon had no direct participation, the lens being shot
out by reflex closure of the lids, generally with more or
less vitreous. Or, owing to rupture of the zonule, whether
at the time of operation or earlier (in cases of dislocated
lens), escaping vitreous necessitated the introduction of a
spoon or loop behind the lens to extract it. And the same
instrumental extraction was sometimes practised owing to
a difficulty experienced in opening the thickened opaque
capsules of some overripe cataracts, or owing to the fear
of pressing upon tremulous lenses with the cystitome.
A. Pagenstecher first introduced the deliberate routine
extraction of all senile cataracts in their capsules. The
method was published* in September, 1865, at the
Heidelberg Ophthalmological Congress. The brothers
Pagenstecher later restricted the application of the
method! to the compulsory cases (dislocated lenses), and
to those in which the risks of rupture of the capsule and of
loss of vitreous by this method were found to be least.
This group included all overripe cataracts, including
Morgagnian and shrunken and calcified lenses, in which
the generally thickened capsule might be expected to
prove stouter than the possibly atrophic zonule. Also
cataracts in eyes with pupil occluded by irido-choroiditis,
because in these cases the lens was loosened in the fossa
patellaris. The operation was found to be inapplicable in
unruly patients, and in eyes with vitreous tension, and for
cataracts which were barely ripe and had ripened rapidly,
whether the ripening were natural or artificial. The tense
capsules of these swollen lenses was liable to burst
during the extraction. The procedure also was modified
* Personal communication from H. Pagenstecher.
f H. Pagenstecher, ' Die Extraction des grauen Stars in der
geschlossen Kapsel' (Wiesbaden, 1873).
Variations in Procedure, and their Value 251
by Hermann Pagenstecher. In the earlier operations a
large shallow spoon (Fig. 38) was inserted for the with-
drawal of the lens, after an iridectomy had been made.
Later it was found safer to pass in the spoon only a little
way between the lens and the vitreous, to serve as an in-
clined plane to guide and support the lens, and to keep
the vitreous back. Pressure was placed upon the globe
by the assistant with a spatula (Fig. 32) at the lower
corneal margin. Only when moderate pressure thus
applied failed to expel the lens, was the edge of the spoon
passed down beyond the posterior pole of the lens, to
obtain an upward pull upon the lens, and so to assist in its
delivery. At times the spoon was not introduced into the
globe at all, but merely used for depressing the upper lip
of the wound.
At the present day H. Pagenstecher does not perform
intracapsular extraction so frequently as in former days,
because he operates generally without iridectomy, and
because " the healing process is generally prolonged if
there is an escape of even a little vitreous," and because
overripe cataracts are getting rare nowadays in Europe.
Numerous modifications in technique have been introduced
from time to time without gaining any general adoption.
Some of the modifications have been intended for application
to senile cataracts in general, others for restricted use only.
The wire loop, forceps, and hook have all been employed for
extracting the lens. Macnamara* made an outer section
without iridectomy, but with previous dilatation of the pupil.
He introduced a spoon and depressed the near edge of the lens,
causing the latter to rotate, so that it was withdrawn with its
posterior surface foremost. Dr. Andrew f operated in the
same manner, except that he tore the zonule at the inner side
of the lens with a wire hook, introduced either through the
incision or, before making the incision, through an outer
* 'A Manual of the Diseases of the Eye,' 2nd edition, 1871.
f Brit. Med.Jonrn., January, 1883, p. 41.
252 Cataract Extraction
puncture. Various other attempts have been made to aid in
the expulsion of the lens by division of the zonule. Cannstatt
(1870) dislocated the lens into the anterior chamber after
making the incision, by means of a needle previously inserted
through the sclerotic. Roosa (1885) tore the zonule by partly
dislocating the lens with the knife. Gradenigo* (1895) an d
his school have more recently practised separation of the lens
from its attachments by a ' zonulotome,' or blunt hook with
stem curved to correspond with the lens surface, and also bent
like the ordinary Graefe's cystitome. One of his pupils, Ovio,
from experimental investigation upon animals' eyes, finds that
the risk of vitreous loss is least with only a limited division of
the zonule. All of these attempts have been overshadowed by
the recent development of the intracapsular operation in India;
but Wolkow's t delivery of the lens by pressure and counter-
pressure with two spoons requires mention.
The work in India was begun t by Mulroney, at Amritsar
in the Punjab, in 1890. He made a downward section
without iridectomy, and expelled the lens by manipula-
tion. Henry Smith at Jullundur, also in the Punjab,
adopted the method, but preferably with an upper section,
and latterly with iridectomy. Obtaining better results, he
has expanded the work greatly. In 1893, 1,145 OI " these
operations were performed at Amritsar. Now the extrac-
tions at Jullundur number nearly three thousand per
annum. In the year from May 31, 1904, to May 31,
1905, Smith extracted 2,616 cataracts in their capsules,
and only 151 with capsulotomy.|| With this extra-
ordinary experience he has clearly and authoritatively
established expression as the correct method of delivering
the lens in its capsule, and has shown that it is applicable
* Saggini, Ann. d^Ocul., cxxii (1899), 344.
\ Wjestnik Ojtal., xi (1894), 366.
\ Meher Chund, Rai Bahadur. ' New Operation for Cataract at
Civil Hospital, Amritsar.' Trans. Ind. Med. Congress, 1894.
Ind. Med. Gazette, xlii (1907), 326.
Ibid., xl (1905), 327 ; and Archives of Ophth., xxxiv (1905), 601.
Variations in Procedure, and their Value 253
to the large majority of senile cataracts. He has obtained
such unexpectedly good results that he has now many
imitators in India ; and ophthalmic surgeons generally,
especially in America, are more ready to use the method
than formerly. Intracapsular expression is not infre-
quently spoken of as ' Smith's operation.' Smith practises
ordinary extraction only in children and for " atrophic "
cataracts, and for others with " semi-gelatinous " cortex of
a bluish tinge evidently the rapidly ripening cataracts of
Pagenstecher.
Operative Procedure.
Smith says " the details of the operation which I
perform are my own," and insists that men must see it
done in order to learn the method completely. On the
contrary, I can find no detail which has not been practised
earlier by others. The originality in Smith's method, if
there be any, lies apparently in the omission of detail. And
those who have seen Smith operate do not appear to have
benefited much, judging from their results. The operation
is merely ordinar)' combined extraction, with the omission
of one step the opening of the capsule.
Unless the patient be very quiet and reliable, the stop-
speculum is replaced by retractor for the upper lid, and
finger depression of the lower lid, before the expulsion of
the lens is attempted. Smith prefers a large strabismus
hook to Desmarres' retractor. But with his left hand he
also inserts a spoon or vectis under the upper lid " to
raise that half of it which is not so fully raised by the
assistant's blunt hook. This may be placed at the nasal
or temporal side, according to the operator's predilection."*
The control of the peripheral fibres of the orbicularis has
been already mentioned p. go.
* Rutter Williamson, The Ophthalmoscope^ v (1907), 556.
254 Cataract Extraction
With the assistant standing at the patient's right side,
the operator has to pass his right hand under the assis-
tant's left wrist in operating on the left eye.*
Few surgeons will be inclined to follow Smith in makinga
purely corneal section, with puncture and counter-puncture
at the limbus, either in, or i millimetre above, the hori-
zontal corneal meridian, and the summit of the arch " half-
way between a normal pupil and the sclero-corneal
junction." Through this low section Smith is able to
deliver the lens whatever be the position of the eye.
He " lays stress upon not making the patient look down,
as doing so encourages prolapse. "f
He employs a strabismus hook for expressing the lens,
as was done also earlier at Amritsar. He does not now
make use of counter-pressure above the wound with a
spoon, as he did formerly. " He finds there is less risk of
vitreous escaping if no counter-pressure be used, and the
expression of the lens is almost as easy, although a trifle
slower.
"With his right hand he places the convexity of a
strabismus hook upon the cornea, over the junction of the
lower with the middle third of the lens. This is not
altered in position till the lens is half-way out. The pressure
is directed to the back of the eye, and at first is neither
towards the wound nor from it, though when the lens has
started on its way there is an almost unconscious slight
adaptation of pressure toward the free edges of the wound.
When the lens is half-way out the hook is shifted, so as to
tilt to some extent the edge of the lens into the concavity
of the hook. If the lens sticks, the hook is moved to one
or other side without lifting it from cornea or relaxing its
pressure, so as to try and disengage the peripheral portions.
* Maynard, ' Manual of Ophthalmic Operations' (1908), p. no.
f Ibid., p. 112.
Variations in Procedure, and their Value 255
" The pressure exerted is moderate, slow and continuous,
gradually relaxing in amount as the lens is seen to be well
on its outward way. The process must be done slower,
and with much more deliberation than in the capsule-
laceration operation. The continued pressure quickly
tires out the iris, which dilates and allows the lens to
emerge very like the process of parturition. If the ex-
pression be attempted rapidly, the capsule will probably
burst just as it is coming out. If this accident does
happen, it is best to keep up the pressure with the hook,
so that the capsule does not retract, and try and gently
drag it out with a pair of ordinary dissecting forceps
applied to the part outside the wound. The broad hold
so secured will often succeed in drawing out the whole of
it with its contained lens matter.
" During all this manipulation the patient is not spoken
to, nor asked to aid in any way, either by looking up or
down. To do so, most of us have probably found, more
often flusters the already nervous patient than succeeds in
getting him to do promptly what is requested of him. As
a consequence, the generality of patients will be found to
turn the eye so that it looks high up into the superior
fornix. . . .
" This is an awkward position for the surgeon, though
the extraction can quite well be performed with the eye in
this position, provided the assistant holds the lids as
described."*
Maynard says : " When the lens is half out it will some-
times be found that . . . the operation seems to come to a
standstill. In such cases, while keeping up pressure with
the strabismus hook, the lens may be gently coaxed out by
means of a spoon applied along its edge with safety,
provided the spoon be rounded and not sharp, and great
* Rutter Williamson, loc, cit.
256 Cataract Extraction
gentleness be used, so as not to rupture the capsule."*
Another aid is " to slowly slide the counter-pressing spoon
along the sclera along the outer edge of the wound"
(Maynard). " When the lens is half-way out ... a clear
point of vitreous will occasionally appear in the wound
behind the lens. . . . The spoon in the left hand . . .
should be pushed beneath the lens through the clear point
and the lens suspended on it. Once the lens is supported
on the spoon the strabismus hook can be used as before to
drive out the lens, the spoon merely coming with the lens,
but not drawing it out. ... If we attempt to lift out the
lens on the spoon merely, the capsule will give way with
exceeding frequency" (Smith) .t
In addition to this occasional insertion of the spoon, the
iris forceps have sometimes to be introduced to seize
ruptured capsule. " If the capsule has retracted, we should
try by gentle stroking to press out its contained lens
matter, . . . and if the capsule be evident to the eye, we
may make an attempt to catch it with an iris forceps and
fetch it out."t Where no accident occurs the only instru-
ment introduced into the globe is the knife. Ordinary
dissecting forceps are used for seizing ruptured capsule
lying in the wound.
The amount of pressure required is sometimes con-
siderable. Maynard mentions that during the period in
which he performed 175 intracapsular operations, he tried,
but failed to expel the lens from eight other eyes with the
degree of force which he felt justified in applying. After
operation the same care is demanded, whether there has
been loss of vitreous or not. At Jullundur both eyes are
* Ind. Med. Gazette, xli (1906), 315.
t Ibid., xl (1905), 327. According to Williamson (loc. cit.\ Smith
introduces the same spoon into the eye which he has been using
for supporting the upper lid, and this without cleaning it in any way.
\ Smith, loc. tit.
Variations in Procedure, and their Value 257
bandaged, and the coverings are not disturbed for four
days unless there is pain.
Major Newman * states that he always attempts expulsion
within the capsule, but if the lens does not come easily he
desists. He thinks that this attempt facilitates the delivery of
the lens in the ordinary way after capsulotomy, the pressure
applied having altered the shape of the lens and detached the
cortex from the capsule. Captain Gidneyt performs the
intracapsular operation only where he considers the making of
a conjunctival flap unnecessary. This because of the possi-
bility of trouble from blood in the anterior chamber, which
could not be washed out J after the zonule had been ruptured.
Trouble from haemorrhage could, however, be prevented by
the instillation of adrenalin beforehand.
The Drawbacks of the Operation.
i. Loss of Vitreous. The question of the applicability of
the method to the general run of senile cataracts hangs
mainly upon the risk of vitreous accidents, with their
ultimate consequences infective inflammations, detach-
ment of the retina, atrophy of the globe, etc. The removal
of the support afforded to the vitreous by posterior capsule
and zonule combined, of necessity adds to the number of
vitreous escapes. Even without external pressure the
vitreous tension may be sufficient to cause an escape as
soon as an opening is made in the supporting diaphragm.
Smith's extraordinarily low percentage of escapes
between 6 and 7 per cent., published in 1903, and again
in 1905 1| came as a revelation of the possibilities in this
respect. And it is said that this rate has been further re-
duced since then. Smith claims that in only nine instances
among 2,616 extractions did the loss amount to more than
* Ind. Med. Gazette, xli (1906), 403. f Ibid., xlii (1907). 448.
\ Maynard, however, considers that, if the vitreous has not pro-
lapsed, irrigation may be employed (' Manual of Ophth. Op.,' p. 114).
Brit. Med.Journ., September 26, 1903. || Loc. cit.
258 Cataract Extraction
" a bead of vitreous." And these nine accidents were " in
supremely nervous patients, who shot out the lens and a
quantity of vitreous the moment the incision was com-
pleted. .... The accident in these cases would have
occurred in any operation." And these statistics included
the extraction of seventy-five lenses couched by quacks.
No other operator has succeeded in approaching this
low percentage. Captain Oxley,* a beginner, in his first
series of forty intracapsular extractions lost vitreous in
30 per cent, of the cases. In a second series of forty cases
the losses amounted to 40 per cent. Major Birdwood,t in
a total experience of 311 of these operations, had at first
vitreous escape in 47 per cent, of the cases, later in 37 per
cent. He does not think the average operator can expect
to reduce the proportion of accidents below 30 per cent.
Maynard J lost vitreous in 38'28 per cent, of the cases in a
series of 175 intracapsular operations. By the ordinary
method he had 4*3 per cent, of vitreous accidents in a late
series of a thousand extractions ; in an earlier series of a
thousand cases the percentage was 6*3. (For other figures
showing the proportion of accidents by ordinary extrac-
tion, see pp. 169 and 170.) Drake Brockman, operating
by Pagenstecher's method, had 28*67 per cent, of vitreous
losses in 293 operations.
2. Rupture of the Capsule "when the lens is partly
out," and when, therefore, the zonule has already given
way, is regarded by Smith as the most serious accident
met with at the time of operation. Efforts to extract the
capsule and its contained cortex, as above given, may
prove unavailing. Smith had to leave the capsule behind
in slightly more than half the cases of rupture, and much
* Ind. Med. Gazette, xl (1905), 456, and xli (1906), 482.
+ Ibid., xli (1906), 201. \ Loc. cit.
The Ophthalmoscope, iv (1906), 121.
Variations in Procedure, and their Value 259
cortical matter was often left, either within the capsule or
lying in the anterior chamber. He does not mention any
attempts to remove or to displace the capsule later.
Folded capsule and cortical remains lying in the pupillary
area must often interfere greatly with vision. Smith had
rupture of the capsule in 8 per cent, of his operations,
Maynard in 17*14 per cent. In one-third of these latter
there was escape of vitreous also. Maynard says : " More
than half the indifferent and nearly half the bad results of
the whole series were in cases in which the capsule had
ruptured." He thinks that the capsule "loosened from its
surroundings is more likely to become entangled in the
wound."*
3. Incarceration and Prolapse of Iris must be met with
somewhat more frequently after this operation than when
the capsule is left. This follows from the higher pro-
portion of vitreous accidents. Birdwood t says : " There
seems to be a great tendency for the iris to be caught in
the angles of the wound at each side. ... If the vitreous
is escaping, it is best to leave them alone." Maynard got
prolapse of iris five times and incarceration three times in
his 175 operations. He says this is above the average of
ordinary combined extraction. Arnold Knapp,^ during a
visit to Jullundur, saw 17 prolapses or incarcerations in
104 intracapsular extractions, but the operations were
mostly without iridectomy. The complication is much
more serious after intracapsular extraction, because the
risk of loss of vitreous in removing the prolapse is much
greater. If vitreous has already been lost at the time of
operation, any attempt at early excision of the prolapse is
absolutely barred.
* Against this is to be counted the fact that in the numerous cases
in which the operation is successful there is no capsule left to become
impacted.
t Loc. cit. \ Arch, of Ophth., xxxvii (1908), 13.
17ii
260 Cataract Extraction
4. Enlarged Pupil. Maynard finds that even where there
has been no vitreous escape the pupil tends to be noticeably
enlarged. The distorted and displaced pupils after some
vitreous losses are mentioned on p. 173. Maynard saw drawing
up of the pupil in four cases in which there had been no loss
of vitreous, and in which there was no iritis.
5. Covneal Opacity. Maynard had three cases of permanent
haziness of the cornea, with low tension and vision only the per-
ception of moving bodies or of light. In one of these cases the
wound gaped for a month, and lymph appeared in the wound.
6. Indefinite Ailments. Maynard mentions two cases in which
the eye remained for long red, painful, and slightly chemosed,
with vision never good. In one of these (possibly infective)
cases the pupil became drawn up. (This is in addition to the
four cases mentioned above.) Maynard suggests that this
irritability of the eye may be due to the amount of pressure
employed.
7. Delayed Union of the wound was complained of by Maynard
in seven of his cases, in spite of conjunctival flaps having been
made in six of the cases.
8. Post-operative Astigmatism is said to be greater after intra-
capsular extraction.*
Advantages. Some surgeons, impressed by Smith's
reports, are inclined to ' strain a point ' in favour of intra-
capsular extraction, feeling that it gives an ideal result
when successful. But there is no doubt that a successful
ordinary simple extraction, followed by satisfactory early
needling, gives a slightly superior result. Thus a small
mobile, perfectly black pupil is obtained, to compare with
the widened pupil and the colobomat of the intracapsular
method.
i. The one definite advantage of the method, as applied
to cataracts which can be extracted in the usual way, is
* Czermak, ' Die Augen. Operationen,' S. 1047.
f Smith formerly performed the intracapsular operation frequently
without iridectomy, but his later practice and the experience of others
show that it is generally unwise to omit both capsulotomy and
iridectomy.
Variations in Procedure, and their Value 261
that when successful it once and for all time eliminates all
possibility of trouble from after-cataract. Until recently
this was a considerable gain, and even now it is often an
advantage not to be despised. The precise value of the
removal of the capsule is this :
(a) A fair proportion of the patients are saved from the
trivial annoyance of an insignificant secondary operation
ten or twelve days after the extraction. (In Smith's
work it is an advantage that the patients need not be
kept in hospital so long as ten or twelve days.)
(b) A number of others eventually see better than they
would do under the usual treatment. This applies to
cases in which, after ordinary extraction, there does not
seem to be sufficient need for early discission, and in
which after-cataract develops later. Many of these
patients do not give us the opportunity of remedying the
defect, and in other cases late discission fails to effect a
wide central opening in the membrane.
(c) In the remaining cases in which no central opacity
would develop in the capsule, were it left in the eye, no
benefit is secured by intracapsular extraction of the lens.
And sometimes, at least the early visual result is poorer
than it would have been otherwise. Whatever be the
explanation, we have been struck by the absence of any
marked superiority in early visual results* in Bombay
after the intracapsular operation, as compared with
ordinary cases. This in spite of more or less after-
cataract frequently left untreated. Maynard had a more
striking experience in this respect. In 33 of his cases the
* The statement applies only to tests made at the time of discharge
from hospital. I have no knowledge of the final visual results. The
vision was tested usually with spherical lenses only, and the pupils
were mostly still dilated with atropin. But in a few cases unsuccessful
attempts were made to bring the vision nearly to the normal, by
correcting the astigmatism and by the use of a stenopaic disc.
262 Cataract Extraction
two eyes of the patient were operated upon, the one eye
intracapsularly, the other eye without removal of the
capsule. In only 7 instances was the visual result better
by the intracapsular method, in 10 cases it was equal in
the two eyes, and in 15 instances it was better by the
ordinary operation. (The remaining case of the 33 was
not available for the comparison, as in this case the intra-
capsular operation was a failure.)
2. Troubles with capsule entanglements in the wound,
and adhesions to cornea and to iris are, of course,
impossible.
3. Pagenstecher* says that in early days the greatest
advantage of the intracapsular method was considered to
be the prevention of iritis, but that since the introduction
of aseptic measures this advantage is no longer so evident.
Smith reported only two cases of iritis in 2,494 extractions
in unbroken capsule, whereas in 263 operations of the
same period in which capsule was accidentally (after
rupture) or purposely left behind, iritis occurred in 5 per
cent, of the cases. In our small Bombay experience of
extraction of lens and capsule, the bright appearance of
the iris afterwards was often noticed. The only obvious
explanation is the absence of irritation of the iris by
particles of lens substance. This should not be a matter
of much importance, since it is generally accepted that
nearly all severe iritis after operation is due to microbic
agency. In Bombay we were able to reduce the propor-
tion of closed pupils from iritis to a very low figure (p. 270)
after the ordinary operation. But we often had to use
atropin freely for some little time. In cases of mild in-
fection doubtless the additional strain thrown upon the
iris by the irritation of lens debris may cause trouble.
Opinions are likely to be widely divided, for some years
* Personal communication.
Variations in Procedure, and their Value 263
at least, upon the merits and demerits of extraction in the
capsule Maynard, after his trial of it, concluded: "In
face of these grave drawbacks it is impossible to recom-
mend the performance of the operation, and personally
I have returned to the practice of removing lenses in their
capsules only when they are overripe and have thick
capsules." He is at present employing the method, how-
ever, for unripe cataracts also.* Birdvvood, in spite of an
appalling number of vitreous losses, was " gradually
getting convinced that it should be the operation of
election in nearly all cases." In Bombay the tendency of
late years has been more and more away from the intra-
capsular method. The number of these operations has
been reduced to the absolute minimum.
During 1905 and 1906, at the Cowasjee Jehangir Hospital,
there were only twenty-four lenses removed in their capsules
among 1,262 flap extractions i.e., in barely 2 per cent, of the
cases. Four of these lenses were forced out without help from
the operator, three by spasm of the lids, and one by vitreous
tension. In four cases there was previous dislocation of the
lens, and in another subluxation. Four other lenses became
dislocated during the making of the section. In all the other
eleven cases the capsulotomy proved insufficient, or the zonule
became torn by the pull of the cystitome. Four of these eleven
cataracts were Morgagnian, and three others had been Mor-
gagnian, but only the nucleus and capsule remained. The
intracapsular delivery was in all cases obligatory or accidental.
It is, perhaps, interesting to note in how small a proportion of
cataracts the method is forced upon one even in India. In
Europe and America, where overripe cataracts are much less
common, the proportion should be still lower.
During the same two years we extracted twenty-two
capsules entire after expulsion of the lens, with three vitreous
escapes. (Only one of these escapes was in the least degree
attributable to the removal of the capsule.) There were also
three removals of portions of capsule, and five punctures of
* ' Manual of Ophth. Op.,' p. 107.
264 Cataract Extraction
posterior capsule. In one of these latter there was one vitreous
loss, due to vitreous tension.
Among the intracapsular extractions the proportion of
vitreous loss was higher, but the vitreous accident was
frequently the cause, and not the consequence, of the intra-
capsular method of operation.
The unintentional intracapsular expulsion of Morgag-
nian nuclei has been dealt with on p. 122, the procedure
being the same whether the fluid part of the lens has been
evacuated by puncture with the cystitome, or has been
slowly absorbed by natural processes before operation.
Even in cases where the zonule has not been torn below
by the pull of the cystitome, the intracapsular expulsion of
a Morgagnian nucleus by the light pushing strokes upon
the cornea already described is at least as safe a pro-
ceeding as the deliberate expression of a Morgagnian lens
in its unopened capsule.
It is always possible that the pull upon very opaque
anterior capsule with forceps, as described on p. 112, may
result in the partial or complete intracapsular delivery of a
shrunken overripe lens. A sharp hook has sometimes been
used instead of forceps to pull out shrunken cataracts,
mainly capsular. Forceps or hook must be employed for
the withdrawal of such lenses whenever vitreous comes
forward in front of the capsule through a rupture of the
zonule below. In some rare juvenile cataracts, chiefly
capsular, the sharp hook may serve best.
There are two advantages in always attempting ordinary
extraction. Firstly, it is not until the contents of opaque
capsule have been removed that one can be sure of the
state of the posterior portion of the membrane. The
lateral displacement of an anterior plaque of fair size
brought about by the expulsion of the lens, or its extrac-
tion with iris forceps before the delivery of the lens, may
Variations in Procedure, and their Value 265
be sufficient to leave the central pupillary area clear and
black, the posterior capsule being possibly quite normal.
In my experience such displacement of opaque anterior
capsule is permanent.
Secondly, if the posterior capsule be found also more or
less opaque, or if the displacement of a large anterior
plaque be insufficient, one has the option of removing the
opaque membrane at once, wholly or in part, or of deferring
its treatment until after the healing of the wound. The
latter decision will be taken if the patient have become
excited and cannot keep the eye still, or if there be any
sign of vitreous tension. Even at a later secondary opera-
tion discretion may suggest the tearing and displacement
of the opaque membrane by two needles, rather than to
risk prolapse or loss of vitreous in extracting the mem-
brane. Ordinarily, however, the immediate extraction of
opaque capsule is indicated, if the opacity be situated so
as to affect the visual acuteness of the eye. Thus we
avoid delay and worry and the patient's dissatisfaction
over a secondary operation. And loss of vitreous is no
more likely to be caused in a quiet patient by this imme-
diate removal than by secondary extraction. The most
opaque and thickened portions of capsule are often a little
displaced upwards, and are thus within easy reach of iris
forceps introduced through the incision. The extraction
of the membrane is accomplished after the conjunctival
toilet has been completed, and usually also after the sub-
stitution of Desmarres' retractor for the stop-speculum.
Elliot* in ordinary extraction removes with iris forceps any
tags of capsule visible after the chamber has been washed
clear. He did this in thirty out of 200 operations. There
were five small vitreous losses among these thirty eyes, and
exactly the same number of small losses among the remaining
* Ind. Med. Gazette, xli (1906), 163.
266 Cataract Extraction
170 eyes. He considers this small addition to the operation a
much less dangerous proceeding than expression of the lens in
its capsule, " inasmuch as it is quite easy to limit the vitreous
escape by at once closing the eye as soon as danger threatens.
The lens being out, this is, of course, possible."
One is satisfied with the least of the measures calculated
to provide a clear central area for vision, and to guard
against impaction of the capsule in the wound. The
practical result should be as good as by intracapsular
extraction of the lens, but the risk of large vitreous escape
is less.
Occasionally after the ordinary delivery of the lens,
opacity may be found confined to the central area of the
posterior capsule, in the form of a circular patch or ring.
Without waiting to inquire into the nature of this opacity
whether, for instance, it may not be lens substance
capable of being absorbed I have punctured the capsule.
This puncture might, however, be more safely deferred till
the day before the patient's discharge.
ASEPSIS.
The problem of the exclusion of exogenous infection
still constitutes one of the most vital questions in cataract
work. For infective complications varying in number and
gravity still occur in the practice of every ophthalmic
surgeon of large experience. And few have reason to feel
altogether secure against even the gravest of these
accidents destructive irido-cyclitis and panophthalmitis.
The question is a very serious one, since theoretically
these troubles are preventable. Yet in the practice of the
vast majority of eye surgeons there is a definite though
very small percentage of total and irreparable loss of
vision thus brought about, and sympathetic involvement
Variations in Procedure, and their Value 267
of the fellow eye is also met with. Minor grades of infec-
tion are not always clearly recognizable, but nearly all
troublesome iritis and irido-cyclitis, and probably many
quite transient exudations are attributable, in part at
least, to infective origin. We know that micro-organisms
capable of exciting such reactions are frequently present
in the conjunctival sac at the time of operation, and it
would be strange if there were no minor grades of infec-
tion leading up to those destructive affections which are
by common consent admitted as due to bacterial agency.
And often there is no other cause assignable for the iritis
met with.
