390
HARLAN: Delayed Union after Cataract Extraction.
published in the Annals of Ophthalmology for April, which presents more points of similarity to the case which I report than any other I have found. DISCUSSION.
DR. H. F. HANSELL. - About three years ago I reported a case similar in some respects to Dr. Worrell's, in which a piece of steel which had been in the an,terior chamber, according to the patient's story, for fifteen years, spontaneously extruded through the cornea. The wound of entrance was invisible. The steel gradually opened a way for itself through the cornea, and more than half of it was exposed when I saw it, so that I simply helped it out with a pair of forceps.
DELAYED UNION AFTER CATARACT EXTRACTION. BY GEO. C. HARLAN, M.D., PHILADELPHIA, PENN.
So far as I have been able to learn, there are no statistics to indicate how long the wound may remain open after extraction without necessitating a grave or hopeless prognosis of the final result. The text-books generally do not refer to the subject, and tabular reports of operations give no definite data. As some of my friends, as well as myself, have looked in vain for comfort when the anterior chamber has remained empty after the first few days, I have thought it might be worth while to bring the subject before the society. A few months ago I operated on a lady eighty-three years of age. She was in fair health, neither diabetic nor albuminuric, but too feeble to take a journey, and the operation was performed at her distant home, but she was left in charge of a good general surgeon and an experienced trained nurse. The operation was entirely smooth, there was no prolapse of the iris, and the pupil remained round and central. The usual compress and bandage were used, and after the second day the eye was carefully douched
HARLAN: Delayed Union after Cataract Extraction. 391 daily with warm boric solution by merely drawing down the lower lid without raising the upper, and atropia was instilled. On visiting her ten days later I was surprised to find not the slightest indication of closure of the wound. There had been no pain, and the eye was quiet. The pupil was round and central -4 mm. in diameter - but lay directly against the cornea. The wound was in perfect apposition and there was no infiltration of its edges; in fact, it was almost impossible to locate it. Her general condition was not good; her tongue was dry, her appetite was failing, and her spirits somewhat depressed. She had been sitting up in bed, but was indisposed to get up. She was urged to dress and to resume as far as possible her usual habits and ordinary diet, and quinine and strychnine and a little brandy were ordered. At my next visit, seven days afterwards, the anterior chamber was normal and the wound was firmly closed. Just when this occurred it is not possible to say, as, fearing infection or disturbance of the wound, I had left particular directions that the lid should not be raised. The edges of the wound were now hazy, though the rest of the cornea was clear, and the base of the iris was adherent :to the corneal cicatrix throughout, slightly dislocating the pupil upwards. V. . 1/5, with probability of great improvement by capsulotomy and cylindrical correction. This case called to my recollection one that I met with a good many years ago. As the patient had only one eye, the general condition was not good, and the lens was white, a preliminary iridectomy was performed. There was a slight escape of fluid vitreous when the incision for extraction was made, and the lens was removed in its capsule with a wire loop, without further loss. There was no vitreous in the wound, and it remained in perfect apposition but refused to unite for three weeks. A compress with bandage was used and atropia was applied. Fin-ally, with the approval of Dr. Norris, who saw the patient in consultation, I applied the point of a mitigated nitrate stick, very lightly, along the whole course of the wound, and it closed in a few days afterwards. V. = 20/30 and remained good, though the patient's general health failed, until she died a few years afterwards in, an insane asylum.
