3I6
KNAPP: Cataract Extractionz
CATARACT EXTRACTION WITHOUT IRIDECTOMY. BY H. KNAPP, M.D., NEW YORK.
AMONG the new operative procedures with which I became acquainted in Europe last winter, I considered two as particularly worthy of being adopted, viz., the eytraction of cataract without iridectomy,- and the advancement of Tenon's capsule in cases of squint. During the last ten years repeated attempts have been made, especially in Paris, to abandon the exsection of a piece of iris in cataract extraction, a custom which had become general through the authority of the late von Graefe. Until two years ago, these attempts had been unsuccessful, but now the difficulties and accidents inherent in the so-called simple extraction seem so far overcome as to let it appear probable that this method will in future be extensively used. It is principally advocated and practised by Galezowski, De Wecker, and Panas. When I returned to New York in May of this year, I had made up n-y mind to perform Graefe's extraltion only for a short time, an cfradually pgo over to the uncombined extraction. I made eight Graefe's extractions. They passed so smoothly, the healing was so kind, and the results were so good that it cost me an effort to remain true to my purpose. On June ioth I began with the simple method. The first patient was a man of seventy-five years, who had a hard, uncomplicated cataract. His eye was cocainized, the upper third of the cornea divided with a Graefe knife and the capsule lacerated freely in the centre. When I endeavored to expel the lens, I found that the iris offered great resistance. I employed more and more pressure, until a bead of vitreous protruded. Then I exsected a piece of iris, divided the capsule at the periphery, and expelled the lens easily and without any
without Iridectomy.
317
more vitreous. The application of the lips of the wound was perfect, the recovery and visual result were good. I saw at once that the section of one third of the transparent margin of the cornea, sufficient for the exit of cataracts when iridectomy is made, is insufficient for extractions without iridectomy. Immediately after the operation just relateJd, I performed anotlher extraction of cataract. This time I succeeded in expelling the lens without iridectomy. The patient was a man, M. D., aged seventy-six, of New York, from whose other eye I had removed a cataract according to Graefe's method, quite successfully, a year before. I made the section larger, lacerated the capsule, and expelled the lens by pressure with the spoon. Some pigment was detached from the protruding iris. The iris receded spontaneously, and when I saw that the pupil was round and central, I injected, with a lachrymal syringe made for the purpose, a few drops of Fanas' solution of biniodide of mercury in alcohol and water (i :400: 20,000). Eserine was instilled into the conjunctival sac. No pain; pupil narrow, central and round on 3d day. Eserine for three days more; then pupil found adherent all around. Atropine instilled; pupil partially freed. Discharged on 23d day; vision 2W; pupillary opacities; eye, however, in excellent condition and sight will be good either spontaneously or by simple needling. The second case was a soft cataract in a man thirty-six years of age. A timid division had been made before, but no lens matter had passed into the anterior chamber. The extraction was done in the same way as in the previous case; the section was smaller. The iris receded spontaneously, the pupil was round, central and clear. Healing undisturbed. on account of optic nerve atrophy; the other, nonV. = cataractous eye has V. =z The third case, a woman of fifty-five, hard cataract, extraction and healing undisturbed. V. =2,0u. The fourth case, a woman of sixty, hard cataract, operated without accident, showed posterior synechiae on fourth day; the eserine instillations replaced by atropia. Discharged on
3I8
KNAPP: Cataract Extraction
15th day, pupil somewhat cloudy, some posterior adhesions; V. = ylu, promising to become good. The fifth case, a woman aged sixty-three, of Brooklyn, was operated on without accident, yet I did not succeed in completely clearing the pupil. She had iritis from the 4th day. Eserine replaced by atropia and leeches to the temple. Two thirds of the pupillary edge became disengaged. The pupil was moderately clouded (no pseudo-membrane) when patient was discharged on 25th day, with some circumcorneal redness and V. =fAf. The sixth case, a woman of fifty-two, with a hard, not completely ripe cataract, was operated on, July gth. Section large, conjunctival flap along the whole secfion; lens came out readily, remnants of cortex pressed ourt with the lower lid. The iris did not recede, but had to be reduced with a style, which performance succeeded perfectly. No pain. Filtration chemosis in lower part on 3d day. Atropia. Pupil dilated, central, no adhesions. Reviewing these six operations, we find three ideal recoveries with round and movable, perfectly free pupils, and three cases with posterior synechiae, in none extensive or membranous, so that all cases may be termed successful. In the mode of operatinzg I followed Panas principally. The outside of the lids was first washed with soap, then with the biniodide solution. The conjunctival sac was sterilized, by instilling biniodide or bichloride solutions with an ordinary atropine dropper. Before this, the everted upper lid and its edge had been carefully wiped with absorbent cotton, saturated with the antiseptic solution. I borrowed this procedure from Hirschberg. The section was made quickly, so that no iris fell before the blade of the narrow knife. The expulsion of the lens was easier when I pressed with a curette on the lower part of the cornea and with the edge of a spoon simultaneously on the posterior lip of the wound. The iris is a decided obstacle to the ready exit of the lens, and even much more so to that of the cortical remnants. I saw Panas very painstaking in cleansing the pupillary field, expelling- the remnants over the prolapsed iris, fishiing, them out with a Daviel's spoon introduced
without Iridectorny.