The problem as generally accepted may be briefly
stated. Modern aseptic surgical principles demand (i) a
sterile field of operation, and also (2) that everything
which may come in contact with the wound surfaces must
be sterile also. (3) Afterwards the conditions must be
such as to favour early union, and the wound must be
protected against external influences.
The first of these three stipulations cannot be met fully
in ordinary present-day hospital work. There is no
provision made for the regular and repeated bacteriological
examination of the eyes an examination requiring a con-
siderable expenditure of time in culture tests. Nor can
patients suffering from chronic conjunctivitis, especially
those coming from a distance, always afford time for the
weeks or, perhaps, months of treatment required to free
their conjunctivse from dangerous organisms. Nor can the
removal of these organisms be quite assured by douching
and swabbing immediately before operation. (It is un-
necessary to refer again in detail to the measures adopted
in dealing with inflammation of the tear sac.)
The question therefore becomes one of compromise.
We take such means as appear to be indicated for cleans-
268 Cataract Extraction
ing the field of operation. But knowing that the
cleansing is often imperfect, we try to avoid transferring
organisms from the conjunctival surface into the wound
by instruments and lotions during operation. We avoid
unnecessary bruising of the tissues, likely to reduce their
resisting powers, and we leave as little blood-clot and lens
cortex in the eye as possible materials which might serve
as culture media for infective organisms. And we protect
the wound afterwards with a conjunctival covering, and
avoid as much as possible the exposure of iris or of
vitreous prolapsed in the wound. Where the danger
appears especially great from an unhealthy conjunctiva,
or owing to some general condition enfeebling the tissues,
there is the additional safeguard of the subconjunctival
operation.
There is thus room for the exercise of individual discre-
tion and judgment. The indications are not exact. We
cannot hope always to exclude pyogenic bacteria, but we
can limit their numbers and perhaps lessen their vitality,
and make the conditions unsuitable for their multiplica-
tion. Experience has shown that by the strenuous
application of such precautionary measures the evil of the
imperfectly sterilized field may be largely neutralized. In
Bombay we claim to have been exceptionally successful in
warding off infection, but the success has been ascribed
primarily to a more effectual cleansing of the conjunctiva
than is commonly practised.
India affords a fine field for conjunctival antisepsis. With
the conjunctiva in so many cases unhealthy, the cleansing
of the field of operation becomes by far the most important
and critical item in our armamentarium for the defence of
the wound. One of the main lessons to be drawn from
cataract work in India is that the major operation can be
quite safely performed in the presence of slight chronic
Variations in Procedure, and their Value 269
conjunctivitis. But to the best of my knowledge safety has
been attained only with the help of perchloride irrigation.
The first series of good results published in India, un-
broken as regards suppurations, was that of 210 extractions
by Surgeon Major Bamber, with i in 2,000 perchloride.
It was reported at the Indian Medical Congress, 1894.
And Smith's Jullundur statistics, under the conditions of
work there, may be accepted as proof of the value of the
same solution. Our Bombay figures afford more detailed
and conclusive clinical evidence of almost complete safety
attained by the use of a rather weaker lotion systematically
applied. Compared with clear clinical evidence in this
question, laboratory findings are of little account. And any
explanation of the mode of working is also of quite minor
importance to the establishment of the essential clinical
fact. But for this large figures are needed. Even in
India, with the conjunctival danger so constantly present,
an experience of at least a thousand operations is needed
to show conclusively the essential merits or defects of any
treatment adopted. Only small differences in results
under rival methods of treatment are to be expected, when
we consider the astonishingly low percentage of failures of
the pre-antiseptic days.
My personal experience of infection in hospital cataract
work* under perchloride treatment of the conjunctiva
may be briefly summed up. It is broken up into periods
by intervals of leave-taking.
The statistics up to the end of January, 1901, were
published in the Indian Medical Gazette, June, 1901,
thus:
With i in 3,000 sublimate lotion freely used there was
* No definite records of my private work are available, but it may
be stated that there were no suppurations at any time, and very little
iritis or irido-cyclitis.
270 Cataract Extraction
a series of 497 extractions completely exempt from grave
infection.
With the same fluid rather more sparingly applied, in
578 extractions there were three grave primary infections,
irido-cyclitis ending in atrophy of the globe.
Where not only the quantity, but in most instances the
strength also of the antiseptic was reduced, panophthal-
mitis followed thrice in 349 operations, and there were
seven closed pupils from iritis or irido-cyclitis. (Closure
of some of these pupils might, however, possibly have
been prevented by freer use of atropin.)
Then followed a period up to the end of March, 1903,
in which 1,172 extractions were performed under the
perchloride treatment as at present carried out. There
was one suppuration, but " no infective iritis or irido-
cyclitis severe enough to have resisted energetic treat-
ment."*
Finally came a period of work from October, 1904, to
April, 1907. It included 1,655 extractions. There were
no suppurations, and the only complications recognizable
as severe infective results at the time of discharge from
hospital were two cases of iritis closing the pupils, prob-
ably susceptible of remedy later by artificial pupil. There
were also the two untreated cases of sympathetic disease
described in Chapter V, in which loss of sight was attri-
butable largely to neglect, and a third case of loss of sight
from chronic cyclitis.
We can claim, therefore, a near approach to perfection
in final results in this latest series of operations, so far as un-
controlled infective inflammation is concerned. But it was
only towards the end that we felt fairly safe in this respect.
For, besides the three losses, there were, until towards
* ' The Practical Details of Cataract Extraction,' 2nd edition,
1903, pp. 53 and 54.
Variations in Procedure, and their Value 271
the end, numerous early exudations, which we regarded as
partly at least representing infective agency. And during
this period we had also one destructive irido-cyclitis in
private practice. The minor manifestations of reaction
became decidedly less frequent latterly. And it was this
which inspired confidence that the graver accidents might
be entirely warded off, and that we could hope to go on
operating indefinitely without meeting with suppurations
or uncontrollable irido-cyclitis. But this recent improve-
ment was not brought about by any change in the treat-
ment of the conjunctiva. It followed the adoption (i) of
the mouth-screen during operation, and (2) of enhanced
precautions in connexion with intraocular irrigation.
Except for the variations in the perchloride treatment
mentioned, these changes, both recent, were the only ones
made during the whole of the periods under review, which
could have had any influence upon infective complications.*
Considering, therefore, the large number of unhealthy
conjunctivae in the eyes operated upon, the influence of
the sublimate douching must have been very great in
enabling us to attain to the results just recorded. And the
figures themselves afford evidence of insufficient protection
when less lotion or weaker lotion was used.
The very bad bacteriological condition of the Bombay
conjunctivae, and the effect of the perchloride in removing
organisms from them, were directly shown by the examina-
tion of a consecutive series of fifty cataract cases just
before operation.
The details of the research were published in The Ophthalmo-
scope, iv (1906), 674. In twenty-four of the fifty conjunctivae
* Another change which should be mentioned here was the fairly
frequent performance of subconjunctival operations. But this merely
enabled us to operate in cases which we should otherwise have
refused for the time being. Our infections have never come when
most feared.
272 Cataract Extraction
there were few or no bacteria except diptheroid bacilli (possibly
all xerosis bacilli) before or after the sublimate douching. In
all the remaining cases other organisms were fairly plentiful
or decidedly numerous. They comprised white staphylococci
alone in five cases. Most of the other conjunctiva? contained
more than one variety of organism in addition to the sapro-
phytic diphtheroids. Besides white cocci, some of them possibly
pathogenic, coloured cocci were fairly numerous, including
Staphylococcus aureus and citreus, and others unidentified, and
probably in some cases incompletely separated. Morax-
Axenfeld diplo-bacilli were found in five cases, and they were
numerous in two of the five. Numerous pneumococci were
found once,* and numerous streptococci once. In four of
these twenty-six cases the effect of the perchloride douching
appeared to be insufficient, several colonies being grown from
each conjunctiva afterwards. But in the remainder the effect
of the treatment was definite, and possibly sufficient. Either
no growth was obtained afterwards or only very few colonies
a single colony in nine instances, two colonies in three cases,
and four colonies once. These results were obtained ten
minutes after the perchloride douching i.e., immediately after
the cocain instillation. They do not include, therefore, the
further effect which would be derived from the supplementary
small douching nearly always added immediately before
operating. If the result had been tested after operation, a
more complete clearance of organisms could have been
anticipated.
It is worthy of mention that, though hundreds of colonies of
diphtheroid bacilli were grown from some conjunctiva? before
irrigation, not a single one was obtained after irrigation.
Diplo-bacilli seem also easy of removal ; no growth was
obtained from the treated conjunctivae. Staphylococci, on the
other hand, in general proved more resistant, and this was the
case whether they were present in large or small numbers.
This resistance suggests frequent embedding of the cocci
rather deeply in the conjunctival epithelium. In several cases
a delay of a day or two was noted in the appearance' of the
colonies grown from the conjunctivae after treatment, suggest-
ing some direct action of the antiseptic upon the bacteria.
* In a conjunctiva normal except for slight injection and roughness.
Variations in Procedure, and their Value 273
It seems probable that in similar tests carried out years
ago by others sufficient time was not allowed for the
action of the perchloride to manifest itself. Bach* even
found mechanical cleansing with salt solution more
efficacious. A germicide was looked for. And when
perchloride was found ineffective in this respect, like other
antiseptics as applied to the conjunctiva before operation,
it was thought to be useless, and even harmful, because
irritating. Perchloride is of use here mainly because of
its irritant and coagulative action upon the conjunctiva.
It excites a secretion of mucus, in which micro-organisms
are entangled and washed away, and microbes also prob-
ably become imprisoned in the epithelium which undergoes
coagulation-necrosis. Finally, in cases where much lotion
is used, it may directly attack the vitality of the organisms.
A sterile field of operation is by no means assured, but of
this we had already been made aware by our clinical
results.
With danger so frequently present and so obvious in
the Indian conjunctiva it seems strange, at first thought,
that it can be so constantly avoided. But the very
frequency of the danger is the patient's salvation, for it
has led to a lavish and regular employment of the necessary
precautionary measure. In European and American
practice the danger is possibly greater, because it is
insidious and comparatively rare. Precaution is unneces-
sary in the large majority of cases, and in cases where it is
required the signs indicative of the necessity may be not
very obvious. In any case the tendency is to minimize
uncustomary irritative measures, from fear of exciting
reaction. Considering the very good results which have
been obtained with simple mechanical cleansing, surgeons
accustomed to working upon normal conjunctive are
* Ref. Haab, ' Operative Ophthalmology,' p. 41.
18
274 Cataract Extraction
naturally loth to use any irritating chemical. But they
must be quite sure of obtaining the good results. And
recognizing the great help derived from perchloride in
India, they should not be reluctant to make free use of
this protection in cases where there is any suspicion of
danger. Since we are working in the dark to a large
extent, the precautions must err rather in direction of
excess if uniform safety is to be attained.
In deciding upon the relative advantages, or, rather,
the applicability of chemical and of simple mechanical
cleansing of the conjunctiva, it is in no sense a question of
antisepsis versus asepsis. In no case is the solution used
after the operation has been begun. Elliot (Madras) is
the only surgeon of large experience in India who has
reported any extensive trial of simple mechanical cleansing
of the conjunctiva before operation. He sedulously treated
cases of conjunctivitis beforehand, accommodating the
patients with sleeping space on the hospital floor when
necessary. But the results were not quite good enough,
and the method has been replaced by perchloride treat-
ment exactly as practised in Bombay, combined with free
subsequent swabbing of the conjunctiva.* Elliot is now
strongly in favour of this plan of treatment, and feels, with
me, that suppuration ought never to occur. He has had a
thousand consecutive extractions with only one suppura-
tion. And this one catastrophe was in a case where the
lacrymal sac had been imperfectly excised.
In Bombay we regarded the skin of the lids and surrounding
parts, and even the lid margins, as almost outside the field of
operation. So far as the lid borders are concerned, this was
unsound, for we found it necessary to express the secretion
from the Meibomian glands, in order that some of the secretion
should not be floated up from the lid borders to the neigh-
* Personal communication. Report to appear shortly in the
Ind. Med. Gazette.
Variations in Procedure, and their Value 275
bourhood of the wound during intraocular irrigation. It is,
therefore, obvious that micro-organisms might be also thus
carried up to the wound in irrigating fluid. We were always
careful, however, to wipe away the expressed Meibomian
secretion with perchloride swabs.
The second requirement laid down for the avoidance of
contamination of the wound applies to instruments,
lotions, the lid borders, and the surgeon's and the
attendant's saliva. There is no excuse for imperfect
sterilization of instruments beforehand. But during
operation considerable watchfulness is required to avoid
soiling an instrument before its entry into the wound, by
unnecessary contact with the conjunctival surface,* still
more with the lid margin. And in repeated introduction
of the same instrument into the eye one must remember
to cleanse it afresh. Sufficient has been said already with
regard to the dangers of unnecessary instrumentation and
especially of intraocular irrigation ; and one objection to
excessive instrumentation is, perhaps, the possibility of
diminishing the resistance of the tissues by slight trau-
matism. The risk of contact between the lid borders and
the edges of the wound is the chief objection to separation
of the lids by ringer traction.
It stands as a confession of weakness and of ignorance,
that a prolonged operation must be admitted practically
as a danger in itself. Since we do not work in a sterile
field, and since we are often uncertain both of the source
and of the exact mode of conveyance of the organisms into
the wound, prolongation of the period of exposure to con-
tamination must enhance the risks. The benefits of
rapidity and simplicity of procedure are seen in work such
as Trousseau's.! Introducing only one instrument, the
* Note the suggestion made on p. 192 with regard to the possible
value of the conjunctival flap in this respect,
t La Clinique OphtaL, November 25, 1905.
18 2
276 Cataract Extraction
knife, into the eye, he has had only 2 per cent, of iritis
and no suppurations, though no special treatment of the
conjunctiva had been adopted, and though cortical debris
must have been left in the eye frequently. Smith's com-
parative success at Jullundur is also thought to be partly
attributable to the introduction of but the one instrument
within the globe.* In analyzing results the operative
technique must be considered as a whole. In our Bombay
work with more prolonged exposure and more elaborate
detail, probably considerably more care was needed to
avoid infection, quite apart from the bad average state of
the conjunctiva.
For the protection of the wound against secondary in-
fection during the healing period the value of a scleral
incision and a conjunctival covering, especially of the com-
plete covering provided by Czermak's operation, cannot be
disputed; otherwise, a smooth section f and close coapta-
tion of the wound surfaces are designed especially to secure
rapid healing. In addition, measures to preclude reopening
of the wound (either by occlusive bandage or ' modified
open ' dressing), and prompt excision of uncovered pro-
lapsed iris, are the chief safeguards. But the danger at
this period would appear to be a minor one compared
with the risks during operation, for results appear to vary
chiefly with the measures adopted for protection during
operation. Nature provides for early union by fairly close
apposition of the wound surfaces without the need of
sutures, and by maintenance of the parts at rest, protected
against outside influences by the upper lid.
-' The Ophthalmoscope, v (1907), 558.
t Hotta (Clin. Monats. f. Augen, September, 1905) published an
account of some interesting experiments upon the infection of corneal
wounds in rabbits with human saliva, showing the influence of the
character of the wound. There was no infection of thirty smoothly-
cut incisions with a Graefe's knife, and invariable infection in thirty
' pocket ' wounds.
Variations in Procedure, and their Value 277
An attempt has been made by Rogman* to heighten the
resistance of the tissues against microbic invasion by the
injection of 5 to 10 cubic centimetres of a mixture of anti-
streptococcus serum (Menzer) and anti-pneumococcus serum
(Rohmer). It was employed for an iridectomy in a patient
with dacryocystitis, and for cataract extraction in a patient
with ozaena. Louis Dor administers 2 grammes of potassium
iodide the night before operation with the same idea of reducing
the risk of infective inflammations.
Endogenous infection, appealed to as an excuse for bad
results, is a refuge of the destitute. Apparently undoubted
cases of destructive metastatic inflammation of the eye have
been reported after cataract extraction. Hildebrandt f reported
a case due apparently to acute rheumatism, and Wopfner J one
due to pneumonia from Friedlander's pneumo-bacillus. It is,
however, certain that infection from within is not to be feared
in healthy people. It is well that suppuration at a distance,
ulcers, fistulae, etc. possible starting points of pyaemia should
be treated before operating.
The general trend of recent work is to fix the responsi-
bility for infective accidents very definitely upon the
surgeon. In the not distant future we may find this
responsibility recognised by the patient, and possibly up-
held in law courts. No exceptional skill is required in the
application of the scheme of defence. Simply the measures
must be complete in every detail, and carried out with
extreme care.
RESULTS.
BAD RESULTS may be due to :
I. Defective Operation, particularized in
(a) Incorrect Method ; especially (i) inefficient measures
for securing asepsis, or (2) inherent defects in the operative
technique adopted.
* Bull, de la Societe beige (fOphtal., Mai, 1904.
f Beitr. zur Augen., viii (1893), 33.
\ Kl. Monats.f. A., xliv (1906), i, 386.
278 Cataract Extraction
(6) Want of Skill on the part of the surgeon, or less
commonly, of his assistant. Dexterity in operating is
made up of three elements, rising in order of importance
thus : (i) A steady hand ; (2) a light hand, combining a
fine muscular sense with a delicate sense of touch ; and
(3), the most important, experience.
Nos. i and 2 are best developed by training apart from
actual operative work. Though No. i conduces particularly
to pretty operations, No. 2 is more helpful in getting over diffi-
culties and preventing accidents. Very nimble fingers are not
required. No. 3 means a prompt recognition of the particular
features of each case, and of difficulties and dangers as they
arise. Practical experience can only to a limited extent be
replaced by reading and by seeing others operate, and by
operating upon dead eyes.
(c) Want of Control on the part of the patient. This
may render the best efforts of the skilled hand unavailing;
but the discerning operator may very often judge before-
hand when trouble from this cause is likely to be en-
countered, and lessen the dangers by suitable precautions
(p. 168).
II. Eyes more or less unfit for operation. The
surgeon may have failed to realize the conditions, or he
may have accepted risks under the pressure of circum-
stances, or he may have rightly decided to expect only a
poor result, where no better was obtainable. The attain-
ment of even poor vision may prove to have been
impossible, the data available not having given sufficiently
definite indications beforehand.
Our Bombay results, as regards infection, have been
already given. The following is an Analysis of Visual
Results of the flap extractions performed during 1905 and
1906, as seen at the time of discharge from hospital :
Variations in Procedure, and their Value 279
Total Operations, 1,262.
Bad Results = vision nil, or moving bodies only, 22=1-7 P er
cent.
Of these bad results, three were of a purely temporary
nature, and accounted for by cortex or blood covering the
pupillary area. Twelve others were due to pre-existing disease
of the eye, including old irido-cyclitis, vitreous opacity, chor-
oidal atrophy, optic atrophy, glaucoma, corneal opacity (one
case, together with cortex left behind). There were seven
failures due to the operation itself = 0-5 per cent. Three of
these failures were due to expulsive haemorrhage, one to large
fundus haemorrhage (not expulsive), one to (?) haemorrhagic
detachment of choroid (a large spontaneous loss of vitreous
occurred during operation). The remaining two failures were
due to iritis.
These are the only two w r hich can be considered definitely
preventable, and even they were not certainly irremediable.
There was a prospect of later improvement by iridotomy, for
which, however, the patients never returned.
If, however, we add what we know of the later results, we
have to record three total losses two cases of irido-cyclitis,
which also destroyed the fellow eyes by sympathetic involve-
ment, and a case of chronic cyclitis, with probable detachment
of retina. The sympathetic cases are mentioned again on
p. 287.
The four certain losses by intraocular haemorrhage all
occurred during 1906. This was a very heavy proportion,
judging from our earlier experience. One of the eyes was
glaucomatous secondary glaucoma, due to traumatic cataract,
with subluxation of the lens. Another eye was highly myopic.
Poor and Fair Results = vision less than . Total 78 = 6-2
per cent.
In 1906 these results were considerably fewer than in 1905,
including only twenty-seven out of the seventy-eight cases, or
4'2 per cent, of the total operations for the year.
The comparatively poor results of 1905 are largely accounted
for by the fact that the practice of early needling had not then
been instituted at the C. J. Hospital. There were eighteen
defective visual results attributable to after-cataract in 1905,
and only four such in 1906 (due to cortex alone or with blood
remains). In eight cases in 1905 and in two cases in 1906 the
280 Cataract Extraction
cause of the defective sight was not ascertained. This was
due to neglect by the assistants of the hospital rule that
cylinders were to be used in all cases where spherical lenses
failed to give ^ vision. The rule was that cases which still
failed with cylindrical lenses were to be examined by me.
The remaining sources of imperfect vision nearly all dated
from before operation. They included : Corneal opacity,
17 cases; vitreous opacities, 5; choroidal atrophy, 3; glau-
coma, 4; occluded pupil, 4; traumatic cataract, 2; squint, i.
Other causes were connected with the operation : Iritis, 2 ;
detachment of retina, 2 ; prolapse of vitreous, i ; prolapse of
vitreous and of iris, i ; (?) fundus haemorrhage, i. Three other
patients appeared to be simply of too defective intelligence to
respond to the tests.
CHAPTER V
AFTER-COMPLICATIONS
The infective processes and non-infective reactions Various forms
of corneal opacity Exfoliation of corneal epithelium Ante-
flexion of the corneal flap Filamentous keratitis Conjuncti-
vitis Acute dermatitis Spastic entropion Prolapse and incar-
ceration of iris Prolapse and loss of vitreous Impaction of
capsule Intraocular haemorrhage Delayed union and re-
opening of the wound Transient detachment of the choroid
Mental disturbance Flatulent distension of the abdomen
Secondary glaucoma After-cataract Detachment of retina.
THE INFECTIVE PROCESSES AND NON-
INFECTIVE REACTIONS.
THE Infective Processes constitute by far the most im-
portant departures from the normal course of events after
operation. They are the most frequent cause of partial or
complete failure to restore sight, and often also of greater
or less destruction of the essential tissues of the eye.
Besides the actual entrance of pathogenic bacteria of
varying degrees of virulence, factors influencing the grade
and extent of inflammatory reaction are those affecting
the vitality of the tissues. The danger of operating upon
the eyes of patients in the later stages of diabetes or
nephritis is well recognized. And one can scarcely expect
the tissues of patients presenting extreme anaemia from
any cause to withstand infective organisms. But ex-
perience shows that only such readily recognizable con-
stitutional conditions predispose markedly to pyogenic
281
282 Cataract Extraction
invasion. Locally the resistance to bacterial invasion
may doubtless be lowered by excessive traumatism, but
this factor is rarely evident. The open door provided
for the later admission of infective material by prolapse of
iris or of vitreous has been already alluded to, and is
mentioned again later. The mere bursting open of the
wound after closure is claimed to admit infection some-
times. Owing to the reduced intraocular pressure after
evacuation of the chamber, organisms are supposed to be
sucked into the eye.
The most severe examples of the effects produced are
grouped as Suppurations. Starting either as corneal
wound infections, or as general intraocular invasions, they
culminate in panophthalmitis. The deep infections soon
give rise to ring abscess of the cornea. The signs and
symptoms are generally pronounced within twenty-four
hours. There is severe pain, much inflammatory swelling
of conjunctiva and eyelids (that of the margin of the upper
lid being well marked), with semi-purulent conjunctival
discharge lying about the borders of the lids. The edges
of the wound may or may not be infiltrated, yellowish,
and swollen. The corneal surface is often steamy, and
the iris and pupil are covered with dirty lymph. In spite
of all treatment the inflammatory conditions rapidly in-
tensify. Fibrinous and purulent exudation accumulates in
the anterior and posterior chambers, and in the vitreous,
distending the eyeball and opening the wound ; and
where the wound itself is directly invaded, suppurative
destruction of the cornea spreads from it. These most
intense cases are quite hopeless from the start ; but there
are other deep infections which begin rather less acutely,
and hang for some days apparently in the balance. And
there are rare destructive inflammations, which begin
later, possibly several days after operation, in which the
After'Complications 283
infection gains access to the eye in some way after
operation.
In one of our suppurations everything went well, with easily
dilated pupil and but little injection of the eye, until the case
was transferred, five days after operation, to another ward,
where some patients were being treated for conjunctivitis,
preparatory to cataract extraction. The next day the eye
became inflamed, and in a few days had advanced to panoph-
thalmitis.
Less intense infections are seen as severe Irido-cyclitis.
One may be in doubt at first whether the case may not
end in panophthalmitis. Short of this, many cases end
equally badly so far as vision is concerned in atrophy
of the globe. And there may be sympathetic implication
of the other eye. Still other inflammations respond to
treatment, and subside with retention of useful vision in
the eye. Early pain, complained of spontaneously by the
patient at the surgeon's first visit, on the day after opera-
tion, is a particularly threatening symptom. On inspec-
tion there may be already a trace of yellowish white
exudation seen at the margins of the pupil and coloboma,
and the surface of the iris presents a very blurred
appearance.
A lower grade of intensity is seen in the cases classed
usually as Iritis simply, though doubtless the ciliary body
is also more or less involved in the process. Though not
very threatening in appearance at first, these inflamma-
tions may persist in spite of treatment, ending, perhaps, in
closed pupils. Still, in treated cases, at least, the eyeballs
do not usually soften. There is a prospect of later restora-
tion of more or less useful vision by secondary operation.
The only two cases of sympathetic ophthalmia, which we
know to have happened after our Bombay operations,
followed upon inflammations classed as simple iritis (one
284 Cataract Extraction
case was not even regarded at the time as iritis), but the
inflammations were neglected.
The symptoms usually set in several days after opera-
tion. Possibly, as a rough rule, the later the onset the
milder the inflammation. There is pain, perhaps more at
night, and usually lacrymation, slight lid-swelling, and
more ciliary congestion than usual. But in feeble, sickly
persons there may be a quiet outpouring of lymph, with
very mild or no symptoms. I noticed an alarming amount
of quiet exudation, but rapidly reabsorbed, in a few anaemic
patients operated upon. In our experience some degree
of muddiness of iris and of pupil is to be found in the
majority of cases on the day following operation. And
probably vigorous treatment with atropin and mercury,
begun at once, prevents many inflammations from develop-
ing. Of the many early threatening appearances which have
resolved under treatment, it has been impossible to decide
how far the signs of exudation have represented infective
agency, and how far simply reaction to traumatism, irrita-
tion from lens debris, etc. We attributed our comparative
exemption from closure of the pupil due to iritis largely
to exceptionally vigorous after-treatment, and not solely to
the measures for guarding the wounds from infection.
In our work focal illumination after twenty-four hours
showed comparatively few clear and active pupils, with
bright iris. There were degrees of reaction culminating
in a pupil largely occupied by, and in thickened iris
partly hidden by, lymph mixed with blood remains and
lens debris. And it often took several days' free use of
atropin, morning and evening, to obtain fair dilatation
of the pupil. In general the exudation was not added to
upon the following days. On the contrary, absorption
took place, though it was sometimes slow and incom-
plete. And pain and lacrymation remained absent. We
AfteivComplications 285
thought that some of these Early Exudations, even though
quite transient, were due probably to the action of micro-
organisms, in part at least. For it was impossible to
distinguish them in the first day or two from other cases
in which pyogenic action was shown by persistence of
exudation and the onset of symptoms. Certainly, however,
infective agency was not a very frequent source of this
early transient exudation.
That the exudation was due mainly to irritation from
minute particles of lens substance left behind, was shown
by its almost sure absence after intracapsular extraction
and after ordinary extraction of Morgagnian cataract.*
The rarity of iritis after the intracapsular operation has been
already referred to. It appears to apply to infective iritis.
If this be so, the only obvious explanation is that con-
tributory factors commonly play a large part in the
development of infective inflammation. Cortical debris
by irritating the iris probably leads to a deposit of fibrin,
in which organisms may develop, and the lens substance
itself may provide a suitable culture medium for pyogenic
bacteria. Also possibly the additional strain placed upon
the absorptive power of the eye may handicap the tissues
in their struggle with micro-organisms. Among other local
causes of early iritic reaction may be mentioned: (i) a
varying degree of traumatism, especially bruising of the
iris in squeezing the lens through a small section, also
accidental pull upon the iris through movement of the eye
or through badly cutting scissors, etc. ; (2) prolonged
irrigation of the anterior chamber, especially with fluid at
an unsuitable temperature; and (3) reflex disturbance
from an exceptional degree of surface irritation by the
* Yet beware of Morgagnian ' milk ' left behind the iris. In two
simple extractions we had early inflammatory glaucoma set up by it,
through exclusion of the pupil.