392 IHARLAN: Delayed Union after Cataract Extraction.
Carl Barck of St. Louis has recently* reported two cases in which the anterior chamber remained open for more than two weeks in one and for two weeks in the other, with an excellent final result in both; and another which ended in corneal suppuration at the end of eighteen days. Berry alludes to the failure of the wound to close after two days as an unusual, though occasional, occurrence. Wecker says " it is a clinical fact that the union of the lips of the wound may, without inconvenience, be retarded for five or six days, either by repeated re-opening or by a faulty coaptation, without the existence of the eye being menaced, provided that infection be carefully guarded against during this period so propitious for inoculation." Becker, in GraefeSaemisch, says he has seen the anterior chamber remain open for five or six days, even after perfectly normal extractions, and that the eye, as a rule, does not present any symptoms of irritative reaction, and the termination is a favorable one. He therefore regards a late restoration of the anterior chamber almost as a favorable condition for the final result. He adds that these favorable cases must not be confounded with those in which union is delayed by increased intraocular pressure, when one may be thankful if the wound finally heals with a cystoid cicatrix. Jacobsont reports a case in which a good result was obtained after the wound had been open for more than four weeks. " The patient had some blepharo-spasm and the aqtueous escaped regularly, as often as I left the bandage off, during the first three weeks. After I had convinced myself of the constancy of the condition, I kept the eye closed by a compressive bandage for ten days and nights in succession, after which time the wound was closed." Becker thinks that the cause may lie in the character of the wound, as, if ragged, it offers an imperfect apposition, but is more frequently to be found in lens substance or capsule lying in the wound and holding it open. In a recent discussion of this subject at two meetings of the Societe d'Ophthalmologie de Paris (November 3, I896, and March 9, i897), Vignes reported two cases in which the wound American Journal of Ophthalmology, September, 1897. t Graefe's Archives, Vol. XI, 194. *
HARLAN: Delayed Union after Cataract Extraction.
393
remained open in one for ten days and in the other for twenty, and finally healed without corneal opacity and with good. vision. The first patient was diabetic and catarrhal. In the secon.d there was no albumin or sugar, but a decided diminution in the amount of urea, which he suggests might have some connection with the delay in union. In this case, in which union was delayed for twenty days, the pupil was slightly drawn up by adhesion of the base of the iris to the lips of the wound, but this did not occur until two or three days before the closure. This is just what occurred in the case that I have reported, and it seems likely that this adhesion of the iris promoted the union by checking the flow of aqueous humor. Valude claimed rapid effects from iridectomy and said he had seen the anterior chamber close twenty-four hours after it was performed in cases that had shown no tendency to unite for several weeks. Terson also referred to a case in which the anterior chamber remained open for a month and a half, and closed completely two days after an iridectomy Was performed. He thinks that delayed union is much more frequent in the simple than in the combined operation. Vacher, in a case which remained for twelve days without reaction and without tendency to union, touched the Lips of the wound with a solution of iodine, and the next day it commenced to cicatrize. Bourgeois and Jocqs reported cases in which delayed union, in one case for two weeks and in the other for three, was attributed to entropion. In the former the anterior chamber was established the day after the entropion was relieved by operation, and in the latter the wound cicatrized completely forty-eight hours after the eye was left unbandaged. Koenig referred to a case in which union was delayed for twenty days. He thinks the facts that union usually occurs promptly in diabetics and often in patients with diminished urea, while it may be delayed in patients whose condition is quite normal, and that the vitality of the cornea is shown by its continued transparency, make it difficult to accuse the general condition;
394
HARLAN: Delayed Unioni after Cataract Extracdion.
and most of those who took part in the discussion attributed delayed union to local rather than to general causes, or, at least, considered the latter as only predisposing. Since this discussion Valois' has reported the case of an alcoholic subject, seventy-four years of age, on whom an unsuccessful operation had been performed on the other eye. There was no sign of union at the end of nine days, when the wound was lightly touched with the actual cautery, and three days later it had firmly cicatrized. There was some corneal opacity, but V. _ 20/50. He also refers to another case in which the wound closed at the end of four weeks under the use of simple compress and bandage. The number of cases of delayed union reported by French surgeons since attention was called to the subject, makes it seem probable that delayed union is much more frequent than has generally been supposed. The fact that Becker, with his extensive experience and well-known accuracy of observation, had never seen the anterior chamber remain open for more than five or six days after normal extraction, suggests the query whether modern methods of operation and the use of cocaine may have any connection with this complication. With a view to getting some idea as to the frequency of delayed union, and, if possible, as to the conditions that cause it, Dr. C. J. Kistler, resident surgeon of Wills Hospital, has examined the records of five hundred consecutive extractions performed at the hospital. Cases which ended in sloughing of the cornea, panophthalmitis, or destruction of the eye by chronic cyclitis were excluded, and only uncomplicated cases are noted. In four hundred and seventy-four of the five hundred cases the anterior chamber was reformed in less than five days, in nearly all of these within forty-eight hours. In twenty-six cases the union was delayed longer than this time, and a tabulated report is given of such cases. In nine the wound remained open for five days, in two for six days, in two for seven days, in two for ten, in three for eleven, in two for twelve, in one for thirteen, in one for fifteen, in one for sixteen, in one for seventeen, in one for nineteen, and in one for twenty days. Fifteen were simple operations and eleven combined. In twenty it is 1 Recueil d'Ophthalmologie, January,
I898.