3I 9
four and five times into the anterior chamber, and the like; yet he injected only very small quantities of his antiseptic into the anterior chamber, apparently less for the purpose of clearing the pupil than of sterilizing the wound. To obtain a central, round pupil does not seem to be difficult. In most cases the iris recedes spontaneously, or can easily be reduced with a style. When once in its proper position, it shows no tendency to prolapse again. I have injected IPanas' solution of biniodide of mercury with E. Meyer's delicate laclhrymal syringe, carefully disinfected beforehand and used for no other purpose. An instrument like that used by De WVecker, or, if we want to be unimpeachable, like Koch's syringe, can as well be used, but finding this syringe very handy, I have not soug,ht for anything else. There was no trace of incarceration of iris in any of these six cases. Prof. Panas told me, that since November, i885, incarceration had not occurred any more in his practice. What is the cause of the non-occurrence, or at least, great rarity of prolapse of iris at present, whereas formerly it was the bane of all operative procedures without iridectomy. The change, to my mind, is due to the introduction of cocaine. In a cocainized eye there is very little tendency to prolapse of the iris, and when after forcible protrusion the iris has been artificially reduced, it stays in the eye. Without cocaine the re-instatement of Daviel's operation would not have been possible. The working at the eye for cleansing the pupil, the reduction of the iris with instruments, the washing out of the anterior chamber when the operation is completed, all this could not be done if the eye had not been rendered insensible and more or less reduced in tension by the cocaine. To judge competently of the value of the revived simple extraction, we as yet lack extensive and careful statistics, in fact none lhave as yet been published, apart from a mention of so and so many operations and the assertion that the operators were highly satisfied with the results. I, for one, would not lay the greatest stress on a round pupil. It remains to be seen how the visual acuteness, and the number of necessary after-operations will compare with the combined
320
WEBSTER: Fifty Cases of
extraction. One advantage, pointed out by several operators, outweighs, in my opinion, all others, that is the perfectfreedom of the section from portions of lenis, caopsule and iris, provided that the latter be obtainable, as it seems it is. The complete reduction of the iris, either spontaneous or instrumental, and the injection of a liquid into the anterior chamber, along the whole section, insure cleanliness of the wound and consequently primary union more than seems possible by any other method.
REPORT OF FIFTY CASES OF CATARACT ,EXTRACTION, WITH REMARKS. BY DAVID WEBSTER, AI.D., NEW YORK.
AT the meeting of this Society, held at the Kaaterskill House, in July, I883, I reported my first thirty-five cases of cataract extraction. I now avail myself of the privilege of presenting the statistics of my next fifty consecutive cases. These fifty extractions were done upon the eyes of forty-three different patients, seven of them having had both eyes operated upon. Five of the seven had the second eye operated upon a longer or shorter time after having recovered from the operation on the first. The other two had the cataract extracted from both eyes at the same sitting. All four of the eyes in these two cases made smooth recoveries, and in one of the cases the resulting vision was 32 when both eyes were used at once, z¢ each when tested separately. I wish to place myself on record, in this connection, that, heretical as it may seem, I approve of douible cataract extractionzs in jzudicioutsly selected cases. I have seen the operation performed upon both eyes at the same sitting four times in all, and every eye in all these four cases healed kindly and recovered good sight. Of course the opportunity to operate upon both eyes at once occurs comparatively infrequently. In the vast majority of
KNAPP: Cataract Extractionz
CATARACT EXTRACTION WITHOUT IRIDECTOMY. BY H. KNAPP, M.D., NEW YORK.