286 Cataract Extraction
perchloride. Also (4) injury to the eye during sleep,
through ill-fitting bandage or screen ; and possibly (5) slight
reaction from adrenalin-constriction of blood-vessels, if
excessive. Albuminuria, with some oedema about the
ankles, and considerable anaemia, must be mentioned here
as a constitutional condition exceedingly likely to lead to
early exudation of lymph. Less likely causes are diabetes,
gout, rheumatism, etc. The purely transient exudations
are of importance only in so far as they form posterior
synechise, preventing dilatation of the pupil, and more or
less permanent after- cataract. It is scarcely necessary to
remark that the formation of posterior synechise is very
common after cataract extraction quite apart from the
occurrence of iritis. Adhesions form readily between the
edges of the capsular opening and the pupillary margin, and
are particularly common after combined extraction at the
projecting angles between pupil and coloboma. Some are
due to imperfect absorption of blood-clot.
In a few of these early cases of muddy iris and pupil,
after about three days the anterior chamber is found
largely occupied with ' spongy ' or ' gelatinous ' exudate.
That is to say, a semi-translucent deposit covering pupil
and iris has begun to shrink. Perfectly clear iris can be
seen at the periphery at one part, but elsewhere the iris,
pupil, and coloboma are covered. The prognosis in these
cases is good. The contraction of the exudate progresses
rapidly under treatment, and any needful discission may
often be performed in little over a fortnight from the time
of operation.
Other exudations fail to clear up, and symptoms develop
pain, lacrymation, etc. indicative of Non-Infective
Iritis. Some degree of inflammation appears to be some-
times kept up mainly or entirely by lens matter. Though a
large quantity of cortical matter may often be left behind,
After-Complications 287
with no effect whatever upon the iris, this is when the
pupil is at once dilated. Probably then the capsule is
for the most part interposed between the iris and the lens
substance. But sometimes sufficiently rapid dilatation of
the pupil is not secured, and the lens cortex lies in direct
contact with the iris. The more irritating lens substance
appears to be that of the more advanced cataracts. The
worst in our experience is the milk of Morgagnian
cataracts, but it is only rarely that any of this is left in the
eye. Elliot (Madras) finds that lens cortex which swells
up and " assumes a gelatinous appearance " is but little
prone to set up adhesions, but that it is otherwise with
stiff, unyielding cortex. Some slight cases of iritis may be
due to injury by the patient's fingers, etc. Other per-
sistent mild inflammations appear to be kept up sometimes
by venous congestion, from constant coughing or from
straining at micturition. Also constitutional taints, such
as are capable of originating attacks of iritis apart from
operation gout, rheumatism, diabetes, nephritis, etc.
may be expected to give trouble at times. Again, the
operation may serve to awaken old mischief.
In one case in which we operated upon an eye with occluded
pupil, and in which a needling was performed afterwards,
chronic iritis followed, with the formation of three probably
tubercular nodules (see ' After-Cataract ').
Rarely corneal wound infections remain localized. The ac-
companying reaction is only very moderate, and the suppu-
rative process can be arrested by suitable treatment. I
remember one such case in which suppuration destroyed only
a small portion of the corneal flap, not extending to its posterior
surface.
Sympathetic Ophthalmia. The only two cases in which
we know that this complication followed cataract extrac-
tion performed by us in Bombay require mention here. One
patient was discharged a month after operation seeing ^ with
a spherical lens. But she was still being treated with atropin
288 Cataract Extraction
drops nine times a day, and with mercury internally. She
insisted upon going home, though advised to stay longer. The
extraction had been ' simple,' and followed by prolapse of iris,
excised the next day. She returned four and a half months
after the operation with pupil and coloboma completely covered
with pigmented lymph. There was no ciliary injection remain-
ing, however, and the eye was not soft, so that there appeared
to be a possibility of later restoration of some vision. The
fellow eye, sound at the time of discharge from hospital, was
now practically destroyed by untreated inflammation.
The other patient was discharged twenty days after a
combined extraction, seeing -^ with a spherical lens. Atropin
and mercury had been used in full amounts for a week only.
After that time the mercury was omitted, and the drops used
less frequently. The patient came back nearly three months
after operation with both eyes quite hopeless.
In both of these instances there appears to be little doubt
that the evil result might have been averted under more
prolonged observation and treatment. In the second case
there was no anticipation whatever of active mischief when
the patient was allowed to go home.
A case of sympathetic inflammation ending in blindness has
been reported by Zentmayer * (Philadelphia), following panoph-
thalmitis after cataract extraction.
Late Infections occurring months or years after opera-
tion, through fistulous and cystoid scars, have earned an
evil repute with respect to their proneness to cause sympa-
thetic ophthalmia. We attributed our almost complete
(apparent) exemption from these results to the broad con-
junctival coverings over such incarcerations of iris and of
capsule as were left in the wounds. I only remember one
late infection. It was an acute case, iritis with hypopyon.
But it subsided rapidly under treatment.
Treatment. It is a safe rule in all cases where the iris is
not perfectly bright and active on the day following opera-
tion, to endeavour to obtain immediate dilatation of the
* At the Amer. Med. Assoc., Ophth. Section, 1905.
After-Complications 289
pupil. Where there is much muddiness, as much atropin
is instilled as seems likely to be borne without con-
stitutional symptoms.* We commonly instilled the drops,
4 grains to the ounce, four or five times in the morning,
with five-minute intervals, and a similar number of times
in the evening. In these cases mercury should always be
given at once also, either by inunction or by the mouth,
or both. And it is perhaps advisable to begin with a dose
of calomel, 3 to 5 grains, partly to act as a purge. Possibly
in threatening cases intramuscular injections should be
given for the first few days, after Schirmer.f His experi-
ence shows the great value of mercury in the case of
infected wounds, both in controlling the local reaction and
in preventing sympathetic involvement of the fellow eye.
In Bombay we had emphatic evidence of the usefulness of
the drug in this respect. After a few days, when the
bandaging is stopped, dionin may be of assistance also,
increasing the action of the atropin and helping in the
absorption of lymph. Sodium salicylate, 60 to 90 grains
daily, has been recommended in place of mercury. But
there is not the same evidence in its favour. It is said
that if sympathetic ophthalmia should follow in spite of
salicylate treatment, it will be benign (Lindahl).
In the more threatening reactions subconjunctival injec-
tions should be used early. The benefit derived from
them is often quite noticeable. It is recommended that
if a subconjunctival injection cannot be made on account
of chemosis in acute inflammations, the needle should be
inserted through the outer part of the lower lid near the
orbital margin. Bourgeois (Rheims) injects f c.c. of I in
1,000 cyanide of mercury, and repeats it several times,
night and morning, if necessary. In Bombay we have
* The assistants must be made responsible that general symptoms
are not occasioned by the solution passing down into the nose,
t A.f. O., liii, i.
19
290 Cataract Extraction
been satisfied with the more ordinary i in 2,000 solution
on the few occasions upon which we have needed injec-
tions, and have inserted about 15 minims. Moissonier*
(Tours) found common salt injections more efficacious
than cyanide injections in one case.
In all cases of definite iritis or irido-cyclitis presumably
infective, the administration of mercury should be pushed
(unless there is some constitutional centra-indication) to
' touch the gums ' within a week.
In all severe infections the coverings of the eye are
removed, and the conjunctival sac irrigated with per-
chloride lotion, I in 5,000, twice a day. Hot fomentations
are applied if they relieve pain.
The insertion of sterile iodoform in powder, and in
small discs (soloids) and rods, into the anterior chamber
has been tried in severe irido-cyclitis and in corneal
wound infections. It was first used experimentally by
Ostwalt (1897), and has been recommended by Haab
and others. The benefit derived has not been very
marked, and the treatment has not been very generally
followed. Cohnt used iodoform pencils in four infected
eyes with no noticeable result.
If the wound surfaces be infiltrated and panophthal-
mitis threaten, it is said that the process may possibly be
arrested by cauterizing the infiltrated surfaces freely.
Kuhnt has suggested scraping of the surfaces and covering
with a strip of conjunctiva. Irrigation of the anterior
chamber with warm cyanide or salt solution is also
recommended.
Evisceration is held to be the correct procedure in pan-
ophthalmitis or suppurative irido-cyclitis ; enucleation for
atrophy following upon plastic inflammation. In the
* Tenth Internat. Congress at Lucerne, 1904.
t Zeitschr. f. A., xiii, I, 31.
After'Complications 2 9 1
milder inflammations which respond to treatment it is
important to keep the pupil widely dilated as long as any
ciliary injection remains. And the administration of
mercury is continued also. A watch must be kept for the
possible onset of secondary glaucoma.
Late secondary infections are treated upon the same
lines as the early ones.
VARIOUS FORMS OF CORNEAL OPACITY.
The striated corneal opacity known as striped keratitis
is seen the day after operation as parallel vertical grey
lines in the upper half of the cornea, running down from
the (upper) section. The streaks have been shown to
represent ridges on the posterior surface of the cornea,
due to oedema, and are commonly the result of bruising of
the cornea in squeezing the lens through a rather small
wound, or by the frequent introduction of instruments.
They have been attributed also to tight bandages, and
to intraocular irrigation. The affection usually clears off
within a week without treatment.
Less often a diffuse cloud of opacity forms, apparently
of similar origin to the striated condition, if one may
judge by its position and equally transient character.
Sometimes a central patch of corneal haziness develops,
with or without streaks connecting it with the wound.
These central patches occurred particularly often in our
practice after subconjunctival extraction by Czermak's
method, and were obviously due to damage of the endo-
thelium of the cornea in the somewhat difficult expulsion
of the lens The area of opacity was nearly always broken
up by fine, clear interlacing lines into a number of
smaller areas giving rise to an appearance very like that
of broken-up soft lens cortex lying in the anterior chamber.
19 2
292 Cataract Extraction
It would seem likely that the stripes running from the
wound indicate bruising of the wound surfaces rather than
injury to the posterior surface of the cornea, judging from
the different appearance of the opacities unconnected with
the wound.
There are other less common diffuse opaque areas (not
broken up into sections) which appear rather later and
tend to be permanent, and which represent contact keratitis.
They are sometimes seen in cases of retarded union of
the wound, from prolonged contact between lens capsule
and cornea. The capsule and the pupillary margin of the
iris may form adhesions to the cornea.
There are other fine lines to be seen fairly often, at the
time of discharge from hospital, on the posterior surface
of the cornea unconnected with the wound. I have not
seen them described as yet. They are so fine that they
require the corneal loupe and focal illumination for their
examination, and so they may readily escape detection.
Many of them crossing about the centre of the cornea,
they may serve to reduce the visual acuteness. They
are fine, double-contoured, grey lines, mostly slightly curved,
of variable length, but ending within the corneal cir-
cumference. They thus closely resemble ruptures of
Descemet's membrane, but, unlike them, appear to be
only temporary, disappearing within a few months. I
think we have seen them most numerous in cases where
there had been earlier central corneal opacity. They are
very variable in number and direction ; both horizontal
and vertical lines may be present together. I once
noticed fine vertical lines on the posterior surface of the
cornea at the close of the operation.
There still remains to be mentioned the permanent
opacity which results from the introduction of sublimate
lotion or other feebly caustic chemical solution into the
AftervCompIications 293
anterior chamber. Our unfortunate experience with sub-
limate solution in Bombay has been already described
sufficiently.
EXFOLIATION OF CORNEAL EPITHELIUM.
A rough corneal surface from irregular shedding of epithelium
is very common after operation under combined adrenalin and
cocain. Even under cocain alone it is frequent unless care be
taken to prevent drying of the surface before and during opera-
tion. It is, perhaps, induced also by much friction upon
the cornea with lens expressors. It is not a matter of any
importance.
ANTEFLEXION OR EVERSION OF THE CORNEAL FLAP
must be very rare as an occurrence taking place after closure of
the lids and the application of the usual bandage. Oatman*
reported such a case, found at the first dressing, forty-eight
hours after operation. The conjunctiva was much contracted
by scarring, and it was thought that the pull from the lower
fornix must have opened the wound sufficiently for the flap to
be caught against the border of the upper lid. The flap was
replaced by manipulation with a probe under the closed lid.
It united without inflammatory complications, and became
highly vascularized. Glaucoma followed. See also Elliot's
case mentioned on pp. 306 and 311.
Bending downwards of the conjunctival flap over the cornea
is a rare occurrence. In one of our cases the flap appeared to
be pushed down by swollen ocular conjunctiva. The dis-
placement recurred repeatedly. The conjunctival flap is more
likely to be carried down by escaping vitreous.
FILAMENTOUS KERATITIS
is given by Knapp as a complication seen occasionally "by
the end of the second week." I have seen it a few times, and
attribute it to too free perchloride irrigation before operation.
It occurred in one of our cases where the operation had to
be deferred after only the puncture and counter-puncture had
been made. Four fine filaments had formed on the upper
part of the cornea two days later. There was also a patch
* Arch, of Ophth., xxv (1906), 481.
294 Cataract Extraction
of pseudo-membrane on the upper tarsal conjunctiva, and
similar material binding together the swollen folds in the
lower fornix (such a condition as leads to the formation of
conjunctival 'bridges' and 'pouches'). The filaments lasted
as long as the conjunctival membrane. Had the operation
been completed, it would have been impossible to evert the
upper lid early, and the condition of the lower fornix might
have escaped recognition also. Thus the association between
the corneal and conjunctival conditions would probably have
escaped notice, and the cause of the corneal complication
would not have been recognized.
Some years ago a patient of mine with ripe cataract in one
eye had almost constant filamentary keratitis in that eye, and
very little in the fellow eye. After trials of many forms of
treatment, we were able to control the condition sufficiently
for operation to be successfully performed, by the daily appli-
cation of i per cent, silver nitrate solution to the everted lids
for some little time before operation. Curiously, he remained
free from the corneal affection until lately, when the second
cataract was ripening. The filaments then reappeared, chiefly
in the cataractous eye, and recurred constantly until the lens
was extracted from that eye also. Since then I believe the
corneae have remained unaffected.
CONJUNCTIVITIS.
Inflammatory reaction to perchloride irrigation is marked
by swelling of the conjunctiva and of the eyelids. But there
is little discharge except in the rare cases, such as that
above mentioned, in which probably the whole thickness
of epithelium is destroyed over some portion of the con-
junctival surface, giving rise to a pseudo-membrane. As
already stated, there is often difficulty in deciding to what
extent simple swelling is due to filtration cedema, and to what
extent due to inflammatory reaction.
Persistent post-operative conjunctivitis is commonly asso-
ciated with the presence of staphylococci. Abelsdorf and
Neumann* found the Diplococcus albicans tardissimus in three
cases. It may be a continuation of a chronic conjunctivitis
* A. f. A., (1900) xlii.
After^Complications 295
imperfectly cured before operation, and may have been
aggravated by bandaging, atropin drops, etc.
Whenever there is discharge, the patient should be en-
couraged to keep the eyes open as much as possible.
ACUTE DERMATITIS.
Apart from atropin irritation, we have seen a few cases
of acute inflammation of the skin of the lids and neigh-
bouring parts. They were evidently due to the perchloride
used in washing the parts. The complication is well recog-
nized as indicating an idiosyncrasy. Yet in one of our
cases both eyes were operated upon (at an interval), and
the complication only occurred on the one side. Evidently
the washing must have been more thorough on this occasion.
In our cases there was no particularly noticeable associated
conjunctival reaction. The sharply defined reddened area of
skin had an erysipelatous appearance. The lids were quite
stiff and swollen, and could scarcely be separated. Obviously
bandaging was unnecessary. In two patients numerous bullae
formed. And in one of these cases the discharge from the
bullae caused an extension backwards of the inflammation over
the scalp, and, entering the conjunctiva, produced a hypopion,
evidently by infection through the imperfectly healed wound.
The pupil dilated easily, however, and the final result was
quite satisfactory.
SPASTIC ENTROPION
of the lower lid in old people, promoted by the bandage, may very
rarely necessitate an early removal of the bandage, with, per-
haps, the application of strapping to the lower lid for its relief.
PROLAPSE AND INCARCERATION OF IRIS.
Prolapse or hernia of iris is the bete noire of simple
extraction ; incarceration is a complication mainly confined
to the combined operation. The base or pillar of a
coloboma may enter the wound in a single layer, other-
wise a knuckle or fold of iris becomes impacted.
Prolapse is generally found at the first dressing, twenty-
296 Cataract Extraction
four hours after operation. An onset a few days later* is
seen rather more after operation with conjunctival flap;
the development may be very gradual where the sclero-
corneal wound is open under the conjunctival flap. In any
case an early incarceration may enlarge later. The dis-
tinction between a visible incarceration and a minute
prolapse is almost inappreciable. Impaction between the
deeper portions of the wound surfaces only is scarcely
distinguishable clinically from mere adhesion to the cornea
in the line of the wound. Even a small prolapse may
include the whole breadth of the iris from base to pupil,
the protrusion being correspondingly prominent. On the
other hand, wider entanglements in the wound, 'including
only the base of the iris, may remain but little elevated.
After simple extraction the greater portion of the incision
may become occupied by a very large prolapse.
The onset of the complication may be marked by more
or less pain. I once saw spontaneous retraction of a
minute prolapse.
I found the prolapse possibly an hour after the first dressing
of the eye by the hospital assistant. The patient was removed
to the operating room, and cocain instilled. The prolapse,
which had not been seen by the assistant, and had therefore
occurred at the time of the dressing or afterwards, had then
disappeared, and the pupil was round and central.
Spontaneous reduction has been recorded after much longer
intervals.
Causes. (i) Prolapse of iris is the result which we fear
most from reopening of the wound after closure. The
wound may be burst open by external influence, as (a) by any
accidental blow or pressure or friction upon the eye, by the
patient's finger or by a pressure bandage, for instance;
* Rarely, when the healing of the wound is imperfect, prolapse of
iris may occur considerably later, as in the case mentioned on p. 309.
After^Complications 297
(b) by pressure of the lids ; (c) by movements of the globe.
Also by coughing, sneezing, vomiting, straining at stool
or at micturition, or in other muscular effort.
Even with the lid muscle at rest the elastic tension of the
lids exerts some pressure, variable in degree, upon the globe,
as may be seen especially in ' slack eyes ' during operation.
It may be sufficient in itself to cause slight gaping of a cataract
incision placed at the lower corneal margin. This pressure
may be greatly increased by contraction of the orbicularis,
especially in prominent eyes. By sudden violent closure of
the lids, a wound at the upper corneal margin may be forced
open, because the pressure upon the globe is increased
unevenly. The pressure of the marginal bundles of the
orbicularis as they come together is applied below the
horizontal meridian of the cornea. The inequality of the
pressure is greatest when the elastic tension of the lids is
least, as in some old people. Similar contraction of the
orbicularis is excited by any pain in the eye, also by a tight
bandage, and is said to occur in coughing, sneezing, etc.
Uneven pressure upon the eye by the lower lid only may be
brought about also in dressing the eye if the upper lid alone be
raised.
Extreme movements of the globe, especially in the vertical
direction, occurring only with the eyes opened, tend to
separate the wound margins by the pull of the muscles and
by increase of ocular tension through the pressure of the
muscles. Opening of the wound is thus sometimes seen
during operation.
Increase of tension may also possibly occur by venous
stasis in coughing, straining, etc.
On any sudden reopening of the wound after simple extrac-
tion, as insisted upon by Fuchs and Swanzy, the iris may be
carried into the wound by the aqueous lying behind it in the
posterior chamber, for the fluid makes directly for the wound
by the shortest route, instead of passing around through the
pupil into the anterior chamber. A narrow coloboma well up
to the base of the iris is sufficient to guard against this. But
even with the chambers empty, on any increase of tension
together with gaping of the incision, the pressure of the
298
Cataract Extraction
vitreous may suffice to force iris into the wound. This is well
seen during operation in cases of so-called vitreous tension.
The vitreous itself may or may not become prolapsed with the
ins.
Where the deep incision remains gaping under a con-
junctival flap, the iris sometimes slowly finds its way
between the wound surfaces.
In simple extraction damage to the sphincter of the
pupil by the knife or by the passage of the lens is a great
predisposing factor. An active pupil is usually an effective
safeguard. And in combined extraction removal of an
unnecessary large portion of the pupillary zone of the iris
with its sphincter muscle whether by scissors or acci-
dentally by the knife predisposes to prolapse, as also does
imperfect replacement of the pillars of the coloboma.
This replacement may be impracticable when the iris is
carried into the incision by escaping vitreous.
The swelling of lens cortex left behind the upper part of
the iris is held to be at least a contributory cause of
prolapse.
SOME PERCENTAGES OF PROLAPSE REPORTED BY VARIOUS
OPERATORS.
Author.
After Simple
Operation.
After Combined
Operation.
Number of Cases
reported upon.
Little
I9'OO
1 06
I
0*30
322
Swanzy
I"I3
354
Schweigger
7-90
451
Galezowski
0-50
200
Drake Brockman..
1179
1,169
Moorfields results /
I3-87
267
(Marshall) .. \
0-87
1,091
My own results ..
8-37
490
Consequences. The most serious effect of a prolapse
which is allowed to remain is a permanent liability to
After-Complications 299
bacterial invasion of the eye. But the degree of risk
undoubtedly varies with the exposure of the protruded iris.
It may lie bare, or may be partly or entirely covered with
conjunctival flap. We noticed in Bombay that with a
large exposure of iris there was often some iritis from
the first, the enlarged and distorted pupil being at once
occupied by a thin layer of lymph. This was, perhaps,
especially to be expected in Indian practice owing to the
general prevalence of chronic conjunctivitis. When the
prolapse was quite small or, if large, completely covered by
conjunctiva, the iris and pupil generally remained per-
fectly clear throughout. And from a large experience of
subconjunctival prolapse intentionally produced in the
treatment of chronic glaucoma, we learnt that a large
degree of permanent protection against infection was
afforded by the conjunctival covering over the weak scar.
Though a bare prolapse becomes soon covered by
epithelium, the layer is possibly thinner than that persist-
ing from a covering conjunctival flap, and therefore more
likely to become abraded. Thus the remains of uveal
tissue may become exposed, there being no conjunctival
and subconjunctival connective tissue beneath the epi-
thelium. Hence the occurrence of late infective inflam-
mations, either acute and suppurative, possibly ending in
panophthalmitis, or chronic and insidious, and possibly
more serious than the acute cases, leading to sympathetic
involvement of the fellow eye.
An exposed knuckle of iris becomes quickly covered
with lymph and adherent to the surfaces of the opening
through which it has escaped. As the union becomes
consolidated the extruded iris gradually loses much of its
pigment, becoming changed into more or less pervious
fibrous tissue. Quite small protrusions often flatten down
within a few months without cicatrizing firmly. A more
300 Cataract Extraction
or less fistulous or filtering track forms, through which
some aqueous passes, often reducing the ocular tension
slightly.
As a final result of a small subconjunctival protrusion
there is more or less osdema of the neighbouring con-
junctiva. Often a sharply defined pale, transparent vesicular
patch of conjunctiva, a filtration area, develops over and
around the remains of iris, which is seen as a dark under-
lying point. The patch is 2 or 3 millimetres or more in
breadth, more or less unevenly elevated, and in dark and
yellow-skinned races generally sharply outlined by the
dark colour of the surrounding conjunctiva, intensified by
an accumulation of pigment washed out of the vesicular
area. This represents the typical subconjunctival fistula.
There are other smaller opaque grey elevations, formed
evidently by the union of the conjunctival covering with
the loop of iris. Some of these, evidently filtering more
freely than the rest, present dark centres bordered by
narrow whitish rims (of sodden epithelium ?).
Large prolapses commonly persist without appreciable
diminution in size, changing to a greyish colour by loss of
pigment and by union with overlying conjunctiva. The
neck of the protrusion, however, evidently tends to con-
tract as regards its internal not its external surface.
For, on laying open the cavity of the staphylomatous pro-
minence, there may be no immediate drainage of aqueous
from the anterior chamber. The term ' cystoid cicatrix' is
applied sometimes to these staphylomatous scars, at other
times to smaller prolapses with vesicular conjunctival
coverings. If used at all, the term should be restricted to
the former class of case.
Displacement and distortion of the pupil result from the
drawing of the iris upwards, the degree of these defects
varying with the width and elevation of the prolapse. A
Aftei>CompIications 301
small but prominent prolapse, including the whole breadth
of iris, may draw the pupil quite up to the cicatrix,
narrowing it also. Increase in width of the pupil with less
complete displacement may result from a wider inclusion
of the base of the iris. In the case of a very exten-
sive prolapse the lower margin of the greatly stretched
pupil may rise well above the horizontal meridian of
the cornea. I have had to perform iridotomy on this
account.
Depending mainly upon the extent of the incision
occupied is the degree of forward displacement of the
corneal flap and consequent astigmatism. A quite localized
protrusion of the whole breadth of iris may have little or
no effect upon the corneal curvature, while an extended
inclusion of the base of the iris may cause considerable
flattening. The astigmatism is often irregular, and there-
fore only partly corrected by cylindrical lenses. By a very
large prolapse the upper part of the cornea may be bent
forward instead of backward, a fine transverse grey line on
the back of the cornea marking the lower limit of the
abnormal curvature.
A prominent staphyloma is not only very disfiguring,
but tends to keep up chronic conjunctival irritation.
The bulbar conjunctiva on either side of the eleva-
tion is no longer cleansed by the movement of the lids
over it.
In ophthalmic literature references to secondary
glaucoma resulting from prolapse and incarceration of iris
are so frequent as to convey an exaggerated impression of
the closeness of the connexion. I have rarely known
high tension together with inclusion of iris visible exter-
nally. The tendency is to the development of low tension
by filtration of aqueous through the weak scar. Possibly
in some cases this may be prevented by impaction of
302 Cataract Extraction
vitreous* together with iris in the wound. In other cases
the high tension may be only temporary. In treating
chronic glaucoma by subconjunctival prolapse I found
that in some eyes a period of high tension, lasting possibly
two or three months, supervened before filtration was
established. But these were eyes in which the iris was
tough and rigid from old glaucomatous changes.
Treatment. If a small prolapse be seen very shortly
after its onset, replacement with a spatula, followed by
eserin instillation, is probably indicated. But when the
prolapse is found simply at the daily dressing of the eye,
and the iris has been exposed in the conjunctival sac
possibly for hours, its reduction is objectionable, lest
adherent infective organisms be carried into the eye.
Immediate excision is the only correct treatment. It
is often, however, by no means easy. The congested loop
of iris is hypersesthetic, and is rendered only partially
insensitive by cocain. The use of a stop-speculum and
fixation of the eye are both inadmissible, lest loss of
vitreous be brought about.
It is generally considered necessary or advisable to
perform the small operation under general anaesthesia ;
and this is the great drawback to the treatment. The
risk of loss of vitreous or possibly of intraocular haemor-
rhage from vomiting after the anaesthetic must be con-
sidered. But I have never found general anaesthesia
necessary. Adrenalin is instilled twice, and is followed
by cocain, 4 per cent, solution, four times at somewhat
prolonged intervals, so that twenty minutes in all is taken
up. If there were still any trouble from pain excited by
seizure of the iris, the application of a few crystals of
* Otherwise, how is it that prolapse or incarceration of iris in a
sclero-corneal wound maybe relied upon confidently to relieve primary
glaucoma ?
After'Complications 303
cocain should be of service. I only remember once
causing a small escape of vitreous in removing a prolapse,
and that was with the help of cocain alone, without
adrenalin. Before the instillation is begun irrigation of
the conjunctival sac with perchloride is indicated. (We
used i in 3,000, drop by drop, for one minute as a rule.)
The lids are firmly separated by the assistant's fingers, or,
if this prove insufficient, Desmarres' retractor is used for the
upper lid, with finger depression of the lower lid. Straight
toothed iris forceps are used for seizing the iris ; or, if
curved forceps be used, their points must be directed
upwards, so that they cannot possibly enter the wound in
case the eye rolls up. The eyeball is very likely to turn
upwards when the iris is pulled upon. The tissue must
of course be released at once, and, if the lids be firmly
held, no harm ensues. If the iris is covered by con-
junctival flap, the latter must first be peeled off, a separate
pair of forceps being used for this purpose.