HARLAN : Delayed Uniton after Cataratct Extraction.
395
noted that no complication occurred during the operation. Of the remaining six, prolapse of the iris occurred in four cases and was excised in two and replaced in two. There was slight loss of vitreous in one case and a bead of vitreous appeared in the wound in another. All very common accidents in cases that follow a perfectly normal course. There were also few complications, beside the delayed union, during the course of treatment. In one case considerable cortical debris was left in the anterior chamber. In one a small shred of vitreous was removed from the wound on the third day and it closed two days later. In two cases there was delirium. In one a prolapse occurred the day after the operation, but subsequently smoothed down completely without interference, and the anterior chamber was reformed on the sixteenth day. V. = i. In one prolapse occurred the second day after the operation. On the sixth day, as the chamber still remained open, preparation was made to perform iridectomv, but under etherization the iris was spontaneously replaced and the wound was closed the next day. The ages of the patients varied from forty-five to seventy-five, a large proportion being over sixty. One is recorded as neurotic and two as feeble, but generally their condition is stated as good or fair. There were no diabetics or albuminurics among them. The degree of vision attained was from I/5 to I; a case in which the wound did not close for fifteen days being included in the latter. In no case was the eye lost. The various causes of delayed union that have been suggested are: An irregular or ragged incision. The presence of bits of capsule, lens debris or vitreous shreds in the wound. Hernia of the iris. Adhesion of the iris to the posterior lips of the wound. Pinching of the conjunctiva or iris in the angles of the wound. Entropion occasioned or increased by the dressing. Disturbance of the wound by too frequent examinations and dressings.
396
HARLAN: Delayed Union after Cataract Extraction.
Failure of reparative power due to something in the condition of the patient. Excessive secretion of aqueous humor. There is no special note as to the character of the wounds in these twenty-six cases, but as they were made by the same surgeons who operated on the rest of the five hundred, it may be presumed that they were made with about the same average skill. In my own case the incision was better than my average, and on the tenth day its margins were in such close apposition that it could scarcely be distinguished. In two cases there was possibility of vitreous in the wound; in two the dressings were disturbed by the patients in delirium, and in two the delay in cicatrization seemed to be caused directly by hernia of the iris. As to simple adhesion of the iris to the posterior lips of the wound, it occurred in the case reported only just before the anterior chamber was reformed, and seemed to me rather to promote cicatrization by checking the outflow of aqueous humor. Also in the case reported by Vignes, in which the wound remained open for twenty days, a similar adhesion occurred two or three days before it closed. There was no entropion in any of the cases, and nothing unusual in the dressing. This leaves twenty cases in which there was no known local cause. The probability that something in the condition of the patients was an important factor seems increased by the fact that in two cases the delay occurred in both eyes, while in a third the wound of a preliminary iridectomy. performed a month before the extraction, remained open for five days. In one of the cases reported by Dr. Barck there was retarded union - eighteen days - in each eye. In the case just reported cicatrization was evidently coincident with the improvement in the patient's condition, which had been much depressed, and I believe that a mistake was made in keeping her too long on an unusual diet and in not insisting upon her getting out of bed. As for treatment: So many cases have been reported in which excellent results have been attained, although the wound has remained open without interference for weeks, that a conservative course seems to be generally indicated. The outflow of
HARLAN: Delayed Union after Cataract Extraction.
397
aqueous humor is a protection against infection, but it is not known how long this flow may continue without endangerinig the nutrition of the ball. A permanent fistula is likely to result in atrophy. With the present light upon the subject, if the wound is clean and in good apposition, I would be inclined to give the compress and atropia at least a month's trial. If there is capsule or lens debris in the wound, it may be well to remove it with the spatula. A prolapse of the iris should be excised, unless it can be readily replaced. Iridectomy, even when there is no prolapse, is reported to have been promptly successful in a number of cases, and, whether it acts by merely freshening the wound or by modifying the secretion of aqueous humor, it seems to have a basis in practical experience. Cicatrization follovwed stimulation of the wound, by nitrate of silver, solution of iodine and the galvanic cautery, in three cases. In case of entropion it becomes a question between relieving the condition by operation and removing the bandage. Berry says, in his text-book, that when the wQund remains open longer than forty-eight hours, a light dressing that makes no compression on the ball should be substituted for the compress and bandage.