AMONG the new operative procedures with which I became acquainted in Europe last winter, I considered two as particularly worthy of being adopted, viz., the eytraction of cataract without iridectomy,- and the advancement of Tenon's capsule in cases of squint. During the last ten years repeated attempts have been made, especially in Paris, to abandon the exsection of a piece of iris in cataract extraction, a custom which had become general through the authority of the late von Graefe. Until two years ago, these attempts had been unsuccessful, but now the difficulties and accidents inherent in the so-called simple extraction seem so far overcome as to let it appear probable that this method will in future be extensively used. It is principally advocated and practised by Galezowski, De Wecker, and Panas. When I returned to New York in May of this year, I had made up n-y mind to perform Graefe's extraltion only for a short time, an cfradually pgo over to the uncombined extraction. I made eight Graefe's extractions. They passed so smoothly, the healing was so kind, and the results were so good that it cost me an effort to remain true to my purpose. On June ioth I began with the simple method. The first patient was a man of seventy-five years, who had a hard, uncomplicated cataract. His eye was cocainized, the upper third of the cornea divided with a Graefe knife and the capsule lacerated freely in the centre. When I endeavored to expel the lens, I found that the iris offered great resistance. I employed more and more pressure, until a bead of vitreous protruded. Then I exsected a piece of iris, divided the capsule at the periphery, and expelled the lens easily and without any
without Iridectomy.
317
more vitreous. The application of the lips of the wound was perfect, the recovery and visual result were good. I saw at once that the section of one third of the transparent margin of the cornea, sufficient for the exit of cataracts when iridectomy is made, is insufficient for extractions without iridectomy. Immediately after the operation just relateJd, I performed anotlher extraction of cataract. This time I succeeded in expelling the lens without iridectomy. The patient was a man, M. D., aged seventy-six, of New York, from whose other eye I had removed a cataract according to Graefe's method, quite successfully, a year before. I made the section larger, lacerated the capsule, and expelled the lens by pressure with the spoon. Some pigment was detached from the protruding iris. The iris receded spontaneously, and when I saw that the pupil was round and central, I injected, with a lachrymal syringe made for the purpose, a few drops of Fanas' solution of biniodide of mercury in alcohol and water (i :400: 20,000). Eserine was instilled into the conjunctival sac. No pain; pupil narrow, central and round on 3d day. Eserine for three days more; then pupil found adherent all around. Atropine instilled; pupil partially freed. Discharged on 23d day; vision 2W; pupillary opacities; eye, however, in excellent condition and sight will be good either spontaneously or by simple needling. The second case was a soft cataract in a man thirty-six years of age. A timid division had been made before, but no lens matter had passed into the anterior chamber. The extraction was done in the same way as in the previous case; the section was smaller. The iris receded spontaneously, the pupil was round, central and clear. Healing undisturbed. on account of optic nerve atrophy; the other, nonV. = cataractous eye has V. =z The third case, a woman of fifty-five, hard cataract, extraction and healing undisturbed. V. =2,0u. The fourth case, a woman of sixty, hard cataract, operated without accident, showed posterior synechiae on fourth day; the eserine instillations replaced by atropia. Discharged on
3I8
KNAPP: Cataract Extraction
15th day, pupil somewhat cloudy, some posterior adhesions; V. = ylu, promising to become good. The fifth case, a woman aged sixty-three, of Brooklyn, was operated on without accident, yet I did not succeed in completely clearing the pupil. She had iritis from the 4th day. Eserine replaced by atropia and leeches to the temple. Two thirds of the pupillary edge became disengaged. The pupil was moderately clouded (no pseudo-membrane) when patient was discharged on 25th day, with some circumcorneal redness and V. =fAf. The sixth case, a woman of fifty-two, with a hard, not completely ripe cataract, was operated on, July gth. Section large, conjunctival flap along the whole secfion; lens came out readily, remnants of cortex pressed ourt with the lower lid. The iris did not recede, but had to be reduced with a style, which performance succeeded perfectly. No pain. Filtration chemosis in lower part on 3d day. Atropia. Pupil dilated, central, no adhesions. Reviewing these six operations, we find three ideal recoveries with round and movable, perfectly free pupils, and three cases with posterior synechiae, in none extensive or membranous, so that all cases may be termed successful. In the mode of operatinzg I followed Panas principally. The outside of the lids was first washed with soap, then with the biniodide solution. The conjunctival sac was sterilized, by instilling biniodide or bichloride solutions with an ordinary atropine dropper. Before this, the everted upper lid and its edge had been carefully wiped with absorbent cotton, saturated with the antiseptic solution. I borrowed this procedure from Hirschberg. The section was made quickly, so that no iris fell before the blade of the narrow knife. The expulsion of the lens was easier when I pressed with a curette on the lower part of the cornea and with the edge of a spoon simultaneously on the posterior lip of the wound. The iris is a decided obstacle to the ready exit of the lens, and even much more so to that of the cortical remnants. I saw Panas very painstaking in cleansing the pupillary field, expelling- the remnants over the prolapsed iris, fishiing, them out with a Daviel's spoon introduced
without Iridectorny.