This peeling of the conjunctival covering may be accom-
plished much later after the cataract operation than one would
expect. I did it once as late as seventeen days after the
cataract extraction for removal of a small late prolapse, which
had appeared gradually. In this case some bleeding occurred
into the anterior chamber, and the chamber did not become
re-established for some days afterwards. Conjunctiva can
ordinarily be separated from underlying iris as late as four or
five days at least after the formation of the prolapse.
In dealing with a small or moderate protrusion the
iris is pulled out through the opening sufficiently to
remove the whole of the tissue which has been nipped in
the canal. It is snipped off with de Wecker's or other
scissors pressed down upon the wound margins. If the
removal be done early, within twenty-four hours of the
occurrence of the hernia, the pillars of the coloboma
304 Cataract Extraction
made should retract well away from the wound, leaving
no adhesion. But if the treatment be delayed for another
day or more, infiltration will have spread into the neigh-
bouring iris, and permanent adhesion between iris and
cornea will form near the wound. One cannot expect to
remove the whole of a very extensive prolapse, but the
greater portion of it can be cut away in one snip without
pulling upon the iris at all to attempt to free it laterally.
Though incarceration of iris is left at either end, the
result in my experience is a flat cicatrix. A certain
amount of retraction appears to take place, even though
atropin be instilled for slight iritis.
After the small operation sterilized eserin drops may be
instilled if the pupil and iris are quite clear ; otherwise
atropin may be required for threatening iritis, and should
be used freely and unhesitatingly.
It cannot be said that the result of the treatment is
always satisfactory. Infection* may have already entered
the eye, or may gain admission at the time of the excision.
Adhesion of iris to the scar may lead to secondary
glaucoma, or the weak scar left after partial excision of a
large prolapse may entail a permanent though small risk
of late infection. At best, after protracted healing, causing
anxiety to the patient, a broad and disfiguring coloboma
may be the result, causing dazzling and defective orienta-
tion. Kuhnt recommends the covering of the site of the
prolapse by a bridge of conjunctiva.
Rarely treatment may have to be deferred for some reason.
For instance, in one of our cases acute dermatitis with
serous exudation from perchloride irritation rendered early
excision of a subconjunctival prolapse inadvisable. And the
dermatitis persisted until it was too late to separate the con-
junctival flap.
* In one of our cases both eyes were lost later by sympathetic
ophthalmia.
After-Complications 305
And one may feel reluctant to undertake so troublesome
a treatment for a minute subconjunctival incarceration or
prolapse, especially if the complication arises late and
gradually ; and after loss of vitreous it appears altogether
too risky. One hesitates even to perform the small opera-
tion where the lens has been extracted in its capsule
without loss of vitreous ; also, perhaps, where vitreous
tension has been very evident during ordinary extraction.
It is, perhaps, hardly necessary to mention that any
operative treatment of a prolapse should precede that of
after-cataract, in case the latter should also be required.
Should the order of procedure be reversed, loss of vitreous
would be very probable when the prolapse was excised.
The main object of later treatment is the reduction of
the liability to late infection. In some cases also dis-
figurement is removed and corneal astigmatism lessened.
Of small low protrusions only those uncovered by con-
junctiva would be interfered with. I have several times
cut away as much as possible, and covered the site by a
band of the neighbouring conjunctiva, undermined and
drawn down by a suture on one or both sides of the
cornea. The accurate fixation of the conjunctival strip
requires care. In the case of a prominent staphyloma it
would appear perhaps wise to wait for a few months for
partial closure of the neck communicating with the
anterior chamber, and then to adopt Berry's treatment.*
After freely laying open the ' cyst,' he cauterizes super-
ficially the defective portion of sclero-corneal cicatrix in
the expectation that the deep inflammatory reaction ex-
cited will consolidate the filtering tissue and lead to firm
closure. The wall of the staphyloma is left as a covering
to the cauterized tissue.
Simple cauterization has been recommended and carried
* Trans. O. S., xxii (1902), 273.
20
306 Cataract Extraction
out to produce flattening and condensation of the tissue of
small elevations resulting from limited prolapse ; but I
believe it is wrong in principle. It does not disconnect
the iris from the surface, and even exposes it afresh by
destroying the epithelial covering. I have seen two late
infections in my own practice following upon this treat-
ment of prolapse.
Where an extensive prolapse has been allowed to heal
in the wound, partial excision of the altered iris tissue
may be combined with the application of a corneo-scleral
suture to produce flattening and approximation of the
wound margins, or with an attempt to cover the tissue with
conjunctiva. In a few such cases, fearing the connexion
of the uveal tract with the weak scar, I have afterwards
separated the adherent base of iris at either side, by an
irido-sclerotomy upwards.
PROLAPSE AND Loss OF VITREOUS.
An extensive prolapse or incarceration of vitreous may be
found at the first dressing, with or without similar involve-
ment of the iris. Vitreous may have presented in the wound
at the time of operation, or, on the other hand, everything may
have gone smoothly then. Major Elliot (Madras) has sent me
notes of several cases in which later prolapse occurred, includ-
ing a wide prolapse found on the ninth day, a small one on the
sixth day, and another bulging wound on the sixth day. Also
of vitreous loss on the thirteenth day, due to anteflexion of the
corneal flap by the upper lid in a case of delayed union of the
wound. Most of the causes of prolapse of iris may also lead
to hernia of the vitreous. On at least one occasion on the day
following operation I have seen the distorted pupil character-
istic of considerable vitreous loss, though no loss had occurred
at the time of operation. Twice I have seen recurrence of
vitreous escape -in one case at the first dressing twenty-four
hours later, in the other case at the second dressing from
eyes which had lost much vitreous during operation. Both
of these eyes became atrophic later, though there was moderate
AfteivComplications 307
vision in one at the time of discharge from hospital in spite of
a retinal detachment.
IMPACTION OF CAPSULE,
besides causing delayed union, may produce a permanently
fistulous scar, with its infective dangers, or may induce glau-
coma. I have not had personal experience of inflammatory
troubles arising obviously from this source, and feel that they
must be rare. Possibly in some of our infections ascribed to
entanglement of iris associated impaction of capsule may have
been equally responsible. Treacher Collins has examined
microscopically three eyes in which entanglement of capsule
in the wound had led, apparently, to irido-cyclitis, and in two
of the cases to sympathetic inflammation of the fellow eye.
INTRAOCULAR HEMORRHAGE.
Bleeding into the anterior chamber is to be expected
occasionally within a few days after operation by sclero-
corneal section. I have known it to occur more than a
fortnight after operation (in a case complicated by slight
iritis). It results from any strain upon the wound suffi-
cient to break down some of the new tissue by which union
is taking place. New blood-vessels form very rapidly from
the episcleral tissue. The strain or injury may or may
not be sufficient to reopen the wound. Thus occasionally
the anterior chamber may be found emptied of aqueous and
containing only a thin, uneven layer of blood. Much more
commonly however the anterior chamber has either not
been emptied, or if it has been emptied, has become re-
filled by closure of the wound.
The absorption is sometimes very slow. And organiza-
tion of clot, producing after cataract, is to be expected
frequently from this haemorrhage, occurring at a time when
the eye is irritable and w r hen more or less exudation
is often present. In some cases there are obviously
20 2
308 Cataract Extraction
repeated haemorrhages, the hyphaema being increased
at intervals for some weeks. In some of these cases
there is no obvious explanation of the persistence or
repetition of the trouble. One of our patients, in
whose eye blood remained for two and a half months,
had diabetes and albuminuria. In another persistent case
there was a troublesome chronic cough. The instillation
of atropin is indicated to prevent synechiae from forming,
especially in cases due to external violence. In chronic
cases dionin may help to promote absorption.
Much more rarely bleeding may take place behind the
iris also, coming obviously from other sources, in part at
least. There are cases intermediate in gravity between
those just mentioned and expulsive retrochoroidal
haemorrhage.
Once, when I perhaps hurt the eye a little in dressing it
three days after operation, the patient, an exceedingly nervous
man, suddenly jerked his head away, and closed his lids so
violently, that blood not only filled the anterior chamber, but also
poured from the reopened wound, and became diffused through
the vitreous. The fundus could not be seen even a few months
later. Detachment of the choroid was diagnosed from a large
lateral defect in the field of projection of light. Vision was
practically destroyed ; fingers could not be counted.
DELAYED UNION AND REOPENING OF THE
WOUND.
Gaping of a sclero-corneal wound under a conjunctival
flap has been sufficiently dealt with. It is not commonly
referred to under the term 'delayed union.' But this
designation is earned at least in the cases where the
tension of the eye remains very low for weeks after the
operation. Where this low tension is associated with
obvious separation of the deep wound one does not
AfteivComplications 309
hesitate to ascribe it to drainage of aqueous through the
wound, though there be no longer any noticeable general
nitration oedema. The anterior chamber is frequently
rather shallow, but not always so. In other cases gaping
of the wound is very slight, and in still others it cannot
be made out at all. These soft eyes without visible separa-
tion of the wound margins, and with partly or completely
re-formed anterior chamber, were, I think, with us much
commoner since we operated with an extensive con-
junctival flap than when we placed the incision at the
superficial sclero-corneal junction. And there does not
appear to be sufficient reason to consider them separately
from cases in which the deep wound gapes visibly, though
there is always the possibility that the leakage may be
between choroid and sclerotic, and not through the
wound. And other explanations of the low tension have
been suggested. For example, Czermak* suggested their
relationship with so - called ophthalmo - malacia, and
Chevalleraut explains a case of enophthalmos after opera-
tion as possibly due to a sympathetic lesion. I looked for
choroidal detachment in several cases without finding it,
but with after-cataract present the signs of this detach-
ment may have escaped notice. I remember one such
case several years ago, discharged from hospital with the
eye soft after operation without conjunctival flap ; the
patient returned a few months later with a prolapse of iris
occupying a portion of the cicatrix. There is a general
feeling that an anterior chamber of normal depth, or
deeper than normal owing to the removal of the lens,
shows an absence of drainage through the wound sufficient
to account for a tension - 2 or- 3. But that this is not so
I have seen in glaucomatous eyes after the establishment of
* ' Die Augenarztlichen Operational,' p. 944.
f La Clin. Opht., 1899, p. 23.
3 r o Cataract Extraction
wide subconjunctival fistulas. It is uncertain how long
the low tension may last. We kept one patient under
observation for nearly a month after a Czermak's opera-
tion, and the eye was still very soft.
In the more generally recognized leakages through the
wound the iris and lens capsule are in contact with the
cornea. With us it has been much less frequent, and the
chamber has remained empty for shorter periods, since we
used a conjunctival flap. With purely corneal incisions
the chamber more commonly remains empty from the
beginning, so far as one can judge from single daily
inspections. With a conjunctival flap it is recognized
that early filling of the chamber is to be expected more
regularly, but re-emptying of the chamber is, perhaps,
rather more frequent a few days after operation. There
may be haemorrhage under the conjunctiva along the line
of the wound, and in the anterior chamber. And blood
in these situations is presumptive evidence of breaking
down of early union, though the anterior chamber may
have become re-established.
In corneal incisions a minute opening can sometimes be
distinguished, a ' capillary fistula ' through which the fluid
escapes, due to entanglement of a shred of capsule, lens
substance, vitreous, or iris in the wound. Sometimes a
leaking wound is a consequence of a large incarceration or
prolapse of iris or vitreous, or of separation of the wound
margins by vitreous tension. Other cases in which the
lips of the wound remain singularly free from signs of
reaction and repair have been ascribed by Mellinger* to
the too free use of cocain during operation.
Among other suggested explanations may be mentioned
an uneven incision, too frequent disturbance by dressings,
entropion, and defective reparative power peculiar to the
* Beit. z. Augenheilkunde, Basel, 1893.
After-Complications 3 1 1
patient. This latter is suggested by the occurrence of the
complication in both eyes, or in two operations on the one
eye (e.g., in a preliminary iridectomy and in the subse-
quent extraction operation).*
The leakage commonly ceases within a week or two, but
considerably longer delays have been recorded. A. Terson
reported one lasting a month and a half. And the forma-
tion of a broad anterior synechia may prevent re-formation
of the chamber after the drainage of fluid has stopped and
the tension of the eye risen.
It is curious that the complication seldom leads to evil
consequences. Invasion of corneal wounds by pyogenic
organisms is probably prevented by the surfaces becoming
covered with epithelium, and by the flow of fluid from
within the globe. But infections have been recorded.!
Prolapse of iris may occur, in eyes other than those with
sclero-corneal incision gaping under the conjunctiva. Also
anterior synechia, with consequent glaucoma and possibly
extensive corneal opacity (contact keratitis). And one fears
lest downgrowth of corneal epithelium into the anterior
chamber should give rise to glaucoma by blocking the
filtration angle. Elliot t (Madras) relates a case in which
the patient turned down the corneal flap with his lid on the
thirteenth day, causing a free vitreous escape. A median
suture was applied several days later to the bulging wound.
In the large majority of cases nothing is required in the
way of treatment beyond continued bandaging of the eye
without pressure, till the anterior chamber refills. The
merely soft eyes, with the chamber normal or nearly so,
appear to require simple protection from injury by a
* Harlan, Ann. of Ophth., vii (1898), 568.
f See, for example, Czermak, ' Die Augenarztlichen Operationen,'
S. 940 ; Barck, Amer. J. of Oph., 1897, p. 281 ; Maynard, ' Manual
of Ophthalmic Operations,' p. 112.
I Personal communication.
3 12 Cataract Extraction
shield, more particularly at night. Light stimulation
of the wound surfaces with silver nitrate or iodine solution
has proved effective for obstinately leaking corneal wounds.
Also cauterization, and freshening of the surfaces by the
introduction of a spatula. These measures may serve to
destroy or remove shreds of tissue incarcerated in the
wound. Massage of the cornea has been tried. Iridectomy
has been successfully employed, and not only in cases
when the iris was involved in the wound. Possibly it acts
by freshening the wound surfaces. Entropion may require
operation or the removal of the bandage. Sometimes
when the chamber is re-established after being long absent,
the wound margins may not be found in good apposition.
And the continuance of (pressure) bandaging may be
required on this account.
TRANSIENT DETACHMENT OF THE CHOROID
after cataract extraction, first noticed by Knapp in 1868, has
been studied especially by Fuchs.* It is rather a pathological
curiosity than of clinical importance, since the sight is only very
temporarily affected. It is associated with low tension of the
eye and a shallow or empty anterior chamber, which may have
persisted since the operation, or may have reappeared. These
clinical signs may precede recognizable separation of the
choroid by an interval of a day. The detachment dates com-
monly from the second to the eighth day after operation, but
it may come on some weeks, or even months, later. It may be
so prominent as to be seen by focal illumination. On the
other hand, it may not be discernible even on ophthalmoscopic
examination, owing to the presence of blood or cortex in the
pupil. And a shallow separation readily escapes detection,
since the separated portion is of the same red colour as the
rest of the fundus. It is recognized by the dark curved line
marking its posterior boundary, with bending and parallactic
movement of the retinal vessels. In these low detachments,
especially soon after their onset, there may be folds concentric
* A.f. O., li (1901), 2, 199.
AfteivComplications 3 1 3
with the curved posterior margin. As a general rule, the
elevation, if low when first seen, remains low. Sometimes
both the development and the subsidence of a large detachment
are very rapid. The disappearance generally coincides with
refilling of the anterior chamber and rise of the tension to
normal. The duration of the detachment is commonly only a
very few days, but it may be a month.
The site of the separation is mainly at one or both sides of
the eye. Both sides are, apparently, not often equally affected.
Detachments above and below only occur associated with
more prominent lateral ones. They are much less frequent
than the latter, and are always shallow. Separation does not
take place readily further back than the points of exit of the
venae vorticosae.
Fuchs attributed the complication to the passage of aqueous
into the supra-choroidal space through minute rents in the
soft tissues at the angle of the anterior chamber. The fluid in
the space has also been regarded as a purely passive serous
accumulation,* depending upon low tension in the eye, the
latter being brought about by drainage through an imperfectly
united or reopened wound.
Other more lasting, and possibly permanent, choroidal
detachments occur rarely from haemorrhage during or after
extraction. See, for example, the case mentioned on p. 308.
Possibly limited supra-choroidal haemorrhages pass unnoticed.
MENTAL DISTURBANCE.
Cataract operations are occasionally followed by various
forms and degrees of mania, with hallucinations, or by
simple confusion of mind, or by noisy and violent delirium,
in which the patient is restrained with difficulty from pulling
off his dressings. The mental equilibrium of some old
people is upset by having both eyes bandaged, or by con-
finement in a very dark room. In alcoholic subjects delirium
tremens is a possibility. But in some cases no explana-
tion has been available beyond the mere influence of the
operation. Fromaget t suggests auto-intoxication as a cause.
* Thomson Henderson, Ophth. Review, xxvi (1907), 191.
t Ann. d'Ocul., cxxiii (1900), 183.
314 Cataract Extraction
In two cases he connected delirium with reduced secretion of
urine and constipation. Finlay * reported a similar observation
connecting the delirium with renal insufficiency. It may come
on early or late, most often after a few days. Most cases
yield to treatment, such as the admission of light and the
administration of sedatives. But a few patients have become
permanently insane, and deaths have occurred. Care must be
taken to prevent injury to the eye so far as possible.
The only troubles of this sort with which we had experience
in Bombay were cases of atropin poisoning years ago, when
ordinary precautions were not taken by the attendants in
instilling the drops.
FLATULENT DISTENSION
of the abdomen is very commonly found in India, especially
in private patients, the day after the operation. The patient
has generally passed a sleepless night, and often has pains in
his loins. These troubles are due to the patient having lain
on his back, afraid of the smallest movement, thinking that
his eyes might be injured thereby.
SECONDARY GLAUCOMA.
Glaucoma follows the operations of cataract extraction
and of needling for after-cataract in a small percentage t
of cases. It may set in at any period. A sudden rise of
tension may develop within twenty-four hours after dis-
cission.^ A slower elevation of tension may mark the
consolidation of the cicatrix a few weeks after extraction
of the lens, or may be found as the cause of a gradual
deterioration of vision years later.
It is impossible to deny that some of the glaucoma seen
after these operations may be primary, the association
* Arch, of Ophth., xxxiii (1904), 5.
f Marshall gives a percentage of 2-08 in secondary operations at
Moorfields.
% Very rarely at such an early period after cataract extraction, and
then only by exclusion of the pupil.
AfteivComplications 315
between the condition and the operation being fortuitous.
But in many cases the causal relationship is unmistakable.
Glaucoma may have been present in the eye before opera-
tion. Or the primary nature of subsequent glaucoma may be
suggested by the same condition occurring in the fellow eye,
if, moreover, the operation and healing of the wound has
been uneventful ; more especially if there is neither incarcera-
tion of iris or capsule in the scar, nor adhesion to the scar, and
if the interval between operation and the recognition of tension
is long.
The secondary nature of the affection may be attested
clinically by anatomical conditions known to be effective, or
may be suggested by almost immediate onset after operation.
And the greater frequency of the complication after com-
bined extraction than after simple extraction is evidence of an
etiological relationship.
Where the complication supervenes upon cataract extrac-
tion supplemented by quite early discission, there may
naturally be some doubt as to the relative parts played by
each operation as causative factors. So far as the evidence
goes, discission cannot be considered accountable for any
glaucoma which is not of early onset, unless it be through the
instrumentality of an iritis or irido-cyclitis.
It is, of course, possible that a predisposition to primary
glaucoma may combine with some result of operation in the
development of the complication. But the conditions clinically
recognizable as predisposing to primary glaucoma shallow
anterior chamber, small cornea, hypermetropia can have
little influence in this relationship. Indeed, one may suppose
that the deepening of the chamber from a satisfactory lens
extraction may at times serve as an efficient prophylactic
against the onset of glaucoma.
Much of the high tension met with after either the
major or the minor operation is inflammatory in origin.
Various forms and degrees of iritis and irido-cyclitis may
act here as they do quite apart from operation, either
through annular posterior synechia excluding the pupil,
or more commonly by the accumulation of albuminous
3i 6 Cataract Extraction
fluid and exudate and the blockage of the filtration
channels.
Interest, however, centres more in the development of
high tension quite apart from inflammatory changes or
insufficiently accounted for by them. After cataract
extraction incarceration of iris or capsule, or both, in the
wound has been most frequently blamed. Besides the
obliteration of the filtration angle at the actual site of the
impaction, broad or narrow, there may be extensive
adhesion between base of iris and cornea in the imme-
diate neighbourhood. This is owing to localized changes
of inflammatory nature, excited around the impacted tissue,
and spreading more or less to the neighbouring iris. The
forward displacement of the iris to the line of the scar,
especially where the wound has been purely corneal, may
be sufficient to narrow the whole circle of the filtration
angle.
In cases of chronic iritis it may be impossible to
apportion the influences of inflammation and adhesion to
the line of the scar. As the inflammation persists, and as
fibrous tissue replaces the proper iris tissue, the drawing
forward of the iris becomes more marked.
Glaucoma is more common after combined extraction
because of entanglements of the tissues in the wound, and
also of mere adhesions to the cicatrix. Here the extent
of the adhesions and the position of the wound-line
(purely corneal or sclero-corneal) are important con-
siderations, for it is comparatively rarely that forward
displacement of the root of one or both pillars of the
coloboma may not be found on focal illumination after
the combined operation. In a glaucomatous eye
whence the lens had been removed in its capsule
Treacher Collins once found adhesion of hyaloid mem-
brane to the scar accountable for closure of the filtration
AfterxComplications 3 1 7
angle. This may possibly result from any vitreous
prolapse.
Inclusion of a tag of iris or capsule in the wound may
also be responsible for (i) delayed refilling of the anterior
chamber, and possibly (2) downgrowth of surface epi-
thelium into the anterior chamber. Later there may be
(3) "a continual drag upon the ciliary processes, exag-
gerated by the perpetual movements of the iris and ciliary
muscle. In this manner ciliary irritation is set up."* The
empty chamber must obviously aid in the formation of
peripheral anterior synechiae.f The downgrowth of corneal
or conjunctival epithelium may be so rapid as to cover the
whole depth of the wound surfaces in four days. It may
extend to line the anterior, and even the posterior,!
chamber completely, perhaps closing the pupil and colo-
boma, or it may be confined to the neighbourhood of the
wound, obstructing the filtration angle. The layer covering
the iris, or actual cyst-formation, may or may not be visible
clinically.
It has been suggested that cortical remains may cause
glaucoma (i) by irritating the iris and ciliary body, and so
causing increased secretion ; (2) by blocking the spaces
leading to the canal of Schlemm ; and (3) by swelling
sufficiently to press forward the root of the iris. Intra-
ocular haemorrhage occurring after the wound has united
has been mentioned also as a possible source of tension.
A sudden rise of tension after discission (said to be
more common in cases where the extraction was without
* Parsons, ' The Pathology of the Eye,' iii, 1083.
t Our three Bombay cases of secondary glaucoma mentioned on
p. 247, due to accidental irrigation of the anterior chamber with per-
chloride lotion, were probably brought about by peripheral anterior
synechia. This would be permitted by destruction of the endothelial
lining of the anterior chamber.
% Elschnig, KL Mbl.f. A., xli (1903).
318 Cataract Extraction
iridectomy) has been explained as the result of additional
obstruction of filtration paths already restricted by sequelae
of the extraction operation. Reactionary swelling of the
ciliary processes pushing the base of the iris forward may
temporarily close an already narrow filtration angle, or
some imprisoned cortical matter may be set free into the
chamber, choking up the meshes of the pectinate ligament.
Some cases in eyes with no obvious peripheral shallowing
of the chamber appear to be explicable only by the advance
of broken-up (perhaps abnormally fluid) vitreous to mingle
with the aqueous.
In one such case of tension following the double-needle
operation in a child in my practice, the presence of vitreous in
the anterior chamber was shown by failure to empty the
chamber on tapping with a narrow knife.
Bajardi's* production of plus tension in aphakic eyes of
rabbits by injecting vitreous into the anterior chamber is
interesting.
Knappt and DalenJ depict the persistent forms of glaucoma
following discission as more or less inflammatory, with forward
protrusion of iris, and presumably seclusion of the pupil. But
many of these cases with bulging iris are certainly not entirely
or mainly due to general iritis or irido-cyclitis. For there may
be little or no exudation visible binding down the pupillary
margin to the capsule, and the signs of seclusion may set in
within twenty-four hours far too rapidly for the formation of
annular posterior synechia from general iritis. The sugges-
tion that these appearances may represent incarceration of
vitreous in the pupil, kept small by spasm of the sphincter,
appears a little strained. A case of my own throws some light
on their origin. On the day following a simple extraction of
a Morgagnian cataract, containing fluid of unusually thick
creamy consistence, the eye was painful and injected, pupil
small, and anterior chamber not refilled. It was not till
* R. Ace. di Med. di Turino, Luglio, 1896.
t A.f.A., xxx (1895), 8.
J Mitteilungen aus der An gen. Klinik in Stockholm, 3 Heft,
Jiinner, 1901, S. 75.
AfteivComplications 3 1 9
another day had passed that the tension was tested and found
to be high. The tension and the pain were relieved at once
by a simple puncture through the iris. There was undoubtedly
exclusion of the pupil, brought about by the irritation of the
creamy lens debris. It had been noted at the cataract opera-
tion that a little of this material repeatedly crept into the
pupillary area from behind the iris even after free irrigation of
the anterior chamber. And doubtless some trace of it
remained behind. It is worthy of note in this connexion that
after Knapp's simple extractions with ' peripheric splitting ' of
the capsule, the reopening of the capsular sac by the needling
is very likely at times to set free imprisoned, overripe, irritat-
ing cortical remains. This form of glaucoma appears to be
the only one which can arise thus early after cataract extrac-
tion i.e., in an eye with a large recent wound. It can
scarcely happen after combined extraction. (In Norris and
Oliver's ' System,' iv. 392, mention is made of the fact that
early onset of glaucoma is seen more after simple than after
combined extraction.)
Treacher Collins has found adhesion of capsule to the site
of a needle puncture as an additional cause of glaucoma.
Clinically, it is, I believe, not rare long after discission through
a corneal puncture to see a fine grey thread running back from
the minute corneal scar. But presumably these threads are
mostly the remains of altered vitreous.
Cases of very slow onset after cataract extraction, whether
supplemented or not by discission cases for which treatment
is sought months or years later are naturally often those in
which the causes above given are least obvious, and in which,
therefore, the presumption of primary glaucoma appears
reasonable.
De Lapersonne believes renal impermeability to be an
important factor in the causation of the plus tension.
Our notable exemption from this complication in
Bombay, so far as cataract extraction is concerned, has
been alluded to already. We considered it due largely to
the use of the conjunctival flap, which not only led to the
formation of many filtering cicatrices, but also ensured
early refilling of the anterior chamber and prevented
320 Cataract Extraction
downgrowth of epithelium. Important also has been the
rarity of inflammatory complications. And satisfactory
replacement of iris and capsule during operation, with
retention of activity in the pupillary sphincter, must have
had a definite prophylactic influence.
Knapp* says, " Glaucoma is the only consequence of dis-
cission which may be fairly considered as inherent to the
operative procedure. A low degree of increase of tension
appears not infrequently, perhaps, during the first twelve
hours as reaction from the operation, and disappears without
treatment."
The treatment of a malady of such diverse origin cannot
be uniform. Many of the early cases, and particularly
those excited by needling, subside under treatment by
eserin. Dionin and both hot and cold applications have
also been used. And Pagenstecher has recommended the
administration of sodium salicylate. Even cases of inflam-
matory origin have been treated by eserin. But it is more
rational to treat them with atropin, relieving the tension
temporarily by paracentesis or sclerotomy. A prolonged
reduction of tension may be secured by a modified subcon-
junctival paracentesis (see Fig. 95). Where there is ex-
clusion of the pupil, transfixion of the pupillary membrane
is indicated, possibly succeeded by iridectomy or irido-
tomy. For adhesion or incarceration of iris or capsule
the mere division of these tissues may be sufficient, or it
may be combined with sclerotomy (Narben-sclerotomie,
Ouletomie). Or iridectomy may be preferred. For the
late chronic forms of glaucoma either iridectomy or one
of the newer operative measures appears to be indicated
Heine's detachment of the ciliary body, or the formation
of a filtering cicatrix (Lagrange, Herbert), provided the
* Norris and Oliver's ' System,' iii, 816.