398
HARLAN: Delayed Unzion after Cataract Extraction. '2
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HARLAN: Delayed Union after Cataract Extraction.
399
400 HARLAN: Delayed Union after Cataract Extraction.
Discussion.
401
DISCUSSION.
DR. H. D. NOYES. - In one instance this experience occurred to me. It was a clergyman over seventy, and the wound failed to unite for more than a fortnight. It was not simply that the anterior chamber remained empty, but the edges of the wound were inclined to evert. There was no infiltration, no opacity, nor secretion, nor pain. The operation was by Graefe's method. The pupil remained clear. In the course of time the wound healed and the man enjoyed good vision for more than ten years. DR. GRUENING. - I think that one cause of the eversion of the lips of the wound, which I have also observed frequently, is the fact that the operation has been done within the clear cornea. If we make a small conjunctival flap, the wound heals very rapidly, and I now always aim to have such a flap. DR. W. B. JOHNSON. - Do you do the simple operation? DR. GRUENING. - Yes. I am speaking of the simple operation. DR. MYLES STANDISH. - It is my custom very frequently to do a simple extraction with what we call a Chandler buttonhole. After the operation of extraction is completed, a minute opening is made through the iris, perhaps + mm. in diameter, and as far back as possible. It is done for the prevention of prolapse of the iris, and seems to succeed admirably. In two instances in which I have done this I have had a sinus left just over this little opening, showing that the flow of aqueous was sufficient to keep it from healing at that point. It stayed open for several weeks, but closed promptly when I touched the wound with the mitigated stick. DR. H. KNAPP. I have seen that often, and once the closure was followed by glaucoma, I think, because probably a piece of conjunctiva was in the wound. We frequently see when we have made a conjunctival flap that there is a gaping of the wound which the conjunctiva bridges over.
HARLAN: Delayed Union after Cataract Extraction.
published in the Annals of Ophthalmology for April, which presents more points of similarity to the case which I report than any other I have found. DISCUSSION.
DR. H. F. HANSELL. - About three years ago I reported a case similar in some respects to Dr. Worrell's, in which a piece of steel which had been in the an,terior chamber, according to the patient's story, for fifteen years, spontaneously extruded through the cornea. The wound of entrance was invisible. The steel gradually opened a way for itself through the cornea, and more than half of it was exposed when I saw it, so that I simply helped it out with a pair of forceps.
DELAYED UNION AFTER CATARACT EXTRACTION. BY GEO. C. HARLAN, M.D., PHILADELPHIA, PENN.
So far as I have been able to learn, there are no statistics to indicate how long the wound may remain open after extraction without necessitating a grave or hopeless prognosis of the final result. The text-books generally do not refer to the subject, and tabular reports of operations give no definite data. As some of my friends, as well as myself, have looked in vain for comfort when the anterior chamber has remained empty after the first few days, I have thought it might be worth while to bring the subject before the society. A few months ago I operated on a lady eighty-three years of age. She was in fair health, neither diabetic nor albuminuric, but too feeble to take a journey, and the operation was performed at her distant home, but she was left in charge of a good general surgeon and an experienced trained nurse. The operation was entirely smooth, there was no prolapse of the iris, and the pupil remained round and central. The usual compress and bandage were used, and after the second day the eye was carefully douched
HARLAN: Delayed Union after Cataract Extraction. 391 daily with warm boric solution by merely drawing down the lower lid without raising the upper, and atropia was instilled. On visiting her ten days later I was surprised to find not the slightest indication of closure of the wound. There had been no pain, and the eye was quiet. The pupil was round and central -4 mm. in diameter - but lay directly against the cornea. The wound was in perfect apposition and there was no infiltration of its edges; in fact, it was almost impossible to locate it. Her general condition was not good; her tongue was dry, her appetite was failing, and her spirits somewhat depressed. She had been sitting up in bed, but was indisposed to get up. She was urged to dress and to resume as far as possible her usual habits and ordinary diet, and quinine and strychnine and a little brandy were ordered. At my next visit, seven days afterwards, the anterior chamber was normal and the wound was firmly closed. Just when this occurred it is not possible to say, as, fearing infection or disturbance of the wound, I had left particular directions that the lid should not be raised. The edges of the wound were now hazy, though the rest of the cornea was clear, and the base of the iris was adherent :to the corneal cicatrix throughout, slightly dislocating the pupil upwards. V. . 1/5, with probability of great improvement by capsulotomy and cylindrical correction. This case called to my recollection one that I met with a good many years ago. As the patient had only one eye, the general condition was not good, and the lens was white, a preliminary iridectomy was performed. There was a slight escape of fluid vitreous when the incision for extraction was made, and the lens was removed in its capsule with a wire loop, without further loss. There was no vitreous in the wound, and it remained in perfect apposition but refused to unite for three weeks. A compress with bandage was used and atropia was applied. Fin-ally, with the approval of Dr. Norris, who saw the patient in consultation, I applied the point of a mitigated nitrate stick, very lightly, along the whole course of the wound, and it closed in a few days afterwards. V. = 20/30 and remained good, though the patient's general health failed, until she died a few years afterwards in, an insane asylum.