3I 9
four and five times into the anterior chamber, and the like; yet he injected only very small quantities of his antiseptic into the anterior chamber, apparently less for the purpose of clearing the pupil than of sterilizing the wound. To obtain a central, round pupil does not seem to be difficult. In most cases the iris recedes spontaneously, or can easily be reduced with a style. When once in its proper position, it shows no tendency to prolapse again. I have injected IPanas' solution of biniodide of mercury with E. Meyer's delicate laclhrymal syringe, carefully disinfected beforehand and used for no other purpose. An instrument like that used by De WVecker, or, if we want to be unimpeachable, like Koch's syringe, can as well be used, but finding this syringe very handy, I have not soug,ht for anything else. There was no trace of incarceration of iris in any of these six cases. Prof. Panas told me, that since November, i885, incarceration had not occurred any more in his practice. What is the cause of the non-occurrence, or at least, great rarity of prolapse of iris at present, whereas formerly it was the bane of all operative procedures without iridectomy. The change, to my mind, is due to the introduction of cocaine. In a cocainized eye there is very little tendency to prolapse of the iris, and when after forcible protrusion the iris has been artificially reduced, it stays in the eye. Without cocaine the re-instatement of Daviel's operation would not have been possible. The working at the eye for cleansing the pupil, the reduction of the iris with instruments, the washing out of the anterior chamber when the operation is completed, all this could not be done if the eye had not been rendered insensible and more or less reduced in tension by the cocaine. To judge competently of the value of the revived simple extraction, we as yet lack extensive and careful statistics, in fact none lhave as yet been published, apart from a mention of so and so many operations and the assertion that the operators were highly satisfied with the results. I, for one, would not lay the greatest stress on a round pupil. It remains to be seen how the visual acuteness, and the number of necessary after-operations will compare with the combined
320
WEBSTER: Fifty Cases of
extraction. One advantage, pointed out by several operators, outweighs, in my opinion, all others, that is the perfectfreedom of the section from portions of lenis, caopsule and iris, provided that the latter be obtainable, as it seems it is. The complete reduction of the iris, either spontaneous or instrumental, and the injection of a liquid into the anterior chamber, along the whole section, insure cleanliness of the wound and consequently primary union more than seems possible by any other method.
REPORT OF FIFTY CASES OF CATARACT ,EXTRACTION, WITH REMARKS. BY DAVID WEBSTER, AI.D., NEW YORK.
AT the meeting of this Society, held at the Kaaterskill House, in July, I883, I reported my first thirty-five cases of cataract extraction. I now avail myself of the privilege of presenting the statistics of my next fifty consecutive cases. These fifty extractions were done upon the eyes of forty-three different patients, seven of them having had both eyes operated upon. Five of the seven had the second eye operated upon a longer or shorter time after having recovered from the operation on the first. The other two had the cataract extracted from both eyes at the same sitting. All four of the eyes in these two cases made smooth recoveries, and in one of the cases the resulting vision was 32 when both eyes were used at once, z¢ each when tested separately. I wish to place myself on record, in this connection, that, heretical as it may seem, I approve of douible cataract extractionzs in jzudicioutsly selected cases. I have seen the operation performed upon both eyes at the same sitting four times in all, and every eye in all these four cases healed kindly and recovered good sight. Of course the opportunity to operate upon both eyes at once occurs comparatively infrequently. In the vast majority of