AfteivComplications 321
posterior capsule has not been punctured, allowing vitreous
to come forward into the cicatrix. The prognosis is not
always favourable, in so far as the condition may possibly
be brought about through epithelial ingrowth, over which
we have no control.
AFTER-CATARACT.
After-cataract is the term applied to the opaque tissues,
mostly membranous, present in some degree in the pupil
and coloboma after the very large majority of ordinary
cataract extractions. It is used also for any folding of
transparent capsule by which visual acuteness is lowered,
and for occlusion of pupil and coloboma, the result of
iritis or irido-cyclitis after the operation. Early after-
cataract may be largely or entirely of temporary nature,
consisting of lens matter, blood-clot or lymph. On the
other hand, progressive capsular degeneration may cause a
slow reduction of vision in the course of years.
Vision may be lowered by the following conditions,
singly or combined :
i. Capsular abnormalities.
(a) Thickenings, proliferations of lens cells, dating from
before operation. A large, dense anterior plaque of an
overripe, shrunken cataract may have been left behind for
some reason. Or there may be a much thinner posterior
central patch or ring of capsular opacity. More common
is the opaque capsule of a Morgagnian cataract either
simple diffuse cloudiness affecting chiefly or entirely the
anterior capsule, or the same with dense white points
added. The edges of the opening already made in such
an inelastic capsule may lie almost in apposition, in which
case the visual defect may be attributable more to the
want of elasticity than to the opacity. Besides these
21
322 Cataract Extraction
more obvious opacities one notices, on careful examination
at the time of discharge of the patient from hospital, that
the anterior capsule seldom appears altogether transparent.
It is faintly cloudy, and the margins of the opening in it,
more or less curled up, are frequently visible as fine grey
lines.*
To what extent proliferation of lens cellst after opera-
tion is accountable for central opacities found later is
uncertain. Certainly in some cases there is no such pro-
FIG. 81. FIG. 82.
LATE AFTER-CATARACT, PURELY CAPSULAR, AS SEEN WITH
CORNEAL LOUPE THROUGH THE DILATED PUPIL.
liferation. It appears more likely to occur peripherally in
pockets shut off from the anterior chamber by union of
the two layers of capsule.
(b) As early as six months after operation, but much
more after several years, changes may be found especially
in the anterior capsule (see Figs. 81 and 82) which have
developed since the cataract extraction and which are
different from anything found shortly after operation. I
The membrane may appear almost or quite clear on
examination by focal illumination, but direct ophthalmo-
* At this early period it may be difficult to decide whether some
faint grey patches belong to the posterior capsule or represent cortex
left behind. It is also sometimes impossible, even with the pupil dilated,
to distinguish the opening in the anterior capsule. It is possible
that in such cases, no capsule having been removed, but the opening
in it having been large, the anterior capsule may have completely re
tracted behind the iris.
f See Wagenmann, A.f. O., xxxv, 173.
J I think that once I found a mere trace of these changes quite
early after cataract operation.
After>Complications 323
scopic examination with a + 20 lens reveals fine opaque
(black) lines, sharply defined. They are mostly disposed
in the form of circles, varying in size, but all minute.
But there are also, usually, other irregularly disposed
lines. From their appearance one would judge that
these changes indicate degeneration of the elastic cap-
sule itself rather than abnormalities of the cells lining
it. I have not seen the exact condition described else-
where.
(c) Fine parallel or radiating folds in the capsule may
sometimes be seen within a fortnight after extraction, but
are more common later. They are more noticeable by
focal illumination than with the ophthalmoscope. They
are often caused obviously by the traction of organizing
deposits of blood or lymph, and they are usually situated
so as to influence central vision more or less. An un-
common and ill-marked form of unevenness is a waviness
of the loose anterior portion of capsule, after operation on
a Morgagnian cataract.
2. Cortex left behind.
If one systematically operates upon rather unripe cataracts,
one must at times leave a layer of lens substance occupying
the whole area of pupil and coloboma, scarcely visible, per-
haps, at the time of operation, but opaque and swollen after
twenty-four hours. Or trouble from haemorrhage into the
anterior chamber, or from escape of vitreous, may interfere
with the removal of ripe cortex. But ordinarily, only thin
layers of one or more sectors of soft flocculent material
are left, projecting into the pupil from the periphery. For
the rapid disappearance of lens debris the free access of
aqueous humour is necessary. Therefore, slow absorption is
to be expected of lens matter which is embedded in vitreous,
or which becomes enclosed in a pocket by union of the two
layers of capsule. This point is insisted upon by the advocates
of the use of capsule forceps. Cortex which is exceptionally
slow of absorption is the cream-coloured, firm, equatorial ring
21 2
324 Cataract Extraction
of the overripe discoid cataract ; but this is almost never left
behind except when there is vitreous accident.
3. A fortnight or so after the cataract operation any
remains of blood-clot still present are usually seen as grey
bands or patches with red centres. Both these and any
pigmented lymph deposits present may be found exclu-
sively or mainly along the edges of the capsular opening.
Almost invariably present with them, though not necessarily
directly continuous with them, are one or more posterior
synechiae. One confidently expects by far the greater part
of this early material to become absorbed, and one is often
surprised at the small effect which it has upon visual acute-
ness. But the fine bands or thin membrane which may
ultimately result from these deposits are often somewhat
centrally situated, and they are apt by contraction to
produce considerable wrinkling of neighbouring capsule.
From the scantiest deposits and those consisting almost
entirely of blood-remains, and recognized as non-in-
flammatory,* it is but a step to others mainly lymphoid,
and found in eyes with somewhat prolonged and intense
ciliary injection, but possibly without the slightest pain or
other symptom of iritis. And from such cases with very fair
central vision, only slightly " complicated," it is but
another step to complete occlusion of pupil and colo-
boma from iritis, reducing sight to moving bodies only.
Many of these cases advance later a further stage to
almost pin-point contraction of pupil and coloboma, with
drawing up to the line of the wound. Together with
this an atrophic and discoloured iris indicates total
posterior synechia, and the existence of a fairly thick
layer of tissue binding together the capsule and remains
of iris. And some opacity of vitreous is probable,
especially if the tension is at all reduced.
* See Bates, New York Med. Jour., July 7, 1900.
AfteivComplications 325
Treatment.
Where vision is obscured by a large quantity of
cortex in the pupil there is, as a rule, no alternative but
to wait for its absorption, hastening this, if possible, by
various means. Whether absorption is hastened by the
administration of drugs is somewhat doubtful. Blue pill
and other preparations of mercury have had a certain
repute, given for this purpose. Possibly any benefit
derived from them in this respect may have been indirect,
through the control of iritis. The use of dionin locally
has been recommended, also subconjunctival salt injec-
tions.*
Especially in eyes where the deep wound gapes a little
under a large conjunctival flap, one may feel tempted
to peel back the conjunctiva at some point ten days or
more after operation, and to express some of the now fully
ripened lens matter. I have elevated the conjunctival flap
sufficiently with forceps to insert a Graefe's knife through
the healing wound for this purpose as late as twenty-two
days after the cataract extraction. One would not care to
do this if there were still any considerable injection of the
eye, or if there were any noticeable conjunctival secretion.
And even so, one would scarcely care to wash out the
cortex with the douche at this early period. But with
proper precautions simple expression through a small sub-
conjunctival opening appears to be free from objection.
Especially in hospital work and where one cannot be
sure of keeping the patient under prolonged observation,
scanty cortex in the pupillary area, with or without blood
remains and lymph deposit, may impel one to early dis-
cission of the after-cataract (see below). One realizes that
most of the opacity is of a purely temporary nature. But
* G. Hirsch, A. f. O., xlii (1900).
326 Cataract Extraction
one has the impression that mild irritation excited by the
lens substance may predispose to organization, rather than
to absorption, of fibrinous deposit, and may tend also to
stimulate the lens cells lining the anterior capsule to
proliferate.
The treatment of after-cataract other than cortical re-
mains is operative. There have been numerous small
modifications in technique and in instruments, but the
outlines of treatment are defined.
The large majority of after-cataracts can be sufficiently
displaced by simple ' needling ' or division with a narrow
knife or knife-needle. Others, more resistant, may be torn
between two needles or cut by scissors. Dense capsular
opacities of overripe cataracts may have to be extracted.
The proportion of after-cataracts for which needling is
unsuitable varies greatly in the practice of different
surgeons and in different hospitals. In Bombay this pro-
portion has been extremely small. It depends (i) on the
amount of iritis and irido-cyclitis complicating the ex-
traction operations; (2) on the number of overripe
shrunken and Morgagnian cataracts met with, and removed
without their capsules; and (3) on the date upon which the
supplementary treatment is generally undertaken. Tough
and inelastic capsules, demanding tearing between two
needles or division with scissors, are much less common
shortly after the primary operation than months or years
later. And there are few capsules already opaque before
the cataract extraction which cannot be removed advan-
tageously with the cataract. It is well before entering
into the details of the treatment to grasp the principles
which govern the application of the various measures. It
is necessary to weigh the risks run against the benefits
hoped for. One must inquire why in some hands even the
simplest of these supplementary operations gained the
After^Complications 327
repute of being more dangerous than the primary extraction
operation. And one must note the precautions which
have sufficed to remove practically all risk from simple
capsulotomy at least (see Kuhnt's results, p. 350, and my
own, p. 346). Disaster is remarkable and disappointing in
so trivial an operation. The accidents which led some
surgeons to give up the treatment of after-cataract almost
entirely were mainly infective, and included both pan-
ophthalmitis and destructive irido-cyclitis. There has
been some trouble also from secondary glaucoma, and
detachment of the retina has been known to follow.
Infection. Devereux Marshall* reported in a list of
512 secondary operations 1*02 per cent, suppurations and
5*58 per cent, slow inflammatory changes, which ultimately
diminished or destroyed sight. Trousseaut reported among
nineteen discissions one panophthalmitis, four cases of
iritis, one of cyclitis, and one irido-choroiditis ; among ten
extractions of capsule two cases of iritis and two of irido-
choroiditis. During the period and at the same hospital
in which these secondary operations were performed, he
extracted 453 cataracts with no suppurations and only
twelve cases of iritis.
It is recognized that infective inflammations have been
mainly attributable to micro-organisms which have gained
entrance through punctures and incisions kept open by
vitreous lying in them. After discission of a membranous
cataract through a corneal puncture, under certain con-
ditions the needle on withdrawal brings with it a fine
thread of vitreous, a few millimetres long, which remains
hanging from the wound possibly for some days. Haab, in
1890, pointed out the nature and the danger of this occur-
rence. And even where no hanging thread is visible, it is
* K. L. O. H. Reports, xiv (1894), 56.
t Ann. d'Ocul., cvii (1892), 338.
328 Cataract Extraction
possible that vitreous, especially if abnormally fluid, may
find its way into the puncture unless the latter close
promptly on withdrawal of the instrument. Thus the
channel for infection from the conjunctival surface is
opened. The gradual backward spread of opacity has
been seen in a band of vitreous thus entangled. That this
has been the main source of disaster in the treatment of
after-cataract is certain, for it is the combination of corneal
puncture with vitreous incision that has proved dangerous.
The mere corneal puncture, as shown in discission of the
complete lens, is harmless in this respect. And the same
appears to be true of vitreous incision, provided the humour
is effectively shut off from connexion with the surface of
the globe. This has been shown fairly well in the posterior
scleral discission of da Gama Pinto and others, in equa-
torial puncture for glaucoma, and so on. In a discission
through the anterior chamber a puncture immediately
behind the limbus may be so readily furnished with a
covering by sliding the movable ocular conjunctiva, that it
seems foolish to neglect this very obvious precaution. Our
Bombay work and Kuhnt's larger experience testify very
strongly to the efficacy of a conjunctival covering in
preventing infection. We could afford to ignore the threads
of vitreous which were occasionally seen on withdrawal
of the knife. Even without sliding the conjunctiva the
insertion of the knife in this situation through vascular
tissues is considered safer than through the cornea. And
the peripheral site is less easily reached by vitreous at
the close of a needling, than if the instrument had been
inserted quite near the opening made in the capsule.
Knapp, however, whose excellent pioneer work did
much to establish the treatment of after-cataract, has
worked always with a corneal puncture placed at some
distance from the limbus. His success is explained by the
After-Complications 329
avoidance of all unnecessary disturbance of the vitreous and
by the use of a satisfactory instrument. He has insisted
upon the importance of cutting instead of tearing the
membrane, and with his needle-knife he has been able to
do this without churning or displacement or deep penetra-
tion of the vitreous. Hence small chance of the vitreous
humour coming forward to the corneal wound. Further,
with a correctly proportioned needle-knife he has commonly
ensured immediate closure of the corneal puncture, as
shown by more or less complete retention of aqueous.
It is obvious that immediate closure of the puncture is
essential if the risk of incarceration of vitreous is to be
excluded. And to this end the opening should be as small
as possible, and made without force. When the blade of
a needle-knife has become worn down a little by repeated
setting, the stem following it has to force an entrance'
through a puncture which is too small for it. Such an
opening cannot be expected to close quickly afterwards.
The same applies if the small wound be distorted by very
free movement of the needle within it.
To sum up, it appears safest to place the puncture
peripherally, partly in the sclerotic, and subconjunctivally.
If corneal, it must be as small as possible, and must be
made with a correctly proportioned sharp instrument,
and must not be unnecessarily enlarged by free movement
of the instrument. And, finally, the vitreous must not be
disturbed more than can be helped.
Inflammatory reaction mostly of low type has been
attributed also to pull upon the ciliary body during the
division of a tough membrane. The awakening of old
dormant mischief appears to explain at least the severer
and more resistant cases, apparently of infective origin.*
* One may suppose that encysted micro-organisms are set free into
the tissues by the stretching ; or more probably that a few enfeebled
33 Cataract Extraction
Naturally this cannot apply when the progress after
the primary operation has been entirely uncompli-
cated.
Particular care is taken nowadays to cut the membrane
always with the least possible display of force. For
this the point and edge of the blade should be of the
utmost sharpness, and many surgeons are careful to cut
with sawing action, and to cut only the thinner portions
of the after-cataract. Where there has been iritis or
irido-cyclitis following the cataract extraction, leaving
organized deposit and more or less adhesion between iris
and capsule, it is not safe to interfere with the result for
some little time after the complete disappearance of ciliary
injection. An irritation-free interval of a few months (two
to six) is laid down as essential. And at the secondary
operation very many surgeons endeavour to avoid pull
upon the iris and ciliary body by dividing the membrane,
often together with iris, by de Wecker's or other irido-
tomy scissors, introduced through a small corneal or
sclero-corneal incision.
The question of glaucoma following upon the needling
of after-cataract is considered later. It may or may not
be of inflammatory origin. It is enough to mention here
that the prophylaxis in this respect includes some of the
precautions against infection and against the relighting of
old inflammatory mischief. And one is careful to avoid all
unnecessary churning up and displacement of vitreous
and pull upon the ciliary body and iris. And quite early
treatment does not appear to be nearly so liable to cause
plus tension as later treatment, as explained below.
micro-organisms still remaining in the tissues obtain suitable material
for their growth in blood and lymph resulting from the slight
traumatism, and develop fresh pathogenic activity, possibly greater
than before.
AfteivComplications 33'
Knapp says :* " Those operations have shown the greatest
reaction glaucoma and cyclitis in which I have endeavoured
to cut dense cords or membranes in the region of the extraction
scar, the most vulnerable part of the aphakic eye. I have,
therefore, avoided disturbing the cicatricial tissue in that
region."
The only things in a needling calculated directly to
cause or predispose to detachment of retina are displace-
ment and breaking up of vitreous, and adhesion of vitreous
to the puncture. In discission with scissors and in
extraction of opaque capsule there may be also loss of
vitreous. The complication is naturally to be feared
chiefly in highly myopic eyes with vitreous opacities, due
either to previous disease of the eye or to loss of vitreous
during the cataract extraction. In highly myopic eyes,
already predisposed to the accident, one hesitates in
connecting the detachment always with the operative
treatment.
In such eyes one is reluctant to perform the simplest
capsulotomy for after-cataract. Even in the ordinary run
of cases the bare possibility of this accident weighs against
the needlings from behind through the vitreous, which
have been practised, and against operations in which
there is any risk of loss of vitreous.
Santos Fernandes f reported four retinal detachments
following the tearing of after-cataract by needles. Morrison
Ray J related a case of immediate detachment on needling.
A considerable vitreous loss had complicated the extraction
operation.
Discission with narrow Graefe or Knife-Needle.
General Considerations. A correctly performed simple
division of an after-cataract being now regarded as prac-
* Archives of Ophth., xxvii (1898).
t Arch, de Offal. Hisp.-Amer., October, 1905.
% Ann. of Ophth., viii (1899), 191.
33 2 Cataract Extraction
tically free from risk, when should it be performed ? And
in which cases is it advisable or necessary ? These two
questions are linked together. For according to the
period at which treatment is undertaken the problem of
the selection of cases presents itself variously.
It may be taken as settled that the interval between
extraction and needling should be as short as possible.
Some surgeons prefer to wait until the eye is perfectly
quiet i.e., free from injection before interfering. This,
however, is by no means necessary. A growing number
of ophthalmologists are strongly of opinion that the dis-
cission should be done as soon as the primary wound is
sufficiently firm to withstand the necessary manipulation.
Mayweg operates on the tenth day, Snellen in about a
fortnight, de Lapersonne in twelve to fifteen days in
some cases, Haab after two or three weeks, Pagenstecher
" as early as possible." Czermak made twelve days the
minimum interval. Knapp recommends treatment within
six weeks. In Bombay we needled generally at the end
of ten or eleven days. In practically all of these early
needlings the eyes were still more or less congested. Pro-
vided the iris appears bright and the globe is free from
pain and tenderness, the presence of considerable ciliary
injection and of moderately copious pigmented deposit on
the lens capsule need cause no delay. They are not to be
regarded as signs of iritis, which, as already stated, would
necessitate a long postponement. Sometimes we had to
postpone treatment because the eye was still quite soft.
This was mostly in cases where too large a conjunctival
flap had led to separation of the sclero-corneal wound,
also after some Czermak operations. But we operated
(always satisfactorily) in many eyes where the tension was
at least i, and where the knife-point in puncturing
indented the globe. Another possible cause for delay in
Aft erv Complications 333
needling is the occurrence of late prolapse of iris, or the
presence of any small prolapse which for some reason was
not at once excised. The treatment of the prolapse should
precede that of the after- cataract, because a reversal of
this procedure would introduce the risk of vitreous escape
on the removal of the iris prolapse.
The great advantage to us of this very early treatment
was that it could be carried out within the ordinary period
of the patients' stay in hospital, or with an addition of one
day only. Thus it was not allowed to reduce the number
of beds available for major operations, and, much more
important, it could be extended to nearly every patient
needing it. It was done as a matter of routine, and the
patients raised no objection. Whereas if they had been
discharged and asked to return for further treatment,
extremely few of them would ever have been seen again,
and the large majority of them would thus by their
ignorance and prejudice have been deprived of the benefit
of the treatment. And the comparatively poor results
which were frequently obtained formerly without the
secondary needling must have tended to discourage
others of their ignorant cataractous friends from seeking
relief.
Apart from all this, early treatment has two important
recommendations, (i) The capsule being now mostly of
normal or nearly normal elasticity, the opening made in it
gapes widely, and the simplest treatment is therefore
effective. Whereas a year or two later loss of elasticity of
the membrane might render a more complicated, and there-
fore less safe, procedure necessary to furnish the desired
opening. (2) The membrane is now often much easier to
divide. Any lymph deposits and remains of blood-clot on
the capsule, which would later organize partly into tough
fibrous tissue, at this early period offer no resistance.
334 Cataract Extraction
Hence there is often much less pull upon the ciliary body
(and upon the iris if there are posterior synechiae) than
there would be later.
There is possibly a third advantage in operating quite
early, at least after cataract extraction with a fairly com-
plete conjunctival flap. Even where there is no visible
separation of the deep wound under the conjunctiva, there
is probably considerably freer filtration through the wound
than there will be later. This must reduce very consider-
ably the possibility of plus tension being excited by the
needling. This may largely account for our practically
complete freedom from trouble in this respect in Bombay.
The drawbacks to operating early are very slight.
Perhaps the most noticeable one is an occasional difficulty
in deciding whether a given case requires treatment or
not whether the benefit, present or future, is likely to be
sufficient to repay the trouble. Some surgeons adopt a
standard of visual acuteness, and operate, as a rule, only
when the result from the extraction is below the standard.
But this can apply only to later needlings. A fortnight or
less after operation it may be difficult, in spite of ophthal-
moscopic examination of fundus and of membrane, to
determine at all accurately the sources of any defective
visual acuteness. We noticed this particularly after intra-
capsular extractions where little or nothing could be found
to account for defective vision. The requirements of the
individual vary so greatly with occupation, temperament,
etc., that no fixed standard can obtain very general
application. And the condition of the fellow eye has some
bearing upon the question. Very good vision in it renders
interference for the slighter grades of opacity superfluous.
Or, if there be ripe or nearly ripe cataract in it, one may
prefer to await the result of the second cataract extraction,
before deciding whether any treatment for after-cataract
AfteivComplications 335
would be advantageous or advisable. If by any chance
this second cataract extraction were unsuccessful, the
question of subjecting the one useful eye to any risk would,
of course, become a much more serious one.
In early treatment one is forestalling future require-
ments. Much of the opacity now present will disappear, and
it is a question to what extent later capsular degeneration
and folding are likely to interfere with vision. Some
operators brush the difficulty aside by needling all capsules
except where the patient declines the operation, or where
the visual improvement is likely to be inappreciable owing
to corneal opacity or fundus changes, or where the treat-
ment is contra-indicated by high myopia or vitreous
opacities, or where the conditions present counsel delay
and perhaps more complicated procedure. If it be admitted
that simple capsulotomy is invariably harmless, there can
be no very serious objection to extending its applica-
tion a little unnecessarily. But it is more scientific to
take steps to learn to recognize the eyes which would
never require, or derive the slightest benefit from, inter-
ference. A systematic examination of old capsules years
after cataract extraction reveals in many cases the
posterior capsule still absolutely transparent and un-
wrinkled. In such an eye it is obvious that the provision
of a sufficiently wide opening in the anterior capsule, at
the time of the cataract extraction, has met the whole
needs of the case. My own somewhat limited observation
has led me to associate these permanently clear posterior
capsules most confidently with cataracts operated upon
while still somewhat unripe or barely ripe. In Bombay
slightly less than a third of our cataract extractions were
supplemented by early needlings, but the proportion would
have been higher if we had always had time to spare for
the performance of the needlings.
336 Cataract Extraction
Capsular treatment is required much less frequently
after cataract extraction in which anterior capsule has
been removed with forceps than when it has been simply
divided with the cystitome. Very many of our need-
lings were for anterior capsule in which the opening for
some reason was narrow or eccentric (Figs. 63-67).
Treacher Collins, by removing anterior capsule with the
lens, reduced the number of his supplementary capsule
operations to 4 per cent. One must here recall the fact
that in some eyes, as already mentioned, the treatment of
after-cataract appears too dangerous to be undertaken.
Another small drawback to early needling is that occasion-
ally it causes a little haemorrhage into the anterior chamber.
One may feel doubtful whether the blood comes from the
FIG. 83. VERY NARROW GRAEFE'S KNIFE, SUITABLE FOR
DISCISSION.
congested sclerotic or from the stretched (or torn) iris.
And at this early period the pull upon iris and ciliary body,
in scarcely recognizable minimal grades of inflammation,
is apt to increase the number of small inflammatory re-
actions, as compared with those one would meet with in
later treatment.
The operator has still to select his instrument. The
choice lies primarily between two types, the one repre-
sented by a very narrow Graefe 's knife, about | millimetre
in breadth, the other by Knapp's knife-needle. The long
Graefe blade, of which only a portion enters the anterior
chamber, is intended to be used with cutting edge directed
backwards only, towards capsule and iris. The short
blade of the knife-needle is introduced completely within
the chamber. Its round stem exactly fills the corneal or
AftetvComplications 337
sclero-corneal puncture made by the blade, and permits of
free rotation of the blade within the chamber without
leakage of aqueous. The Graefe's knife is used mostly for
making a single long cut in the after-cataract. It may be
readily swung around in the sclero-corneal puncture to
make a second incision at an angle to the first one. The
two cuts necessarily converge towards the puncture, and
the angle between them cannot be large, but it is
sufficient for all needs. The knife-needle, on the other
hand, allows of a crucial or T-shaped incision, since a
section may be made with the blade on the flat at right
angles to that made with the cutting-edge backwards. A
much more important difference lies in the fact that the
long-bladed instrument is suited for cutting by free sawing
FIG. 84. KNIFE-NEEDLE.
movements, whereas the short blade is adapted for
dividing the somewhat mobile elastic membrane only by a
sweeping cut, or by very restricted sawing movements.
The blade of Knapp's medium-sized instrument, which he
recommends for most after-cataracts, is 4^ millimetres
long, but only about half of the blade has a sharp cutting
edge. The portion nearest the stem does not admit of
being sharpened. Consequently any but the most re-
stricted to-and-fro movement is apt to bring the blunt
portion of the edge into action, tearing rather than cutting,
and pulling upon the membrane and its attachments.
And we have doubted whether the Knapp's needles, even
when quite new from a well-known London maker, were
quite so sharp as our old Graefe's knives. (We have
used very old cataract knives, ground down to a suit-
22
338 Cataract Extraction
able width, and tapering gradually. These blades are
thin, and easily sharpened.) Either on this account or
because of the difference in mode of cutting, we un-
doubtedly had more reactions after operating with the
cutting needle than with the straight knife. The latter,
with free sawing action, undoubtedly furnished satisfactory
capsular openings with a minimum of pressure. One is
apt, however, unconsciously to enlarge the (sclero-corneal)
puncture while dividing the capsule with the long blade.
In theory it should be easy to avoid this by keeping the
back of the blade pressed against the tissues in the punc-
ture. But in practice, with one's attention given up to the
capsular division, this precaution is not always taken. In
Bombay this enlargement of the sclero-corneal puncture
during sawing occurred not infrequently. On this account,
and because of a liability to pass the long blade deeply into
the vitreous unwittingly while sawing, some operators have
quite unnecessarily discarded the long-bladed instrument
after giving it a trial. A subconjunctival puncture appears
to be quite an adequate guarantee against evil consequences
from vitreous exposure. The knife may enter deeply because
there is nothing in the shape of the blade, at some little
distance from its point, to show the depth of penetration.
I have never had personal acquaintance with any harmful
result of this deep penetration. The vitreous is simply
incised, and not ploughed up, by the knife.
For general use in hospital practice, especially far away
in India, a point against the Knapp's needle is its limited
period of usefulness, owing to the disproportion between
blade and stem brought about by repeated resetting,
already alluded to.
The long Graefe's blade may be used to divide matted
tissues iris, organizing exudation, and capsule where
the pupil is occluded after iritis and irido-cyclitis. It may
AfteivComplications 339
also be expected to cut some tough capsules which seem
likely to prove too resistant for Knapp's needle.
The lighting is of some importance, ordinary daylight
being insufficient to enable one to see the membrane
clearly unless it be unusually opaque. A small electric
hand lamp is commonly made use of, or, when this is not
available, some arrangement for focussing the light from a
gas or oil lamp. An acetylene lamp has been used by
Koster and van Geuns.* Focal illumination in a dark
room affords the clearest view of the after-cataract, and
some surgeons operate always in a dark room. In Bombay
we found that bright daylight was sufficient for the
performance of the needling after examination of the con-
ditions present and of the procedure required, carried out
in the dark room with dilated pupil. Ed. Jackson uses
also a binocular magnifier, with a working distance of
6 inches.
A. Discission with the narrow Graefe's Knife.
The line of the incision being determined within broad
limits by the position at which the narrow knife is entered,
it is convenient to puncture at the outer or lower and
outer t margin of the cornea. One is thus enabled to
operate with the lids separated merely by the assistant's
fingers. It is well, as a rule, to avoid the use of a speculum
for early needlings. For (i) the union of the wound is not
yet very firm, and is therefore not suited to withstand
much strain, such as might be brought to bear by forcible
contraction of the lids upon the speculum. And (2) the
Meibomian glands at this period are commonly filled with
* Med. Tijdsch. v. Geneeskunde, No. 12, 1904.
f In early needling the puncture cannot be much above the
horizontal corneal meridian, owing to the proximity of the healing
wound.