392 IHARLAN: Delayed Union after Cataract Extraction.
Carl Barck of St. Louis has recently* reported two cases in which the anterior chamber remained open for more than two weeks in one and for two weeks in the other, with an excellent final result in both; and another which ended in corneal suppuration at the end of eighteen days. Berry alludes to the failure of the wound to close after two days as an unusual, though occasional, occurrence. Wecker says " it is a clinical fact that the union of the lips of the wound may, without inconvenience, be retarded for five or six days, either by repeated re-opening or by a faulty coaptation, without the existence of the eye being menaced, provided that infection be carefully guarded against during this period so propitious for inoculation." Becker, in GraefeSaemisch, says he has seen the anterior chamber remain open for five or six days, even after perfectly normal extractions, and that the eye, as a rule, does not present any symptoms of irritative reaction, and the termination is a favorable one. He therefore regards a late restoration of the anterior chamber almost as a favorable condition for the final result. He adds that these favorable cases must not be confounded with those in which union is delayed by increased intraocular pressure, when one may be thankful if the wound finally heals with a cystoid cicatrix. Jacobsont reports a case in which a good result was obtained after the wound had been open for more than four weeks. " The patient had some blepharo-spasm and the aqtueous escaped regularly, as often as I left the bandage off, during the first three weeks. After I had convinced myself of the constancy of the condition, I kept the eye closed by a compressive bandage for ten days and nights in succession, after which time the wound was closed." Becker thinks that the cause may lie in the character of the wound, as, if ragged, it offers an imperfect apposition, but is more frequently to be found in lens substance or capsule lying in the wound and holding it open. In a recent discussion of this subject at two meetings of the Societe d'Ophthalmologie de Paris (November 3, I896, and March 9, i897), Vignes reported two cases in which the wound American Journal of Ophthalmology, September, 1897. t Graefe's Archives, Vol. XI, 194. *
HARLAN: Delayed Union after Cataract Extraction.
393
remained open in one for ten days and in the other for twenty, and finally healed without corneal opacity and with good. vision. The first patient was diabetic and catarrhal. In the secon.d there was no albumin or sugar, but a decided diminution in the amount of urea, which he suggests might have some connection with the delay in union. In this case, in which union was delayed for twenty days, the pupil was slightly drawn up by adhesion of the base of the iris to the lips of the wound, but this did not occur until two or three days before the closure. This is just what occurred in the case that I have reported, and it seems likely that this adhesion of the iris promoted the union by checking the flow of aqueous humor. Valude claimed rapid effects from iridectomy and said he had seen the anterior chamber close twenty-four hours after it was performed in cases that had shown no tendency to unite for several weeks. Terson also referred to a case in which the anterior chamber remained open for a month and a half, and closed completely two days after an iridectomy Was performed. He thinks that delayed union is much more frequent in the simple than in the combined operation. Vacher, in a case which remained for twelve days without reaction and without tendency to union, touched the Lips of the wound with a solution of iodine, and the next day it commenced to cicatrize. Bourgeois and Jocqs reported cases in which delayed union, in one case for two weeks and in the other for three, was attributed to entropion. In the former the anterior chamber was established the day after the entropion was relieved by operation, and in the latter the wound cicatrized completely forty-eight hours after the eye was left unbandaged. Koenig referred to a case in which union was delayed for twenty days. He thinks the facts that union usually occurs promptly in diabetics and often in patients with diminished urea, while it may be delayed in patients whose condition is quite normal, and that the vitality of the cornea is shown by its continued transparency, make it difficult to accuse the general condition;
394
HARLAN: Delayed Unioni after Cataract Extracdion.