22 2
340
Cataract Extraction
secretion, evidently owing to the prolonged period of
inactivity of the eyelids under the bandage. The pressure
of the arms of the speculum therefore forces out a good
deal of Meibomian secretion, and this is carried over the
surface of the globe by any irrigating fluid used, unless the
glands are well emptied beforehand by squeezing. And
one has to be careful in the manipulation of the lids
required for emptying the glands, not to allow one's fingers
to slip, so as possibly to press upon the globe. Thus in
early needlings the speculum is seldom used except where
FIG. 85. DISCISSION OF AFTER CATARACT WITH THE NARROW
GRAEFE'S KNIFE.
a vertical or nearly vertical section of the membrane is
thought advisable.* It is necessary in this case, because
with finger depression of the lower lid the assistant's
finger would interfere with the correct placing of the knife.
(The use of McGillivray's lid depressor might perhaps get
over this difficulty.) For a vertical section it is necessary
that the patient shall rotate the eye well upwards, and we
found our patients often rather stupid over this much
* In Fig. 85 the speculum is shown in use for an almost horizontal
division of after-cataract, but this is merely for the purpose ,of the
photograph.
AfteivComplications 341
more so than at the time of the major operation. All this
applies only to early discission while the wound is weak,
the lid margins unclean, and the patient nervous.
The conjunctival sac is washed out with perchloride
before the cocain instillation, as for an extraction opera-
tion. Care is taken in this also not to press upon the eye
and not to evert the upper lid, if the extraction has only
recently been performed. (Mucus resulting from the
perchloride irrigation may, if desired, be removed with a
curette.) The pupil has been already dilated for the dark-
room examination, if not still dilated from the after-treat-
ment of the cataract extraction.
In performing early discissions, if ciliary injection be
still present, the anaesthesia produced by cocain alone
is sometimes insufficient. Pain is felt chiefly when the
ciliary attachments are pulled upon in cutting the capsule,
and it may be so marked as to prevent the making of a
long incision. Therefore it is a sound rule in early
needlings always to use some adrenalin preparation before
or with the cocain, for the more complete anaesthesia which
is obtainable with blanching of the eye. Should adrenalin
not have been instilled, and should the patient show signs
of feeling the insertion of the speculum or the seizure of the
conjunctiva by the fixation forceps, it will be well to desist
for five or ten minutes, to obtain the help of adrenalin.
The globe being fixed with forceps at the nasal side, the
point of the knife is engaged in the loose ocular conjunctiva
at a distance of about 2 millimetres from the site of the
intended puncture downward and outward from the
common outer puncture. (In some of our old Indian
patients the conjunctiva close to the cornea about its
horizontal meridian the most exposed part of the con-
junctiva is fixed by old fibrous changes, rendering the
horizontal meridian an unsuitable site for puncture.) The
34 2 Cataract Extraction
conjunctiva is then pushed up in a fold to the corneal
margin, and the point of the knife, directed towards the
centre of the pupil, pushed through the sclerotic to
i millimetre from the corneal boundary, to enter the
anterior chamber. In making this puncture the back of
the blade is forwards, towards the operator, and not
downwards, as shown in the figure.
The point of the knife is passed inwards or upwards and
inwards across the centre of the pupil to the far side of the
dilated pupil or coloboma, and there thrust through the
capsule by depressing the point slightly and continuing its
onward movement a little behind the iris. The movement
of the blade is then reversed. A single withdrawal move-
ment may suffice to make a long incision through a thin
FIG. 86. BRANCHED CAPSULAR INCISION MADE WITH THE
NARROW GRAEFE'S KNIFE.
capsule, and the margins of the slit may be seen to separate
widely, providing a broad perfectly black central space.
Much more commonly some to-and-fro sawing movement
of the knife is required to divide the whole or greater part
of the extent of the visible membrane. The instrument
should be held lightly, to avoid all unnecessary pressure
upon the membrane, and the blade must not be allowed to
penetrate more deeply than necessary into the vitreous.
But the handle of the instrument may have to be raised a
little for sawing close to the near side of the pupil, lest in
the sawing movements the sclerotic be also incised.
The long slit in the capsule usually opens widely. The
blade is withdrawn, and the small operation is at an end.
If the puncture has not been unintentionally enlarged, and
AftetvComplications 343
if the vitreous has not been entered too deeply, there
should be no considerable leakage of aqueous and no
appearance of vitreous in the puncture.
In a few early needlings where the opacity represents
the old capsular thickening of an overripe cataract, and in
a still larger proportion of later needlings, where degenera-
tion of the capsule has reduced its elasticity, or where the
capsule is more or less covered by fibroid tissue, the edges
of even a long opening do not separate widely. It is usually
a simple matter then to swing the point around without
withdrawing the blade, and to push it onwards again to
puncture the membrane afresh at a spot 2 millimetres or
more from the opening already made, and so to make a
short branch incision to join the original one.
This, in my experience, may be relied upon to provide a
sufficiently wide opening. The tongue of capsule between
the two cuts retracts or becomes displaced. A few times,
when dissatisfied with a transverse opening, I have imme-
diately punctured afresh below the cornea,* and added a
vertical incision to make the whole T-shaped. One is
tempted often, instead of puncturing afresh, to attempt to
widen a rather narrow slit in a thin membrane by sweep-
ing the blade around in it. One is tempted especially to
push aside a sheet of quite inelastic membrane, in order
that the advance of vitreous into the gap may keep it
open. Though often effective, at least for the time being,
it is scarcely correct procedure to do anything calculated
to displace vitreous. But even the second puncture of the
membrane, whether made by swinging the point around
or through a fresh sclero-corneal insertion, is not free from
objection on this account. The backward displacement
of the membrane produced by the point of the knife in
* This second incision might, of course, have been deferred for
some days if for any reason this had been thought advisable.
344 Cataract Extraction
puncturing afresh, with the cutting edge directed back-
wards, must force some vitreous through the slit already
made into the anterior chamber.*
Provided a wide opening is secured, the meridian in
which it is made usually matters nothing. The width of
the gap depends very largely upon its length. If only a
rather short single cut were to be made, it would have to
be vertical or inclined downward and inward. The loca-
tion and direction of the incisions are by many surgeons
arranged to avoid tough bands of tissue, but this applies
rather to old after-cataracts than to recent ones, and to
the use of Knapp's knife-needle rather than to the use of
the narrow Graefe's knife. In operating with the latter,
deposits of fibrin, and even old fibrous bands, can be sawn
through safely and readily, and their tendency to later
retraction may be relied upon to widen the gap. The line
of the incision may, therefore, at times be arranged to
cross any dense band at right angles. Where the pro-
jecting angles of the iris at the coloboma are adherent to
the capsule one often prefers to cut between them, to
utilize their lateral pull (under atropin) upon the edges of
the slit. Hence, one not infrequently has to cut vertically,
inserting the knife (subcorijunctivally) below the cornea, t
and passing its point well up in the coloboma. Rarely
some displacement of the line of section may be necessary
on account of corneal leucoma.
Occasionally, in eyes fit for early needling the anterior
chamber is still rather shallow. There appears to be still
* There is not the same objection to a second perforation of the
membrane with the flat of the blade parallel to the iris, as is done with
Knapp's needle. Therefore the latter instrument is preferable for
double cuts ; some increase of the pull upon the ciliary body, by loss
of the sawing action, being probably less to be feared than displace-
ment of vitreous.
t Fixation forceps applied at the inner side of the cornea, as for the
transverse cuts.
After<Complications 345
some leakage through the healing wound, but not so
much as to make the globe too soft for operation. Some
care is needed to direct the point of the knife slowly
through sclerotic and cornea into the angle of the chamber.
The puncture is easier in these eyes with a Knapp's
needle, as the blade can be inserted on the flat. These
have been the only eyes in which I have ever felt that
there was any real (though very small) advantage in using
an instrument which could be rotated on its axis.
Many of our patients were sent out of hospital with
the eye bandaged up for a day. For patients kept in
hospital the wire shade should suffice.
Complications.
A. At the time. i. I failed to divide one extraordinarily
elastic membrane.
The tissue was scarcely at all opaque, but a good deal
folded. And since the attempt at division produced a reaction
lasting several days, I did not try again.
I refrained altogether from interference with another
peculiar capsule, fearing the same trouble, or possibly detach-
ment of retina in case the discission were accomplished. It
was in a girl, after linear extraction. The lens had been
transparent, but operation had been undertaken for myopia
and for a small, dense posterior polar opacity. This opaque
patch was left in the centre of a distinctly tremulous transparent
posterior capsule.
2. Rarely a tough membrane may tear near its inner, or
upper and inner, attachment when the pressure of the
knife is placed upon it to perforate it. This may be
partly due to a slightly blunt knife, or to the application
of too much backward pressure with too little onward
movement of the blade. Otherwise it indicates that the
case would have been better dealt with by the double
needle operation, or more complicated procedure. The
346 Cataract Extraction
large central leaf may often be considerably displaced
outwards and downwards by the knife, at the cost of
only moderate disturbance of vitreous ; but usually it
springs back sufficiently to cover the centre of the pupil.
It is not sound practice to make repeated attempts to
depress the membrane in the vitreous. Should the vision
obtained through the irregular and eccentric opening be
insufficient, the offending membrane may be extracted later
or divided by scissors, though with almost certain loss of
some vitreous.
3. In a small percentage of cases slight haemorrhage
occurs. Next day a little blood may be found at the
bottom of the anterior chamber, with some turpidity of
aqueous. The reduction in vision thus produced is very
transient. This complication occurred in one of our dis-
cissions which was not at all ' early.'
B. Later. i. Very occasionally either a repetition of
the same operation at a different angle, or a tearing apart
with two needles, may be needed for an inelastic capsule,
the slit in it having failed to remain sufficiently open.
This is especially likely to happen where the cataract has
been Morgagnian.
2. Inflammatory reaction should be rare, and should
yield quickly to treatment.
The only acute reaction noted in Bombay of late years was
in a case where the cataract was of traumatic origin, and
where some iritis had followed the original injury. The
reaction subsided in ten days, with satisfactory improvement
in vision.
In another patient early discission was followed by chronic
nodular iritis, lasting a few months. It was probably excited
more by the extraction operation than by the needling. The
eye had been inflamed several years before. And the recru-
descence of apparently tubercular mischief after so long an
interval was somewhat interesting. There was no evidence of
After'Complications 347
tubercle elsewhere. The nodules, three in number, which
formed in the lower part of the iris subsided, together with the
iritis, leaving the capsular opening sufficiently wide and clear
for very fair vision.
Apart from these cases only a few trifling reactions have
occurred in our practice, passing off in a few days under
treatment by atropin drops, with perhaps warm fomenta-
tions.
By the subconjunctival puncture we have been secure
against fresh infections, such as might lead to suppuration.
Once, years ago, I had a panophthalmitis after puncturing
through the cornea. Vitreous had entered the small
wound. Da Gama Pinto, puncturing through the cornea
with a narrow Graefe's knife, reported nine incarcerations
of vitreous in 198 discissions. In four of these eyes sup-
puration occurred, and two of the eyes were lost.
In eyes affected by chronic uveitis, whether in any way
dependent upon the secondary operation or not, the cap-
sular opening may gradually become occluded by in-
flammatory deposit. Some rare instances of membrane
formation in the capsular opening have been seen in eyes
quite free from irritation (some of them highly myopic).*
3. I can certify that after nearly all of our opera-
tions for after-cataract in Bombay of late years, and
certainly in all where there was the slightest suspicion of
trouble, the tension of the eye was tested. It was only
once found a little elevated, and this rise disappeared in a
few days without treatment. We performed 251 early need-
lings, in addition to 33 late needlings within the last fifteen
months of my work in Bombay.
McGillivray,! impressed with the importance of cutting by
sawing movements, has designed a curved knife-needle with
* A. von Hippel, A.f. O., xlix, 2, 387.
f Trans. Oph. Soc.^ xxvii (1907), 108.
34$ Cataract Extraction
long convex cutting edge and with cylindrical stem. The
incision in the membrane is made entirely with the convex
edge. He prefers an oblique incision from above, downwards
and a little inwards.
Schnabel * used either a narrow Graefe's knife, or a similar
blade, sharpened at both edges for 8 millimetres from its
point. The introduction and the cutting were done with the
flat of the blade parallel to the iris.
B. Operation with Knapp's Knife- Needle.
Knapp prefers the knife-needle, "because needles cutting
on both sides can for equal sizes not be made so sharp. "t
The straight instrument is preferred because " curved
needles are difficult to introduce through the cornea, and
still more so through the capsule. . . . The straight point
transfixes the membrane with greater ease, less pressure,
and therefore less tearing at the ciliary processes." If there
are no special indications he inserts the needle, with cutting
edge backwards, in the horizontal meridian of the cornea
3 millimetres from its margin. A horizontal incision 4 or
5 millimetres long is made in the capsule. And then with
the needle rotated to present the cutting edge downwards
the membrane is transfixed above, and a short vertical cut
is made downwards to join the horizontal incision. The
addition of a similar short vertical cut below provides a
crucial opening. The first cut is made by a simple with-
drawal movement of the instrument, the secondary ones
by sweeping action. The incisions have to go through the
softest parts of the capsule ; hard and inelastic bands and
patches should not be attacked. " Two incisions may suffice,
in the shape of a T, or the one crossing the other at an
acute angle."
* Elschnig, Wiener Kl. Wschr., ix (1896), No. 53.
f Norris and Oliver's ' System,' iii, 812.
After^Com plications 349
It may well be that the central crucial or T-shaped
opening with Knapp's needle is particularly suited to his
work. The untouched central capsule, after simple ex-
traction with ' peripheric splitting ' of the capsule, must
give fairly uniform and accurate results from comparatively
short incisions. On the other hand, the central and para-
central adventitious bands, lying along the margins of the
ordinary central capsular opening, as in our work, suggest
the need for freer division. Knapp tabulated the vision of
seventy eyes before and after needling. The amount of
vision was more than doubled by the operation. It
averaged slightly less than one-fifth before, two-fifths after
treatment.
Should a corneal puncture be used, after Knapp, and should
vitreous enter it, any hanging thread would be cut off. Similar
threads unconnected with vitreous, and representing fila-
mentary keratitis, have been mentioned in connexion with
discission punctures (see Haab, ' Operative Ophthalmology,'
p. 168).
Ed. Jackson,* using Knapp's knife - needle, makes two
incisions, meeting one another in the form of a V, each made
by sweeping movement. The blade is inserted on the flat and
kept so i.e., with cutting edge downwards, not backwards.
The puncture is at the limbus, down and out. The nearer limb
of the V is cut first. Stress is laid upon the mechanical advan-
tage of the peripheral insertion in the longer leverage obtained.
" The same length of sweep of the knife edge will be obtained
with one-half of the twisting of the shank in the puncture
less than one-half of damage to adjoining tissues." The short
sweep obtainable through Knapp's corneal puncture may
accomplish almost nothing, owing to elasticity of the capsule,
and owing at times to the near approach of the capsule to the
cornea through leakage of aqueous beside the needle. This
leakage may occur with a perfectly proportioned instrument,
owing to the pressure exerted upon the rigid corneal tissue in
the swinging movements of the needle. With the peripheral
* Arch, of Ophth.^ xxxv (1906), 127.
35 Cataract Extraction
insertion there may be some slight difficulty in accurately
locating the capsule puncture, but the difficulty is too trifling
to be of practical importance.
Czermak* used Knapp's needle, inserted at the limbus, to
make usually a single long incision by sawing action. The
opening was made T-shaped in inelastic capsules.
Kuhnt f uses Knapp's needles with stems bent to admit of
their (subconjunctival) insertion at any selected point of the'
limbus. He also is satisfied with a single incision 7 to 8 milli-
metres long in thin capsules. For a T-shaped opening he
uses two needles, inserted rather close together, with cutting-
edges in opposite directions. The second portion of the
incision is made by the two edges approximated to cut with
scissor action. Where there are posterior synechiae, the two
cutting needles are made to penetrate the membrane together
centrally, and cut in opposite directions towards the periphery.
Special forms of incision are designed also for cases in which
there has been loss of vitreous, and where the capsule has
healed in the wound. In an experience of about six hundred
discissions there were no losses, and the vision improved in
nearly every case. In the last hundred cases there was a
improvement in visual acuity from 23-8 to 58-7.
De Lapersonne and Poulard .{ have divided secondary
membranes from behind by a sickle-shaped needle introduced
above, i to 2 millimetres above the summit of the flap made
in the extraction operation. They operated from the eighth to
the fifteenth day after the extraction.
Posterior scleral discission was practised largely by the old
Vienna school, and later by Da Gama Pinto. A cutting
needle or narrow knife was inserted in the region of the ora
serrata, 6 to 8 millimetres behind the limbus, and passed
forward through the vitreous to transfix the capsule at the
near side. The point of the instrument was then pushed on
parallel to the membrane, and again passed through the
capsule from in front at the far side of the pupil, and the
division completed by sawing movements. In the light of
* Die Augen. Op., S. 864.
f Zeitsch.f. A.,\ (1899), 151 and 260.
J Tenth International Congress, Lucerne, 1904.
Ann. d'Ocul., cxvii (1897), 22.
After'Complications 351
what has been said above upon unnecessary disturbance of
the vitreous, further detailed description of the procedure and
discussion of the suggested dangers appears superfluous
risk of haemorrhage into the vitreous, dislocation of the capsule
into the vitreous, danger of detachment of retina from healing
of vitreous in the puncture. Pinto in 133 operations improved
the vision in ninety-five, and reduced it in seven cases. In
three cases glaucoma followed. Noyes* considers that this
treatment should be adopted one to three months after the
original operation, where a small and undilatable pupil
(whether simply rigid or bound down by synechiae) does not
provide sufficient room for ordinary discission of the capsule
through the pupil. In such cases, however, no particular
harm follows limited incision of the iris.
Opinions upon the treatment of the thicker, denser, and
inelastic forms of after-cataract, including those resulting
from iritis and irido-cyclitis, vary greatly. All of these
after- cataracts are divisible primarily into those which can,
and those which cannot be cut with a narrow Graefe's
knife. The latter membranes may be torn, or divided with
scissors, or extracted. The former group includes the
results of iritis and irido-cyclitis after cataract extraction,
even to complete occlusion of pupil and coloboma, and
matting together of iris and capsule by organized exuda-
tion.
I have been in the habit of practising simple division of
such membranes with the narrow knife, cutting the iris
freely together with the tissues behind it when necessary.
This is not commonly considered sound practice, for the
pull upon the ciliary body is considered to be too great.
Further, on this account only one incision must be made
at a time. If there be dense occlusion of pupil, the single
incision in the matted tissue does not gape well. A
second incision at right angles to the first may be needed
* Medicine, January, 1900.
35 2 Cataract Extraction
to make the whole T-shaped, as soon as the eye has
become perfectly ' quiet ' after the first attempt. My ex-
perience with fully occluded pupils has been small. So far
I have not seen any bad results from this treatment. The
openings have not become closed by blood-clot or lymph,
as they are said to do sometimes. I have made the
primary incision vertical, because it has sometimes sufficed
alone, even though narrow. But it is usually made
horizontal to obtain the benefit of the vertical pull of the
stretched iris. It is questionable whether the complete
division with a really sharp knife entails any more pull upon
the ciliary attachments than any other mode of cutting, for
in order to be cut with scissors the matted tissues must be
first pierced, to allow of a blade of the instrument being
inserted behind the membrane. If, as is usual, this puncture
be made with the keratome or scissor point, this must
almost certainly need as much pressure upon the membrane
as the long incision with the much sharper narrow knife.
And the scissor operation has the serious drawback of
very frequently allowing vitreous to enter the wound, and
perhaps to escape through it. This disadvantage is not
shared by the simpler operation. A fair result may be
hoped for by operation after severe irido-cyclitis, provided
the tension of the globe has not been much reduced, and
provided the field of projection of light is good. In testing
this field allowance must be made for extreme upward
displacement of the pupil. One is surprised to note how
light penetrates through a densely occluded pupil.
Haab * supports the iris by two Bowman's needles, and cuts
between them. The needles are introduced one after the
other from the temporal side through cornea and iris, parallel
to each other and 3 millimetres apart. They are then
held by the assistant, who also fixes the globe. The cutting
* ' Operative Ophthalmology,' p. 172.
AftervComplications 353
is done with a Knapp's needle,* introduced in the horizontal
meridian near the nasal margin of the cornea.
Galezowski,t in cases of after-cataract with iritic adhesions,
has employed two needles with sickle-shaped blades, one
nearly straight, the other more curved. The membrane is
perforated twice by the point of the more curved instrument,
first on the near side from before backwards, and on the far
side of the pupil from behind forwards. The two needles are
introduced through the cornea, and either may be used to
support the membrane while the other cuts with sawing
action. Thus the cutting may be done from in front by the
straight needle or from behind by the curved needle.
Kugel I operates upon these cases with an ordinary Graefe's
knife, introduced at the outer margin of the cornea, with its
edge directed down or up. The iris is supported by a bent
needle passed behind the iris from the inner corneal margin.
The cutting is confined as far as possible to the site of the
former pupil, several small punctures being made, leaving,
perhaps, only isolated threads crossing the pupillary area
which may admit of extraction. For this extraction the
corneal opening made with the knife is enlarged slightly to
admit of the entry of forceps.
In the practice of various surgeons the remaining pro-
cedures receive a much wider application than is absolutely
essential. Opinion differs chiefly with regard to after-
cataracts which are inelastic and somewhat tough, but
which still admit of incision with cutting needle or narrow
knife. Tearing between two needles is evidently used as
routine procedure for ordinary after-cataract in some
places. And Panas practises extraction of the majority
of them.
It may be stated broadly that in tearing the membrane
the use of two instruments is necessary, the one to counter-
act the pull of the other, and to prevent the pull being
* Better would be a narrow Graefe's knife.
t Rec. (TOphf., October, 1896, p. 587.
I A.f. A., Ixiii(i 9 o6), 3.
Elliot, hid. Med. Gazette, xli (1906), 165.
23
354 Cataract Extraction
transmitted to the ciliary body. The simplest procedure
is the Double Needle Operation.* The two needles can
be inserted subconjunctivally on either side of the cornea
to penetrate the centre of the capsule at the one opening,
and to tear the membrane from the centre outwards by
separation of the needles in various directions. It has an
obvious advantage over all operations which require definite
incisions for the insertion of instruments, in being free
from the risks attending possible impaction of vitreous in
the wound and loss of the humour. The objection to the
method lies in a tendency to ploughing up and displace-
ment of vitreous. It is, therefore, a distinctly severer
operation than simple capsulotomy. If the needles be
inserted at the two ends of a corneal meridian, their
points, when separated in the capsular opening, swing
directly backwards into the vitreous, often carrying one or
other leaf of capsule back also. Their points of insertion
may be placed at some distance from a corneal meridian,
so that the needles converge obliquely to the capsular
puncture from above. The separation of their points then
does not plunge them deeply into the vitreous. The
needles remain still nearly parallel with the surfaces of iris
and capsule. But the separation is apt to be less effective in
tearing, in that it does not admit of being repeated in
such varied directions as when the sclero-corneal punc-
tures lie in a corneal meridian.
The method is suited to old after-cataracts, inelastic,
and somewhat dense from capsular degeneration and from
the development of fibrous bands and membrane, with or
without posterior synechiae. Also for many capsules of
overripe cataracts, including Morgagnian and those with an
anterior plaque which is not very dense, at least at its centre.
* Bowman, Medical Times and Gazette, October 30, 1852 ; and
Medic.-Chirurg. Transactions, 1853, p. 315.
After^Complications 355
Techniqite.The preliminaries are the same as for
division with the narrow knife. The speculum is inserted
and the operator stands behind the patient's head with a
Bowman's stop-needle in each hand. The globe is fixed
below by the assistant. If the membrane appears dense,
the needles are inserted subconjunctivally at each end of
the horizontal corneal meridian, or near it. Each needle
is directed parallel with the surface of the iris toward the
FIG. 87. BOWMAN'S STOP-NKEDLE WITH CUTTING SIDES.
middle of the dilated pupil. The one at the nasal side of
the eye is inserted first, the globe being rotated outwards
to allow of this. Either needle is thrust through the
thinnest part of the centre of the capsule, and followed by
the other at the same point, or quite close to it. Since
the angle at which each needle meets the capsule from the
limbus puncture is very acute, the point naturally does
not penetrate the membrane so easily as if it had entered
FIG. 88. DISCISSION WITH Two NEEDLES.
nearer the centre of the cornea. One needle is therefore
used to fix the tissue, while the opposing point is thrust
through. If any difficulty is experienced in puncturing, a
small central tear may be made by separating the points
caught in the tissue. The points are then separated widely
by bringing the handles of the instruments together in
front. The width of the capsular slit thus made is tested by
allowing the points to come together again. Usually they
232
356 Cataract Extraction
need separating again as much as possible, at least once,
in another direction to secure a wide opening. The leaves
of the torn capsule are kept apart more by the forward
projection of vitreous than by the tension of the membrane.
But the vitreous must not be unnecessarily displaced.
Only where the membrane is fairly thin, as, for example,
in many Morgagnian cataracts, may the limbus punctures
be both placed above the one up and in, the other up
and out. With both needles directed to the capsule from
above neither can be quite so useful in fixing the mem-
brane to resist the thrust of the other needle as when they
meet from directly opposite points. There is, therefore,
some loss in efficiency in this respect, as well as in the
tearing apart of the capsule, to make up for the gain in
safety from the reduced disturbance of vitreous.
The displacement of vitreous in this operation must intro-
duce a slight risk of exciting increase of tension, or possibly
detachment of retina (see Santos Fernandes' experience,
already mentioned). Our experience of the method in Bombay
was small. A rise of tension followed in two of our cases.
Curiously, both cases were in children. One was relieved by
leakage of aqueous through the needle punctures on manipula-
tion of the eye.
One must be prepared, also, rather frequently to find the
margins of the opening in the inelastic membrane approximat-
ing more or less, though not, in my experience, so much as to
necessitate extraction of the capsule. The method has been
practised a good deal in England. Bowman punctured
through the cornea well within the limbus. Streatfield used
two needle-hooks. Knapp has used two of his needle-knives
in place of Bowman's needles.
Stilling* has operated similarly with two harpoon-needles,
introduced at the limbus. If it were desired to extract the
membrane, these needles, introduced through small incisions
made with a Graefe's knife, sufficed to draw out the tissue.
* Centralbl. f. prakt. Augen., September, 1899, S. 261.
After^Complications 357
Pfliiger* modified the needles to render them easy of with-
drawal.
Some operators! have used a cystitome introduced through
a small marginal puncture to cut or tear the capsule.
In Agnew's J operation both cornea and capsule are pierced
with a broad needle near the upper margin of the cornea.
This needle is retained in position while a wound is made at
the lower corneal margin, and through this a small sharp
hook introduced. The point of the hook^ is inserted into the
capsular opening occupied by the broad needle, and traction
put upon the hook to tear the membrane. The broad
needle defends the ciliary region from the traction. As much
tissue is drawn out of the wound as possible, and cut off by
the assistant with scissors.
Noyes has described a similar operation with two hooks
pulling against one another. The hooks are introduced
through limbus puncture and counter-puncture, and through a
central capsular opening, made with a Graefe's knife.
Discission with Scissors. This is applied for the varying
results of irido-cyclitis i.e., where the after- cataract is fairly
dense and more or less attached to, or united with, the iris.
The operation is a capsulotomy or irido-capsulotomy, accord-
ing to the degree of occlusion of pupil and of coloboma, and in
performance is almost identical with de Wecker's iridotomy.
The eye having been prepared as usual, an incision is made
5 to 6 millimetres long, with a keratome, at the limbus or a
little within it. Should the cataract extraction have been com-
bined, and should the pupil be not much displaced upwards, the
incision is placed above in front of the old cicatrix to allow of
vertical section of the membrane. If, however, there has been
no coloboma made, as after simple extraction and when the
condition results from a traumatic cataract, or if the pupil and
coloboma has been drawn up|| to the line of the old wound,
the corneal incision may be made at the outer side to allow of
horizontal division of the membrane. Sym's blade (Fig. 89)
* Ophth. Klinik, vi (1902), No. 13, S. 193.
t Prouff, Rev. Clin. d'Ocul., novembre 3, 1884.
% Noyes, Ophth. Hasp. Rep., vi (1869), p. 209. Loc. at.
|| The vertical traction of the iris may then be expected to open the
slit in the membrane.
Cataract Extraction
is suitable for the section. The fixation of the globe is on
the opposite side of the cornea to that selected for the incision.
The knife is introduced into the chamber slowly parallel with
the iris. It is then nearly withdrawn to allow aqueous to
escape and the diaphragm to come forward, and the point
again thrust onward to pierce the capsule and, if necessary,
the iris, close to the corneal wound. The blade being then
withdrawn, de Wecker's scissors are introduced. One
FIG. 89. SYM'S KNIFE (FULL SIZE).
blade is passed in front and the other behind the membrane
through the small puncture, to make a central incision, long
or short according to the apparent needs of the case, as
indicated by the thickness of the tissue and the size of the
pupil and coloboma, and the appearance of the iris.
Should a single incision fail to gape, a second is made at an
angle to outline a >- shaped section. The tongue of tissue
included between the two cuts may be expected to shrink
FIG. 90. BROAD IRIDO-CAPSULOTOMY (LINE OF INCISION IN
IRIS AND CAPSULE).
slowly if it does not at once retract sufficiently. The tongue
of tissue may be made broad by using a broader keratome and
placing the two diverging cuts at each end of the (longer)
incision made by the keratome in the diaphragm (Fig. 90)
instead of from its middle.
The after-cataract may be pierced by the sharp blade of
de Wecker's scissors, if preferred, or by a Graefe's knife,
instead of by the keratome for the single or > -shaped section.
Schweigger* makes a smaller incision, and uses scissors
* A.f. A., xxxvi (1897), S. i.
After -Complications 359
like de Wecker's, but reduced in size to lessen the risk of
vitreous escape.
The main objection to this operation viz., the considerable
risk of incarceration and loss of vitreous, has been already
mentioned. The danger of infection from this cause, however,
might be diminished or removed by inserting the knife sub-
conjunctivally through sclera and cornea instead of simply
through the cornea. This should increase the difficulty of
the operation but slightly.
Apart from accident (infection or retinal detachment, due to
vitreous prolapse), and from insufficient retraction of the
membrane, and from subsequent closure of the opening by
recurrent inflammatory changes, the visual result is often poor
from vitreous opacities and other changes in the eye due to the
previous iritis or irido-cyclitis.
Strawbridge * designed a scissor-like instrument, with fine-
pointed blades, 8 millimetres long, cutting at their outer edges.
The closed instrument was used to pierce the after- cataract,
and the opening was enlarged by separation of the blades, as
in discission with two needles. Blades cutting at both edges
were also used.
Lewinsohn f later used scissors like de Wecker's, but with
blades rather narrower and shorter, and cutting at their outer
edges. These' closed blades can be thrust through the uncut
cornea like a needle. There is, however, little advantage in
this certainly no guarantee against the entrance of vitreous
into the puncture.
Where the iris is atrophic, and therefore devoid of resiliency,
partial Excision of the matted tissues iris, capsule, and
inflammatory membrane has been held to be necessary. This,
however, appears doubtful, for slow retraction of a severed flap
or tongue of the diaphragm should take place. Even the pro-
jecting angles of. tissue formed by a T-shaped division com-
monly retract a little, in spite of a dense substratum of new
fibrous membrane. And excision operations are extremely
likely to lead to considerable loss of vitreous in eyes quite
unfit to bear the loss. Hence the results obtained by excision
have been very uncertain.
* Amer. Journal of Med. Science, 1877, p. 449.
t Centralbl. f.prakt. Augen., Juli, 1899, S. 207.
360 Cataract Extraction
De Wecker designed two methods (iritoectomie) of operating,
shown in the accompanying figures. In the first method an
upper corneal incision, 6 to 8 millimetres long, made with a
keratome, is followed by a parallel incision through the dia-
phragm, after emptying the anterior chamber of aqueous.
Then two cuts are made by de Wecker's scissors, as in irido-
capsulotomy, but the cuts converge instead of diverging.
Thus a triangular piece of membrane is isolated, and may be
withdrawn by the scissors or by iris forceps. Its apex should
be a little below the centre of the cornea. In making the
second of these cuts, the leaf of membrane needs to be drawn
tight with forceps.
FIG. 91. FIG. 92.
DE WECKER'S IRITOECTOMIE, Two METHODS.
In Fig. 91, <i, b, corneal and iris incision ; c, e, d, triangular portion
excised.
Second Method. Where the pupil and coloboma are drawn
up to the scar (above), and the diaphragm is thick and dense,
the incision through cornea and diaphragm is made below by
puncture and counter-puncture with a narrow Graefe's knife.
The aqueous is allowed to leak away as soon as the corneal
puncture has been made. There may be considerable difficulty
experienced in dividing the tissues with the scissors.
Punches have been designed for the cutting away of portions
of tough membrane. Stevenson* described an improvement
upon an instrument devised by Kruger-Krjukow. Vacher
has used a somewhat similar instrument.
Knapp describes an operation, indo-cystectomy, in which he
draws out iris and pupillary membrane by means of a blunt
hook, after section, to be excised by scissors.
Extraction. There is only one form of after-cataract
which appears almost to demand this treatment. It is
* Ophthalmology, January, 1906.
Aftei>Complications 361
where a large dense anterior plaque has for some reason
been left behind. But in Europe such capsules must be
decidedly rare. And when met with they are likely to
escape extraction with the cataract only under exceptional
circumstances,* especially now that an impulse has been
given to intracapsular extraction by Smith of Jullundur.
Smaller anterior plaques admit of ready displacement
sufficient to clear the pupil, and thin ones admit of being
torn by two needles. Extraction of after-cataract, at one
time considerably practised, has been brought somewhat
into favour again of late years by Panast and de Wecker
for all capsules which are not too thin to permit of extrac-
tion, and not broadly adherent to iris (a few fine synechise
are of no consequence). Panas finds that the conse-
quences which might be supposed to follow cyclitis from
pull on the ciliary body, vitreous opacities, glaucoma, and
detachment of the retina do not occur even so frequently
as after simple discission (!). Apart from the risk of pro-
lapse and loss of vitreous, it is a great drawback to the
treatment that it cannot follow early after the cataract
extraction. An interval of three to six months must be
allowed for all the reaction to have passed off and, accord-
ing to Panas, for the membrane to acquire firmness. Not
many patients can be induced to return for a second
operation after so long an interval.
Technique. The pupil must be dilated, and the eye prepared
as usual.
An incision is made with a keratome above, 5 millimetres or
more long (8 to 10 millimetres, Panas), either i to 1-5 millimetre
* I have had to leave them behind at the time of the cataract
extraction on account of loss of control by the patient during operation,
and in other cases because I did not care to risk prolapse of vitreous
when the conjunctiva was unhealthy. I have not met with them in
eyes with vitreous tension.
f Arch. d'Opht., xxii (1902), 149.
362
Cataract Extraction
within the limbus, or subconjunctivally just behind the limbus
(the conjunctiva being pushed downwards by the knife from a
point i -5 or 2 millimetres above the cornea). The purely
corneal site is to enable the operation to be performed without
iridectomy if a coloboma has not already been made. The
more peripheral site necessitates a coloboma, either dating
from the primary operation or made at this time, to facilitate
the seizure and removal of the membrane, and to guard against
prolapse or incarceration of iris. But there seems little doubt
FIG. 93. PANAS' CAPSULE FORCEPS.
it should always be chosen. One has no right to expose the
eye to the risk of vitreous being left uncovered in the wound.
A small iridectomy may be useful, also, to free the capsule
from one or more small iritic adhesions.
Suitable capsule forceps must be selected, or an attempt
may be made with a sharp lens hook. There is no difficulty
in seizing a dense anterior plaque with any kind of capsule
forceps. But if the whole capsule is to be extracted, an
instrument with fairly numerous teeth is needed to give a firm
FIG. 94. EXTRACTION OF CAPSULE.
hold and to guard against slipping of the forceps and against
tearing of the membrane.
In dealing with more ordinary after-cataracts, Liebreich's
and de Wecker's forceps, with few teeth, have been used
mainly for partial extraction, the central portion being seized
and often torn away as in operating for cataract extraction.
Panas' forceps afford a large firm hold. One blade, pointed,
is thrust through the capsule and passed down close behind it
in the vitreous. The membrane is then seized between this
and the other blade in front. Slow traction with slight lateral
After-Complications 363
movements is used to free the opaque capsule gradually from
its zonular attachments. An impatient pull is likely to tear
the membrane and to bring vitreous forward into the
wound.
If a dense after-cataract resist considerable traction, it is
recommended to alter the procedure to a capsulotomy with
de Wecker's scissors, especially where there are posterior
synechiae, lest irido-dialysis be occasioned.
Should the capsule tear and the opening be insufficient, it is
recommended to enlarge the opening by de Wecker's scissors
introduced through the wound. Should the capsule be adherent
to the scar of the cataract operation, it is cut away with scissors
close to the wound.
Cortex imprisoned between the two layers of capsule may
be set free into the anterior chamber by the manipulation of
the forceps It may be removed by irrigation, if the diaphragm
in front of the vitreous is still intact. Otherwise some slight
attempt may be made to express it.
The sharp hook, like forceps with few teeth, is apt to tear
the capsule instead of pulling it away from the zonule. The
point is passed down to piece the lower part of the membrane
at a comparatively thin spot. Its hold may perhaps be
strengthened by twisting the instrument on its axis in an
attempt to roll up the capsule. Should the capsule tear after
being considerably loosened and displaced, ordinary iris forceps
may serve to withdraw it ; otherwise capsule forceps may be
needed.
Tearing of the membrane may interfere with anything
approaching complete removal of it, but repeated attempts to
seize torn capsule embedded in vitreous are not advisable if a
fairly central incision has been made.
Complications. There may be prolapse or incarceration of
iris if iridectomy is not done at the time or at the primary
operation. Loss of vitreous is frequent. It is practically
certain to take place should the operation be undertaken after
an unsuccessful discission, by which the diaphragm has already
been perforated, and vitreous brought forward into the anterior
chamber.
364 Cataract Extraction
DETACHMENT OF THE RETINA.
Loss of vision from this complication is feared especially
after large escape of vitreous. The complication has also
been attributed to healing of the vitreous in scars, whether
following actual loss or not. It is then due to the forma-
tion of bands in the vitreous, connected with the scar. It
has also been ascribed to the mere displacement and
' ploughing up ' of vitreous in some discissions. And in
highly myopic eyes it seems that some of the retinal
separations which have followed removal of the lens, if due
to the operation at all, must be ascribed to the uncompli-
cated operation, the diaphragm consisting of zonule and
posterior lens capsule having been kept intact. In highly
myopic eyes it appears advisable to refrain from inter-
ference with posterior capsule, at least in the present state
of our knowledge with regard to the complication. The
accident may happen while the patient is in hospital, or
only after a considerable interval. Its early recognition
may be difficult owing to after-cataract, and possibly owing
to vitreous opacities. Lately I observed a case which
underwent spontaneous cure.
A fortnight after a Czermak's subconjunctival extraction a
prominent grey opaque retinal detachment was found down-
wards and outwards. The vision was fingers at 8 feet with a
suitable lens. Ten days later the detachment was very shallow
and folded, and the retina grey only in the ridges. V^^.
Shortly afterwards no detachment was made out.
Complete separation of the retina is one of the conse-
quences of protracted irido-cyclitis, but in itself is of
little consequence, as vision is otherwise destroyed.
CHAPTER VI
COMPLICATED AND SOFT CATARACTS
Cataract with glaucoma Cataract secondary to irido-cyclitis^-
Removal of the transparent lens in high myopia Dislocated
lenses The extraction of soft cataract Suction.
CATARACT WITH GLAUCOMA.
THE shallow anterior chamber commonly seen with the
swollen liquefying form of cataract has been repeatedly
referred to in the foregoing pages. As might be anticipated,
this shallowing sometimes causes, or assists in causing,
glaucoma.
In Bombay the triple association is fairly frequently
seen of recent congestive glaucoma with swollen cataract
and very shallow anterior chamber. And the connexion is
emphasized by the following considerations: (i) These
cases include, perhaps, the majority of the subacute
glaucomas seen there, the great bulk of primary glaucoma
in India being distinctly chronic, simple, or congestive.
(2) Other forms of cataract associated with recent attacks
of congestive glaucoma are decidedly uncommon. (3) The
shallowing of the anterior chamber is frequently extreme.
Where comparison can be made with the chamber of a
fellow eye as yet uninfluenced by glaucoma, by cataract,
or by cataract extraction, that of the glaucomatous eye is
generally distinctly the shallower of the two. In a few
365
366 Cataract Extraction
cases the difference in depth is inappreciable ;* but it must
be borne in mind that the dilated pupil and altered iris of
the affected eye prevent very exact comparison between
the two eyes. This difference in anterior chambers, though
not quite exclusively the property of these cataractous
glaucomas, is sufficiently so to remain their chief dis-
tinctive feature. During the period of collection of the
statistics given below it was found but five times in
glaucomatous eyes without cataract, or with only incipient
cataract. In ordinary congestive, subacute or chronic f
glaucoma the relation is commonly reversed; the chamber
of the affected eye is shallow, but less so than that of the
unaffected, but predisposed eye. (See Czermak, quoted in
the Ophthalmic Review, xvi [1897], 199).
It is by no means contended that the cataract formation
always takes a very large place in the etiology of these high
tensions. For the large majority of such swollen cataracts
pass through their whole course without altering the tension
of the eye at all. And of the thirty-three of these cataracts
associated with recent congestive glaucoma, of which I have
notes,]: five had advanced to the Morgagnian stage, though in
four out of these five cases the glaucoma was by no means
advanced. In two of them there was still some pupillary
reaction obtainable ; in one of these two and in another case
the tension gave way completely to eserin before operation ;
and in the fourth case the attacks of high tension had been
intermittent.
Among other factors in etiology may be noted the predis-
position to glaucoma frequently shown by the (less) shallow
chamber of the unaffected fellow eye. And at times there is
* I have very rarely seen congestive glaucoma together with Mor-
gagnian cataract and an anterior chamber deeper than that of the
unaffected eye ; but in only one case was the glaucoma apparently of
recent origin. In this case it must De assumed that the cataract
played no part in the production of the high tension.
f I cannot speak from experience with regard to acute glaucoma,
having had but a small acquaintance with it.
% Collected some years ago.
Complicated and Soft Cataracts 367
a. definite exciting cause for the onset of high tension ; in two
of our cases it was operation upon the other eye, and in at
least one other case it was probably the use of a mydriatic.
During the two and a half years over which the above
thirty-three cases have been spread, six similar cataracts were
seen with only a low degree of phis tension, in eyes quite or
nearly free from injection. And ten others were found without
high tension, but with some enlargement and sluggishness of
pupil. In six of these cases the abnormality of pupil was very
slight, and might easily have escaped notice. In two of the
remaining three, there was contraction of the field of projec-
tion also, evidently from high tension that had passed off for
the time.
Thus the prima facie presumption in favour of this
etiological relationship between swollen cataract and
glaucoma is supported by a considerable body of evidence.
It is in our experience further borne out in treatment. In
two of our first few cases treatment of the glaucoma was
attempted on orthodox lines, but both cases gave a lot of
trouble.
In one case the anterior chamber failed entirely to refill
after a perfect iridectomy with conjunctival flap. Plus tension
returning after three weeks necessitated cataract extraction,
assisted by preliminary posterior scleral puncture. The
incision had to be made mostly with scissors, owing to the
absence of an anterior chamber. Some cortex was left obscur-
ing vision ; and three weeks later still, plus tension was again
evident. After another posterior scleral puncture the patient
disappeared, tired of treatment.
In the other case the tension was finally reduced, and useful
sight restored by a ' sclerotomy with conjunctival infolding,'
after the failure successively of (i) eserin with small sclero-
tomies, (2) iridectomy, (3) cataract extraction, and (4) sclero-
tomy with division of adherent root of iris.
In the light of these cases it was then recognized that if
the cataract were admitted as a factor in the production of
the glaucoma, the correct treatment of the latter neces-
368 Cataract Extraction
sitated the prompt removal of the lens. This was done
with combined iridectomy in a considerable number of
cases, with very satisfactory results upon the whole. Where
possible, the tension was reduced by eserin beforehand.
But in the majority of cases the tension was still high at
the time of the cataract extraction. It was considered that
the danger of intraocular haemorrhage was probably slight
in these eyes, owing to the glaucoma being usually of quite
recent origin, and being, partly at least, secondary. It was
thought that the changes in the blood-vessels were prob-
ably not marked. We have, however, met with two cases
of expulsive haemorrhage in such eyes, and we had
another unsatisfactory result from large prolapse of iris
and of vitreous (without loss). Hence latterly we have
always reduced the tension before removing the lens. In
some cases eserin has sufficed for this. In other cases I
obtained a lasting reduction in tension by a form of sub-
conjunctival paracentesis. Thus I have been able to wait
for two or three weeks, if necessary, for the congestion of
the eyes to subside mainly or entirely before operating
upon the lens. I have preferred this to preliminary iridec-
tomy because of our unfortunate early experience of
iridectomy in these cases, above mentioned. One feels
that should the anterior chamber remain empty in these
congested eyes, there is every opportunity for consolidation
of adhesion between the base of the iris and the periphery
of the cornea, closing the filtration angle permanently, and
ensuring the return of plus tension. By the paracentesis
which I have performed the tension has been reduced
though the anterior chamber has not remained empty.
Hence its superiority here over iridectomy. A small tongue
or flap of cornea and sclerotic is isolated, with its base at
the corneal margin, thus. Selecting a site preferably
upwards and outwards, a very narrow Graefe's knife,
Complicated and Soft Cataracts 369
slightly less than i millimetre in width, is inserted through
the sclerotic at a distance of about 1*5 millimetres from
the corneal margin, into the angle of the anterior chamber.
1 he puncture is made subconjunctivally by sliding the
conjunctiva. The blade is introduced parallel to the iris,
and a small incision made 1*5 to 2 millimetres long. Then
at each end of this small section the edge of the knife is
turned forwards, and with slow sawing movements a small
subsidiary incision made as far as the corneal circum-
ference. The whole is subconjunctival, as the conjunctiva
is raised by escaping aqueous. The sawing movements
with the back of the blade pressing on the iris, the anterior
chamber being empty, may be painful. For this reason,
and also to avoid unnecessary haemorrhage, adrenalin is
FIG. 95. MODIFIED PARACENTESIS.
instilled beforehand with the cocain, and the cutting is
done mostly or entirely in the withdrawal movements of
the knife. It is uncertain yet how long these small
incisions drain. Some at least appear to leak permanently.
It is necessary to keep the pupil under the influence of
eserin afterwards, to prevent adhesion of the iris to the
wound.
A causal relationship between cataract and glaucoma
exactly the reverse of the above is frequently seen. In
India cataract, as a result of primary glaucoma, frequently
comes on sufficiently early to reduce what would be other-
wise useful vision. It is not, however, sufficiently ripe
to permit of extraction at the time when operation is
demanded for the high tension. It may be expected to
24
37 Cataract Extraction
go on developing slowly after the glaucoma has been
relieved, and may need extraction months or years later.
The chance coincidence of cataract and early glaucoma
in the same eye is seen at times. The absence of etio-
logical relation between the two may be assumed with the
forms of cataract that lead to no shallowing of the anterior
chamber. Incipient cataract and incipent glaucoma are
seldom seen together, probably because most lenses in the
early stage of cataract formation are reduced in volume. I
have notes of a few cases of glaucoma developing together
with hypersclerosis of the lens ; these lenses are probably
not smaller than normal. Supposing operation for the
reduction of tension has failed, one may feel tempted to
extract an unripe cataract to get rid both of the tension and
opacity. The only two cases in which I operated thus
turned out badly.
CATARACTS SECONDARY TO IRIDO-CYCLITIS,
with occlusion of pupil, and often with total posterior
synechia (cataracta accreta), may give good results if the
eye be not softened and if the projection of light be fair.
The cataract may not be detected until an artificial pupil
has been made, and after the lens extraction there may
possibly be a third operation required for membranous
opacity. This is rather tedious. If it seems very probable
that cataract is present e.g., in old dense occlusion,* or if
the lens can be partly seen through thin pupillary mem-
* It is, as a rule, scarcely too much to assume that in old dense
occlusion of pupil a fairly ripe cataract is present, and that it is fit for
extraction if the tension of the eye be fair and the projection of light
good. But in one patient, aged thirty-two years, acting on this
assumption, I made a large incision unnecessarily, and lost some
vitreous. The lens had become absorbed. A simple free incision of
the remains of iris, capsule, and inflammatory tissue would have been
sufficient.
Complicated and Soft Cataracts 371
brane the operation for extraction may be combined with
an iridectomy upwards. And in some cases opaque capsule
may be removed at the same time. It is surprising how
readily the capsule comes away from its old adhesions to
iris,* whose tissue may now be more or less atrophied and
friable. Proceeding thus in the one operation, but step by
step, I have had unexpectedly good results. The number
of cases has, however, been very small.
In Wenzel's Methodt the knife, while making the
corneal incision, passes through iris and often through the
ns capsule, a portion of these matted membranes being
afterwards cut away with de Wecker's scissors. This
mode of operating may be almost forced on one by a
very shallow chamber, and is perhaps preferable when
there is much matting together of iris and lens capsule.
I have only operated thus in three glaucomatous eyes,
where there was no occlusion of pupil nor any past iritis,
but merely very shallow chamber. Unless the chamber is
very shallow, aqueous must be allowed to escape as soon
as the puncture has been made, to bring the lens and iris
forward. Unless the chamber be nearly emptied, the
capsule of the lens may escape division in the making of
the section. The equator of the lens must then be forced
forward to the wound by pressure on the cornea below, for
incision of the capsule along the whole length of the wound
by the cataract knife. Where there is a firm diaphragm
made up of iris, lens capsule, and inflammatory membrane
the blades of de Wecker's scissors may have to be intro-
duced into the eye after the expulsion of the lens, to excise
a portion of the combined membrane. Two converging
* However, in one case I tore iris away from its base below. The
coloboma made above became closed, but the patient counted fingers
at 8 feet with lens through the gap below.
f 'Manuel d'Oculistique,' i (Paris, 1808), 120.
24 2
372 Cataract Extraction
cuts are made, one scissor-blade being passed in front of
the membrane and the other behind it.
REMOVAL OF THE TRANSPARENT LENS IN
HIGH MYOPIA.
The scope of this volume does not include the con-
sideration of the operative treatment of high myopia. The
treatment here claims our interest merely with regard to
the various methods of extraction practicable alike for
transparent lenses, and for lamellar and other partial
stationary cataracts their relative advantages and risks,
and their bearing upon cataract work generally. The
patients being mostly young, linear extraction is commonly
applicable. And this is usually preceded by discission, to
soften and to loosen the lens substance, and followed by
discission for after-cataract.
Though pacification and loosening of the posterior
layers may often be obtained by slow cataract formation
from very limited discission, repeated once or twice if
necessary, yet owing to the tediousness of the process and
to the difficulty experienced in regulating it so as to avoid
the complications, plus tension and irritation of the iris,
many surgeons find it preferable to secure rapid breaking
up of the lens by very free needling. The complications
are prevented or forestalled by the use of iced applications
and rest in bed, and by early extraction. Others advocate
primary linear extraction, with later discission of after-
cataract (Weber, Hess, Sattler) ; others primary flap
extraction (Vacher, Fukala, Hirschberg).
High tension from swelling of the lens is not in itself a
very serious matter. It causes trouble, however, by neces-
sitating extraction of the lens necessarily very incomplete
before the ripening process is sufficiently advanced, and
Complicated and Soft Cataracts 373
while the eye is painful and irritable. General anaesthesia
may be required on this account, and afterwards the con-
gested iris may not respond to the instillation of atropin.
For the wide opening of the capsule at the preliminary
discission, either a single long cut or a crucial division is made.
And the lens is rather deeply incised. Some operators use a
Graefe's knife for this. Emmert* breaks up even the nucleus
and the posterior layers of the lens with a very broad discission-
needle. It is considered wise to avoid allowing the aqueous
to escape, lest the pupil should thereby contract, and the iris
form adhesions to the torn capsule. Mooren, however, com-
bined massage of the lens with discission.
At the linear extraction the capsular opening is still further
enlarged if not already very wide.
For primary extraction of the transparent lens Sattlerf
makes an incision 6 to 8 millimetres long, 1-5 to 2 millimetres
within the upper corneal margin, with Weber's curved kera-
tome (p. 26). He introduces a sharp iris hook, and makes first
a horizontal slit in the capsule behind the lower margin of the
widely dilated pupil, and from that tears freely the whole of
the anterior capsule. Then, with the back of the hook, he
loosens the lens substance from the equatorial and posterior
portions of capsule, and proceeds to evacuate the lens by
depression of the peripheral lip of the wound with a Daviel's
curette, together with external spoon pressure about the lower
corneal margin. The nuclear portions of lens matter are first
expressed. Two-thirds or three-fourths of the lens matter are
thus removed, and atropin is instilled. The remainder left
behind is insufficient to give rise to high tension by swelling. If
the iris enters the wound during the operation it is replaced.
Discission of the posterior capsule and lens debris, practised
after a week or so, " is sufficient to obtain a clear pupil in a
fortnight or little more." He considers that preliminary dis-
cission should be given up entirely.
Axenfeld | and Gelpke remove the anterior capsule with
* A./. A., Iv(i 9 o 3 ), 2, 358.
t Ber. der xxvii Vers. der ophth. Ges. zti Heidelberg, 1899, S. 207.
t Kl. Mbl.f. A., xli (1903), i, 60.
A.f. A., xlix (1904), 2, 152.
374 Cataract Extraction
forceps to obtain the widest possible opening, and so to reduce
the need for treatment of after-cataract. Emmert extracts
the lens twenty-four hours after the free needling which he
practises. Though after this early extraction often a con-
siderable time is taken up in the absorption of lens remnants,
he has found discission for after-cataract nearly always
unnecessary. The avoidance of any interference with the
posterior capsule is a matter of importance in these highly
myopic eyes, having regard to the danger of causing detach-
ment of the retina by displacement of vitreous. And the risk
of post-operative glaucoma is thus reduced also.
In order to lessen existing astigmatism, the incision has been
sometimes placed at right angles to the meridian of greatest
corneal curvature.
Rogman* prefers suction to ordinary linear extraction.
Primary linear extraction necessitates a larger section
than suffices for evacuation of lens substance after free dis-
cission ; hence possibly a slightly greater risk of infection
and of prolapse or incarceration of iris.
Should there be adhesions of vitreous or capsule to the
corneal scar after linear extraction, Sennf divides the ad-
herent tissue, lest the pull upon the vitreous should lead to
detachment of the retina. Sattler had vitreous loss in 20 per
cent., Schweigger in 10 per cent., and Pfluger in 10 per cent,
of their extractions. Detachment of retina occurred in 4-34
per cent, of Sattler's cases, in 14 per cent, of Schweigger's,
and in only i per cent, of Pfliiger's. The latter operator
practised discission of after-cataract in more than half of his
cases. Thus his experience is that this discission does not lead
to retinal detachment.
In patients over thirty-five years of age primary flap extrac-
tion of the transparent lens is commonly preferred, followed,
if necessary, by discission. Linear extraction after pre-
liminary needling is, however, practised by some operators in
older patients, since often in these highly myopic eyes there is
not a- large, hard nucleus. But one cannot be sure of the
condition of the nucleus beforehand, and in these older patients
* Ann. d'Octil., cxxi (1899), i. f A.f. A., xliii (1901), 241.
Complicated and Soft Cataracts 375
the needling frequently causes reaction. To lessen the risk of
exciting high tension, the discission has been sometimes com-
bined with an iridectomy.
DISLOCATED LENSES.
A. In the Anterior Chamber.
Replacement of the lens through the pupil has been
practised occasionally. It seems applicable only to lenses
spontaneously dislocated, which are often shrunken, and
have lain formerly subluxated behind the iris without
causing irritative symptoms, and may still retain their
connexion with stretched zonule.
The most suitable and safest extraction is by Czermak's
lower subconjunctival method. The lens occupying the
lower portion of the chamber is then quite close to the
section, which can be made with scissors without dis-
placing the lens. And there is little risk of loss of vitreous.
This risk constitutes the chief danger and difficulty with
other incisions. Should the lens have lain long in its
abnormal position, however, it may have become fixed to
the cornea, rendering a lower section difficult and only to
be accomplished by transfixion or displacement of the lens.