and most of those who took part in the discussion attributed delayed union to local rather than to general causes, or, at least, considered the latter as only predisposing. Since this discussion Valois' has reported the case of an alcoholic subject, seventy-four years of age, on whom an unsuccessful operation had been performed on the other eye. There was no sign of union at the end of nine days, when the wound was lightly touched with the actual cautery, and three days later it had firmly cicatrized. There was some corneal opacity, but V. _ 20/50. He also refers to another case in which the wound closed at the end of four weeks under the use of simple compress and bandage. The number of cases of delayed union reported by French surgeons since attention was called to the subject, makes it seem probable that delayed union is much more frequent than has generally been supposed. The fact that Becker, with his extensive experience and well-known accuracy of observation, had never seen the anterior chamber remain open for more than five or six days after normal extraction, suggests the query whether modern methods of operation and the use of cocaine may have any connection with this complication. With a view to getting some idea as to the frequency of delayed union, and, if possible, as to the conditions that cause it, Dr. C. J. Kistler, resident surgeon of Wills Hospital, has examined the records of five hundred consecutive extractions performed at the hospital. Cases which ended in sloughing of the cornea, panophthalmitis, or destruction of the eye by chronic cyclitis were excluded, and only uncomplicated cases are noted. In four hundred and seventy-four of the five hundred cases the anterior chamber was reformed in less than five days, in nearly all of these within forty-eight hours. In twenty-six cases the union was delayed longer than this time, and a tabulated report is given of such cases. In nine the wound remained open for five days, in two for six days, in two for seven days, in two for ten, in three for eleven, in two for twelve, in one for thirteen, in one for fifteen, in one for sixteen, in one for seventeen, in one for nineteen, and in one for twenty days. Fifteen were simple operations and eleven combined. In twenty it is 1 Recueil d'Ophthalmologie, January,
I898.
HARLAN : Delayed Uniton after Cataratct Extraction.
395
noted that no complication occurred during the operation. Of the remaining six, prolapse of the iris occurred in four cases and was excised in two and replaced in two. There was slight loss of vitreous in one case and a bead of vitreous appeared in the wound in another. All very common accidents in cases that follow a perfectly normal course. There were also few complications, beside the delayed union, during the course of treatment. In one case considerable cortical debris was left in the anterior chamber. In one a small shred of vitreous was removed from the wound on the third day and it closed two days later. In two cases there was delirium. In one a prolapse occurred the day after the operation, but subsequently smoothed down completely without interference, and the anterior chamber was reformed on the sixteenth day. V. = i. In one prolapse occurred the second day after the operation. On the sixth day, as the chamber still remained open, preparation was made to perform iridectomv, but under etherization the iris was spontaneously replaced and the wound was closed the next day. The ages of the patients varied from forty-five to seventy-five, a large proportion being over sixty. One is recorded as neurotic and two as feeble, but generally their condition is stated as good or fair. There were no diabetics or albuminurics among them. The degree of vision attained was from I/5 to I; a case in which the wound did not close for fifteen days being included in the latter. In no case was the eye lost. The various causes of delayed union that have been suggested are: An irregular or ragged incision. The presence of bits of capsule, lens debris or vitreous shreds in the wound. Hernia of the iris. Adhesion of the iris to the posterior lips of the wound. Pinching of the conjunctiva or iris in the angles of the wound. Entropion occasioned or increased by the dressing. Disturbance of the wound by too frequent examinations and dressings.
396
HARLAN: Delayed Union after Cataract Extraction.
Failure of reparative power due to something in the condition of the patient. Excessive secretion of aqueous humor. There is no special note as to the character of the wounds in these twenty-six cases, but as they were made by the same surgeons who operated on the rest of the five hundred, it may be presumed that they were made with about the same average skill. In my own case the incision was better than my average, and on the tenth day its margins were in such close apposition that it could scarcely be distinguished. In two cases there was possibility of vitreous in the wound; in two the dressings were disturbed by the patients in delirium, and in two the delay in cicatrization seemed to be caused directly by hernia of the iris. As to simple adhesion of the iris to the posterior lips of the wound, it occurred in the case reported only just before the anterior chamber was reformed, and seemed to me rather to promote cicatrization by checking the outflow of aqueous humor. Also in the case reported by Vignes, in which the wound remained open for twenty days, a similar adhesion occurred two or three days before it closed. There was no entropion in any of the cases, and nothing unusual in the dressing. This leaves twenty cases in which there was no known local cause. The probability that something in the condition of the patients was an important factor seems increased by the fact that in two cases the delay occurred in both eyes, while in a third the wound of a preliminary iridectomy. performed a month before the extraction, remained open for five days. In one of the cases reported by Dr. Barck there was retarded union - eighteen days - in each eye. In the case just reported cicatrization was evidently coincident with the improvement in the patient's condition, which had been much depressed, and I believe that a mistake was made in keeping her too long on an unusual diet and in not insisting upon her getting out of bed. As for treatment: So many cases have been reported in which excellent results have been attained, although the wound has remained open without interference for weeks, that a conservative course seems to be generally indicated. The outflow of
HARLAN: Delayed Union after Cataract Extraction.
397
aqueous humor is a protection against infection, but it is not known how long this flow may continue without endangerinig the nutrition of the ball. A permanent fistula is likely to result in atrophy. With the present light upon the subject, if the wound is clean and in good apposition, I would be inclined to give the compress and atropia at least a month's trial. If there is capsule or lens debris in the wound, it may be well to remove it with the spatula. A prolapse of the iris should be excised, unless it can be readily replaced. Iridectomy, even when there is no prolapse, is reported to have been promptly successful in a number of cases, and, whether it acts by merely freshening the wound or by modifying the secretion of aqueous humor, it seems to have a basis in practical experience. Cicatrization follovwed stimulation of the wound, by nitrate of silver, solution of iodine and the galvanic cautery, in three cases. In case of entropion it becomes a question between relieving the condition by operation and removing the bandage. Berry says, in his text-book, that when the wQund remains open longer than forty-eight hours, a light dressing that makes no compression on the ball should be substituted for the compress and bandage.
398
HARLAN: Delayed Unzion after Cataract Extraction. '2
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HARLAN: Delayed Union after Cataract Extraction.
399
400 HARLAN: Delayed Union after Cataract Extraction.
Discussion.
401
DISCUSSION.
DR. H. D. NOYES. - In one instance this experience occurred to me. It was a clergyman over seventy, and the wound failed to unite for more than a fortnight. It was not simply that the anterior chamber remained empty, but the edges of the wound were inclined to evert. There was no infiltration, no opacity, nor secretion, nor pain. The operation was by Graefe's method. The pupil remained clear. In the course of time the wound healed and the man enjoyed good vision for more than ten years. DR. GRUENING. - I think that one cause of the eversion of the lips of the wound, which I have also observed frequently, is the fact that the operation has been done within the clear cornea. If we make a small conjunctival flap, the wound heals very rapidly, and I now always aim to have such a flap. DR. W. B. JOHNSON. - Do you do the simple operation? DR. GRUENING. - Yes. I am speaking of the simple operation. DR. MYLES STANDISH. - It is my custom very frequently to do a simple extraction with what we call a Chandler buttonhole. After the operation of extraction is completed, a minute opening is made through the iris, perhaps + mm. in diameter, and as far back as possible. It is done for the prevention of prolapse of the iris, and seems to succeed admirably. In two instances in which I have done this I have had a sinus left just over this little opening, showing that the flow of aqueous was sufficient to keep it from healing at that point. It stayed open for several weeks, but closed promptly when I touched the wound with the mitigated stick. DR. H. KNAPP. I have seen that often, and once the closure was followed by glaucoma, I think, because probably a piece of conjunctiva was in the wound. We frequently see when we have made a conjunctival flap that there is a gaping of the wound which the conjunctiva bridges over.