In India a considerable proportion of the patients came
for treatment only when sight had been lost by secondary
glaucoma caused by the luxated lens. Operation was
merely for the relief of pain. In these eyes loss of vitreous
mattered little, and the ordinary upper section sufficed.
In making the ordinary section vitreous may begin to
escape even before the incision is completed, especially if
there be high tension. Desmarres' retractor should be
used for the upper lid, and finger depression for the lower
lid, instead of the stop-speculum. The upper portion of
the lens may lie in the path ordinarily taken by the knife
376 Cataract Extraction
in making the section, or possibly the upper part of the
iris may be pressed forward against the cornea by vitreous
tension. In an eye in which the attainment of useful
vision is still possible, it is important not to risk displace-
ment of the lens backwards by transfixion with the knife.
There is always room for an incision of moderate extent,
made in the usual way with a very narrow Graefe's knife,
i millimetre or less; and this may be enlarged, if necessary,
with scissors. If the upper part of the anterior chamber
be extremely shallow, the iris must be cut with the knife, or
the section might be begun by sawing from in front, as was
done by Spencer Watson,* in 1871, with a scalpel. Some
operators have preferred linear extraction by outer section,
the point of the keratome being thrust behind the lens.
And Miiller recommends his operation (p. 201) for dis-
located lenses. The lens is removed with a loop or spoon.
The instillation of eserin beforehand is indicated t in
order that the lens may be supported by the iris and
prevented from slipping backwards through the pupil.
There is then no need for the very inconvenient fixation
of the lens by transfixion with a needle, or for operation
with the patient in the semi-prone position methods
which have been adopted.
The instillation of adrenalin before or with the cocain is
advisable in all cases, and especially necessary in painful
eyes, to ensure quietness I so far as possible.
* The Practitioner, 1871, p. 271.
| According to Eversbusch (Vers. der ophth. Ges. zti Heidelberg,
1878), eserin instillation is inadmissible before operation for a con-
genitally ectopic lens, still attached to an elongated zonule. The pull
on the zonule caused by myosis may draw the shrunken lens back into
the posterior chamber.
J In one of our operations upon a dislocated lens adherent to the
cornea a shrunken lens which evidently had been Morgagnian, but
from which all the fluid had been absorbed its detachment from the
cornea with the spoon caused pain sufficient to excite spasm of orbi-
Complicated and Soft Cataracts 377
B. In the Vitreous.
I have no experience of extraction of lenses dislocated into
the vitreous. It would be undertaken only if sight were being
lost through high tension or other complication due to the
displaced lens. Smith of Jullundur has removed many dis-
located lenses with a spoon or by simple expression, but gives
no details. Possibly in his cases the lenses had resumed their
normal position.
Should the lens lie quite free in the vitreous, it may be
possible to bring it into the anterior chamber merely by
dilating the pupil and placing the patient in the prone position.
Euphthalmin and cocain are recommended as mydriatics.
Should this succeed, the prone position is maintained while
myosis is obtained by eserin, and the lens is then extracted.
Often the lens retains some connexion with the ciliary body
either by means of zonule or by bands of new tissue. It may
then lie quite close to the iris. Knapp * has succeeded in
delivering such lenses, with little or no loss of vitreous, mainly
by external pressure finger pressure applied below through
the lower lid. A speculum is used only for the making of the
section. This is upwards, the summit of the flap being placed
2 millimetres within the corneal margin. The final delivery
is aided by the introduction of a spoon by the assistant.
Von Graefe and von Arlt have succeeded in piercing more
deeply placed lenses with a needle through the sclerotic, and
so bringing them up into the pupil or into the anterior chamber
for removal with a spoon or loop. Agnew's ' bident 'I has
been used similarly for bringing lenses up for extraction
lenses which are too freely movable to be readily pierced by
a needle. The bident consists simply of two straight needles
fixed in a holder parallel to one another, | inch apart. The
two needles are passed into the vitreous behind the lens, and
are swung forward supporting the lens.
cularis. Thus there was a considerable loss of vitreous. Cocain alone
had been instilled. If it had been combined with adrenalin, possibly
the accident might not have happened. The visual result of the
operation, however, was good at least, while the patient was under
observation.
* A.f. A., xxii (1890), 171.
t Trans. Arner. Oph. Soc., 1885, p. 69.
378 Cataract Extraction
C. Subluxated Lenses.
1. In the Pupil. Spontaneously displaced lenses in this
situation are more or less shrunken lenses, either ectopic or
merely the nuclear remains of Morgagnian cataracts, lying in
collapsed capsule. In the case of the larger lenses, and there-
fore particularly in traumatic displacement, treatment may be
demanded for the relief of secondary glaucoma.
Possibly by the use of a weak mydriatic and forward bend-
ing of the head, further displacement of a shrunken lens into
the anterior chamber may be secured. And after sufficient
eserin instillation to fix the lens there, it may be extracted.
Otherwise operation must be undertaken with the lens still
lying in the pupil. Czermak's subconjunctival, also L. Miiller's
and Bourgeois' sections, have each been recommended. It is
suggested, also, to place the section at that portion of the
corneal margin towards which the lens margin points, in order
that a spoon or loop may the more readily be introduced
behind the lens. If the small lens lies loosely in the pupil, it
may be fixed by a needle passed in through the sclerotic.
2. In the Posterior Chamber. Here, again, there may be high
tension, or operation may be advisable on account of double
vision or cataract formation. In cataractous cases without
plus tension an optical iridectomy, sphincterectomy, or irido-
tomy may give a fair visual result. The iris may be difficult
to seize with forceps, but may be drawn out with a hook.
In children repeated discission may be preferable to extrac-
tion. On account of the mobility of the lens, it may be difficult
to make a large enough opening in the capsule in discission,
and there is some risk of displacement of the lens backwards
into the vitreous. For this reason Eversbusch opened the
capsule with a cystitome introduced through a peripheral
corneal puncture.
Zion* recommends transfixion of the lens with a needle
introduced from behind through the sclerotic to prevent its
displacement during discission by a second needle introduced
through the cornea.
Linear extraction after discission is inapplicable because of
vitreous in the anterior chamber. Terson recommends aspira-
tion with Bowman's syringe.
* Ophth. Klinik, iii (1899), 121.
Complicated and Soft Cataracts 379
In older patients extraction of the lens in its capsule is
indicated, with loop or spoon, or, if the capsule be thickened
and opaque, with forceps. L. Miiller's or Bourgeois' section
might be made. In one case of traumatic subluxation down-
wards I found the lens firmly adherent below. Only partial
removal was possible. A good deal of cortex was left and
much vitreous lost, and the resulting vision was worse than
before operation.
Where operation is required on account of double vision,
further lateral displacement of the lens with a needle may
suffice.
In a case of ectopia lentis with congenital coloboma and
small cornea, the fellow eye was useless, and the patient
could count fingers at 3 feet with a + 6 D lens. Though the
lens was opaque, I refused operation, fearing the loss of
vitreous.
THE EXTRACTION OF SOFT CATARACT.
Operation for the removal of soft cataract '.?., opacity in
lenses which have not yet developed hard nuclei is per-
formed mostly upon lenses which have been rendered
more or less completely cataractous by discission. The
treatment is usually for partial stationary cataract, most
often lamellar, or for the removal of the transparent lens
in high myopia. In other cases operation is needed for
traumatic cataract, or for ripe or overripe general cataract
in young persons. Extraction must, however, be rejected
in favour of repeated needlings of cataract in young people
if the cataract be complicated, and if at the same time the
tension of the eye be at all reduced, also possibly in very
high myopia. Traumatic cataract in my experience has
been practically always met with at an age when the lens
was still fairly soft throughout. There is often inflamma-
tion, infective or otherwise, which may render considerable
delay in operative interference advisable. The delay is
until the eye has become normally pale, and remains so
380 Cataract Extraction
after moderate friction through the lids. Operation may
be deferred also because of unripeness of the cataract.
But at other times early interference is necessary on
account of high tension excited by the swollen and dis-
integrating lens. This compulsory removal of lens matter
is sometimes a supplement to discission. And it is often
only a very partial operation, much unripe, sticky lens
substance being unavoidably left behind. In other cases
extraction is an expeditious alternative to the very tedious,
but on the whole safer, absorption of the lens under
repeated needlings.
The operation is known as linear extraction (Lanzen-
extraction), or 'curette evacuation.' It may sometimes
FIG. 96. FIG. 97.
LINEAR EXTRACTION.
be applicable for traumatic cataract in people over thirty-
five years of age. Where the lens has been penetrated
deeply, the nucleus may become softened and broken up.
The pupil having been dilated widely, if possible, a
nearly straight incision, 5 to 10 millimetres long is made
in the cornea with a triangular lance-knife or keratome
The shorter section (with a comparatively narrow blade)
is made in infants, and also in older patients if the cataract
is fully ripe or overripe. It is placed usually I to 1*5 milli-
metres within the corneal margin. If the capsule of the
lens has not been opened previously, it is opened freely
now with a cystitome. If the cataract is fully ripe, depres-
sion of the peripheral lip of the wound with a curette
should enable most of the soft lens matter to escape, with-
Complicated and Soft Cataracts 381
out injury to the iris. The material may also, if necessary,
be pressed out by stroking movements over the cornea
with a tortoise-shell spoon or other expressor, the globe
being fixed by the assistant. The curette may also be
inserted a little way into the chamber to break up and to
withdraw some of the lens substance. And it is recom-
mended sometimes to wait for the re-accumulation of a
little aqueous, and to practise repeated reinsertion of the
curette. (The instrument must be cleansed before each
reinsertion.) If iris prolapses early, it may have to be
excised, but generally replacement suffices.
The position of the section and other details of the
operation vary with the ripeness of the cataract. If it is
fully ripe, the incision may be placed in the outer part of
the cornea. This is an advantage in young children, as it
permits of the operation being completed without a general
anaesthetic, the patient not being required to look down.
But if it is anticipated that a portion of the lens is still
incompletely cataractous, the incision should be placed
above. Probably an iridectomy will be required to
facilitate the evacuation of the chamber, and because of
bruising of the iris during the manipulation. Iridectomy
may also be required on account of posterior synechiae.
The removal will probably be incomplete, and therefore
the wound may be left occupied by shreds of translucent
cortex. It may be impossible to clear these shreds out of
the incision, where they constitute a grave danger, possibly
serving for the admission of infective organisms. There-
fore the wound should not only be above, but it should be
in the limbus and subconjunctival. (The conjunctiva
should be pushed down a little on the point of the kera-
tome.) I have preferred to make such a section with a
narrow Graefe's knife, i millimetre or less in breadth.
Thus the incision can be lengthened a little if desired.
382 Cataract Extraction
That is, a very shallow flap section may be made instead
of the so-called linear section.
Irrigation is often a great help in the removal of cortex,
especially when alternated with external pressure, and with
introductions of the curette to break up the lens matter.
It is, however, better to leave much of the lens behind,
and to trust in atropin and mercury afterwards, than to
continue in prolonged efforts at removal. A very partial
evacuation suffices for the reduction of high tension. In
the case of a very overripe cataract opaque capsule may
have to be extracted in part or whole. Iris forceps are
commonly suitable.
As a small modification, the lens capsule may be opened
with the point of the keratome. But the opening thus
made may be too small, and if the lens happens to be very
thin the posterior capsule may be punctured. The kera-
tome may also be used instead of the curette for depres-
sing the lip of the wound, but care must be taken in this
again to avoid the posterior capsule.
Where a general anaesthetic is required, much less of it
need be used if local anaesthesia with cocain alone, or with
cocain and adrenalin, is utilized also.
Complications.
1. Iris prolapse is rare after this operation because of
the slight tendency to gaping of the section, and because iri-
dectomy is often performed at the time of the extraction.
2. Vitreous may prolapse during operation through
puncture of the posterior capsule with the point of the
knife, or in breaking up lens matter with the curette, or
owing to the extraction of opaque capsule, or possibly, in
cases of traumatic cataract, through the injury already
sustained by the eye.
3. Unripe lens matter left behind may give rise to
Complicated and Soft Cataracts 383
trouble, either alone or adding to the work of infective
organisms.
4. Infection maybe introduced through a purely corneal
wound, kept open by shreds of lens substance, by capsule,
or by vitreous.
In India we meet fairly often with a class of patient for
whom neither extraction nor simple discission is quite
applicable. The patients are children with overripe
cataracts dating generally from infancy. There is usually
much irregular anterior capsular opacity, and enclosed in
the sac is only a thin layer of milky fluid, sometimes with
a few small flakes of cortex or granular debris. What is
required is discission, plus evacuation of the fluid and
cortical remains. A wide and satisfactory opening in the
opaque membrane can be secured by the use of two
Bowman's stop-needles. But if any of the turbid fluid be
left behind, there is a liability to an acute glaucomatous
attack setting in within a few hours. We found this by
experience, and we found that relief of the tension followed
at once upon evacuation of the chamber through a small
puncture. The complication was afterwards prevented by
removing the fluid completely immediately after opening
the capsule. This is done by a subconjunctival puncture
at the limbus with a narrow (i millimetre) Graefe's knife.
Even with the eye soft from leakage through needle
punctures, the narrow knife can be introduced without
much pressure. The puncture is enlarged to about double
the width of the blade, and the latter rotated in the wound,
and the iris pressed a little backwards until the milk
leaks gradually away. The knife is passed in front of the
iris to the neighbourhood of any milky or granular remains,
and then by intermittent jerky pressure serves as a director
for the gradual passage outwards of the material. If by
384 Cataract Extraction
chance both layers of capsule are punctured by the needles
so that vitreous is a little displaced forwards, this inter-
feres but little with the evacuation, though it may delay it
a little. It is very satisfactory to note how patient con-
tinuance of the jerky pressure upon the iris gradually
directs piece after piece of soft cortex along the blade and
through the puncture. Chloroform is seldom needed even
in young children, if the head be held firmly. There is
practically no pain. The assistant fixes the eye and
rotates it for the insertion of the needles.
Linear extraction of the opaque capsule and of its
contents is quite unsuitable at the early age of most of
these patients, even with a subconjunctival wound.
Vitreous is almost sure to enter the wound, and the
healing of the latter is further interfered with by rubbing
the eyes and by contraction of the lids, thus predisposing
to infection.
SUCTION (ASPIRATION) OF SOFT CATARACT.
A brief reference is due to the removal of soft lens matter
through a linear wound by suction, a method known of old to
the Arabs and Persians, and associated in its later develop-
ment with the names of two Englishmen. Teale's * cannula
for suction by the mouth and Bowman's pump for instrumental
aspiration have been very generally used. The method
recommended by Terson (pere) for subluxated traumatic
cataracts in young subjects, and advantageous in quite young
children, owing to the small size of the incision (less than
5 millimetres) required has fallen into disuse, apparently
from its very limited field of usefulness. In older patients it
offers no especial advantages. Owing to the liability of the
cannula to become blocked, it is suitable only for quite ripe
cataracts, which are readily removable without suction. In
suction by the mouth the older method the degree of force
employed could be regulated to a greater nicety. And very
* R. L. O. H. Rep., iv, 2, 197 ; and The Lancet, 1880, i, 29.
Complicated and Soft Cataracts 385
slow removal of the lens matter was insisted upon to prevent
complications, such as bleeding from the iris, indrawing of iris
into the opening of the cannula, rupture of posterior lens
capsule, and presentation of vitreous. The tough capsules of
some congenital cataracts, insufficiently opened, and therefore
not easily penetrated by the cannula, sometimes led to dis-
placement of the lens. The capsule was sometimes opened by
preliminary discission, at other times by the broad needle or
keratome, after the making of the small corneal section. Sub-
sequent infective inflammations were probably attributable to
want of sterilization of the instruments employed.
I NDEX
' ADHERENT conjunctival flap ' ope-
ration, 203
Adhesion of iris to cicatrix, 156
Adrenalin instillation, 53, 223
After-cataract, i, 321
capsular, 321
complicated, 324, 351
excision of, 359
extraction of, 360
treatment of, 325
After-treatment, 149, 155
Age of patients, 18
extreme old, 17
Agnew's method of needling, 357
Air-bubble in anterior chamber, 134
Albuminuria, 17
Amblyopia from disuse, 159
Anaemia, extreme, 17
Anaesthesia, 52
general, 182
Angelucci's fixation, 188
Anteflexion of corneal flap, 293
Anterior chamber shallow, 67, 68,
70, 82, 83, 84, 344, 365
Aqueous, early loss of, 69, 85
Artificial ripening, 19
Asepsis, 266
Astigmatism, post-operative, 157,
196, 301
Atropin instillation, 146, 156, 289,
308
Attendant, the irrigator, 59
B
Bacteria, conjunctival, 185, 271
Bandaging, 148
Beer's knife, 23
Black cataract, 9
Bleeding from iris, 98
into anterior chamber, 74, 83,
104, 134, 307
Blue vision, 159
Bourgeois' operation, 200
Bronchitis, 17
Buttonholed iris, 97, 231
Capsular after-cataract, 321
cataract, i
incisions, various, no
plague, anterior, 9, 112, 123,
264
Capsule, extraction of anterior, 238
extraction of, 265, 362
forceps, 34, 239
P anas' , 362
incarceration of, 83, 142, 143,
307, 316
opacity of, 5, 6, in, 112, 123,
240, 264
puncture of posterior, 242
replacement of, 142
rupture of, 258
Capsulotomy, 101
incomplete, 122
peripheral, 236
preliminary, 238
with the knife, 237
Cataract, after-, i, 321
capsular, 321
black, 9
capsular, i
complicated, 2, 10
incipient, 3
infantile, 19
liquefying, 4
previously Morgagnian, 6, 113,
123, 264
Morgagnian, 5, in, 122, 264
overripe, 3, 5, 8, 111, 250, 264,
383
primary, 2
ripe, 3, 5, 8
secondary, 2, 369, 370
shrinking, 7
soft, extraction of, 379
suction of, 384
traumatic, 2, 10
unripe, 3, 5, 7, 11, 323
with glaucoma, 365
Cataracta accreta, 370
Chibret's double-current syringe, 41
7 252
588
Index
Choroidal detachment, 312
Cicatrix, cystoid, 300
fistulous, 300
Clark's speculum, 29
Cleansing of conjunctiva, 59, 144,
183, 273
of lids, 179
Cocain instillation, 52
Collapse of cornea, 131
of globe, 132
Combined operation, the, 62, 216
Complicated after-cataract, 324, 351
cataract, 2, 10
Conjunctival bacteria, i8^ t 271
cleansing, 59, 144, 183, 273
flap, the, 63, 71, 74, 79, 95, 191
adherent, 203
folding, 76
tearing, 77
Contact keratitis, 292
Corneal collapse, 131
drying, 61
epithelium, exfoliation of, 293
flap, eversion (anteflexion) of,
293
margin, the, 64
opacity, 15, 291
linear, 292
Cortex left behind, 219, 323
removal of, 135, 226
Counter-puncture, the, 68
Curette, the, 38
Cyanopsia, 159
Cystitomes, 34
Cystoid cicatrix, 300
Czermak's operation, 61, 79, 206,
375
D
daGama Pinto's needling, 350
Dacryocystitis, 15
David's operation, 23
de Wecker's scissors, 34
section, 28
Delayed union, 308
Delivery of the lens, 114, 226
Dermatitis, acute, 295
Desmarres' retractors, 31, 90, 187
Detachment of choroid, 312
of retina, 175, 331, 364
Diabetes, 17
Discission, 19, 331, 339, 348, 354
posterior scleral, 350
with scissors, 357
Discoid lenses, 8, 125
Dislocated lenses, 375
Displacement of lens upwards, 116,
117
Distortion of pupil, 173, 300
Double extraction, 16
needle operation, 354
Downward section, 197, 206
Dressing, the, 146
hollow, 248
test, 44, 1 80
Early exudations, 285
Entropion, spastic, 295
Epilation, 180
Erythropsia, 159
Escape of vitreous, 164, 220, 257.
306
causes of, 166
consequences of, 171
management of, 170
percentage of, 169
prevention of, 168
Eserin instillation, 230
Eversion of corneal flap, 293
Excision of after-cataract, 359
Exfoliation of corneal epithelium,
293
Expression of Meibomian secretion,
56, 181
Expressors, lens, 36
Expulsive haemorrhage, 16, 160
Fellow eye, the, 16
Filamentous keratitis, 293
Filtration osdema, 153
Finger separation of lids, 90, 187
Fistulous cicatrix, 300
Fixation, 65, 76, 92, 188
Angelucci's, 188
forceps, 32
Flap, the conjunctival, 63, 71, 74,
79, 95, 191
Flatulent distension of the abdomen,
3H
Folding of conjunctiva, 76
of capsule, 34, 239
Forceps, fixation, 32
iris, 33
Fornices retracted, 61, 71, 76, 87
Forster's ripening, 20
Galezowski's needling, 353
Gaping of the wound. 80, 153
Glaucoma, cataract with, 365
secondary, 218, 301, 314, 330
Index
(89
H
Haab's needling, 352
Haemorrhage, expulsive, 16, 160
from iris, 98
into anterior chamber, 74, 83,
104, 134, 307
Hand, support of the, 67, 75
Healing of the wound, 115
High myopia, extraction in, 372
Hypersclerosis, 9
I
Impaction of capsule and iris. See
Incarceration
Incarceration of capsule, 83, 142,
Jffs. 307, 316
of iris, 83, 96, 172, 217, 259,
295, 316
of vitreous, 164, 171
Incomplete capsulotomy, 122
Infantile cataract, 19
Infection of the eye, 172, 244, 266,
299, 327
late, 288
localized wound, 287
salivary, 178
Infective processes, the, 281
results, 269
Instillation of adrenalin, 53, 223
of atropin, 146, 156, 289, 308
of cocain, 52
of eserin, 230
Intracapsular extraction, 249
Intraocular irrigation, 137, 243,
382
Iridectomy, the, 91
peripheral, 231, 232
preliminary, 20, 234
Irido-cyclitis, 283
Iridotomy, 232
Iris, adhesion of, to scar, 156
buttonholed, 97
cut by the knife, 84
forceps, 33
incarceration of, 83, 96, 172,
217, 259, 295, 316
prolapse of, 77, 85, 86, 217, 259,
295
treatment of, 302
replacement of, 141, 228
repositors, 38
scissors, 34
Iritis, 262, 283, 286, 315, 346
Irrigation, intraocular, 137, 243,
382
perchloride (sublimate), 13, 51,
58, 183, 269
Irrigators, 39
Jackson's, Edward, needling, 349
Jacobson's section, 24
K
Keratitis, contact, 292
filamentous, 293
striped, 291
| Knapp on capsulotomy, 106
- Knapp' s knife-needle, 336, 348
I Knife, von Graefe's, 33
narrow,
0.1 .1 W VV , < 3j'~ / JjV
Kugel's needling, 353
Kvhnt's needling, 350
Lacrymal passages, 14
Lashes cut short, 61
Lebrnn's section, 27
Left-handed cutting, 76
Lid-margins, 179
Lids, cleansing of, 179
separation of, by fingers, 90,
187
Liebreich's section, 27
Linear extraction, 18, 372, 380
Liquefying cataract, 4
Loss of aqueous, early, 69, 85
of vitreous, 164, 220, 257, 306
causes of, 166
consequences of, 171
management of, 170
percentage of, 169
prevention of, 168
Lower section, 197, 206
M
McKeown's irrigator, 39
Meibomian secretion, expression of,
56, 181
Mellinger's speculum, 29
Mental disturbance, 313
Modified linear extraction, 25
Morgagnian cataract, 5, in, 122,
264
previously, 6, 113, 123, 264
Mouth-screen (mask), the, 55, 178
Mutter's section, 201
Myopia, extraction in high, 372
N
Needle, Knapp's knife-, 336, 348
Needling, 326, 339, 348, 354
early, 332
preliminary, 18, 19
Nervous patients, 43, 61, 89, 105,
168
390
Index
o
CEdema, filtration, 153
Old age. extreme, 17
Opacity, corneal, 15, 291
Opaque capsule, 5, 6, 112, 123, 240,
264
Open treatment of the wound, 247
modified, 248
Operability, u
Orbicularis spasm, 89, 150, 186,
187, 297
Outer sections, 199
Overripe cataract, 3, 5, 8, in, 250,
264, 283
P
Punas' capsule forceps, 362
Palpebral aperture contracted, 71
Paracentesis, subconjunctival, 368
Perchloride irrigation, 13, 51, 58,
183, 269
Peripheral capsulotomy, 236
iridectomy, 231, 232
linear extraction, 25
Pigmentation of cicatrix, 154
Plehn's section, 201
Preliminary capsulotomy, 238
iridectomy, 20, 234
needling, 18
Preparation of the patient, 43
Prolapse of iris, 77, 85, 86, 217, 259,
295
treatment of, 302
of vitreous, 164, 170, 306
Puncture, the, 67
Pupil, distortion of, 173, 300
reaction of, 12
sphincter of, 96, 97
R
Red vision, 159
Removal of cortex, 135
Reopening of the wound, 308
Replacement of capsule, 142
of iris, 141, 228
Repositors, iris, 38
Respirators, 55, 178
Results, bad, 277
infective, 269
visual, 159, 278
Retinal detachment, 175, 331, 364
Retracted fornices, 61, 71, 76, 87
Retractors, Desmarres', 31, 90, 187
Ripening, artificial, 19
Rocking motion of the knife, 71
Rupture of capsule, 258
of zonule, 74, 125
Salivary infection, 178
Sawing action of the knife, 71
Schulek's section, 201
Scissor discission, 357
Scissors, iris, 34
Sclero-corneal section, 62, 195
Secondary cataract, 2, 369, 370
glaucoma, 218, 301, 314, 330
Section, the, 62, 189
de Wecker's, 28
downward, 197, 206
Jacobson's, 24
Lebrun's, 27
Liebreich's, 27
Miiller's, 201
Plehn's, 201
purely corneal, 196
outer, 199
sclero-corneal, 62, 195
size of, 77
too small, 78, 121
too peripheral, 83
von Arlt's, 27
von Graefe's peripheral linear, 25
Sedative draught, 46
Self-control, the patient's, 43, 105,
129
Separation of lids by fingers, 90,
187
of the wound, 80, 153
Shallow anterior chamber, 67, 68,
70, 82, 83, 84, 344, 365
Shrinking cataract, 7
Simple extraction, 216
linear extraction, 24
Size of section, 77
Skopomorphin, 183
Slack eyes, 131
Smith's operation, 253
Soft cataract, extraction of, 379
suction of, 384
Soiling of the knife, 70
Spasm of orbicularis, 89, 150, 186,
187, 297
Spastic entropion, 295
Speculum, the, 28, 60, 88, 144, 186
Sphincter of pupil, 96, 97
Sphincterectomy, 99
Spoons, 38
Sterilization of instruments, 47
Stilling' s harpoon needles, 356
Stop-speculum, the, 28, 60, 88, 144,
186
Striped keratitis, 291
Stupid patients, 44, 89
Subconjunctival extraction, 61, 79,
202, 375
Index
Subconjunctival paracentesis, 368
Sublimate irrigation, 13, 51, 58,
183, 269
Subluxated lenses, 378
Suction operations, 384
Suppurations, 282
Suture of wound, 213
of conjunctival flap, 215
Sympathetic ophthalmia, 16, 287
Syphon-douche, the. 137
Syringe, Chibret's double-current,
4 1
T
Tearing of conjunctiva, 77
Tension, vitreous, 130
Test dressing, the, 44, 180
Toilet of the eye, 133
Traumatic cataract, 2, 10
Tremor of lens, 6
U
Union, delayed, 308
Unripe cataract, 3, 5, 7, n, 323
Upward displacement of the lens,
116, 117
Vectis, the, 37
Visual results, 159, 278
Vitreous, escape of (loss of), 164,
220, 257, 306
causes of, 166
consequences of, 171
management of, 170
percentage of, 169
prevention of, 168
incarceration of, 164, 171
prolapse of, 164, 170, 306
tension, 130
Volume of cataractous lenses, 21
von Arlt's section, 27
von Graefe's knife, 33
narrow, 336, 339
modified linear extraction, 25
W
Weber's knife, 26
Wenzel's operation, 371
Wol/berg's kalorisator, 20
Zonule, rupture of, 74, 125
Baillitre, Tindall &> Cox, 8, Henrietta Street, Covent Garden
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