ON THE OPERATIVE PROCEEDINGS FOR ARTIFICIAL PUPIL.
By Surgeon-Major F. Odevaine, F.Il.C.S., JBhopal Battalion 8c Political Agency. In a country like India, in which diseases of the eye are at once so common and so frequently neglected or mismanaged, owing to the ignorance of the people and the', comparatively speaking, few hospitals or dispensaries within easy reach of avast number of the population, very many suffer from dense leucomata, witli or without partial staphyloma, the consequence of deep ulceration of the cornea. The density and extent of these corneal opacities are frequently much aggravated by the practice of using locally so common amongst the natives phool," or oxide of zinc, which they apply for all forms of ophthalmia ; and, should abrasion or ulcer of the cornea exist, an indelible white patch is left at the site of the previous ulceration. It is in cases of leucoma, whe ther complicated or not with synechia), staphyloma, and perhaps opacity of the lens or its thickened capsule, that we are so frequently called upon to attempt the restoration of useful vision by the performance of some operation with a viesv to the admission of light to the "
fundus of the eye. Within the last eleven months, out of a total of 312 operations on the eye and its appendages, I find from my notes that 72 of these were for artificial pupil, but this number does not include many applicants, in whom, from there being no clear cornea, or owing to the existence of complications, such as extensive glaucomatous changes, atrophy of the discs or retina,
presumed
or
detachment of the
refuse any operative the patient.
interference,
latter, as
not
I have been
being likely
obliged to
to
benefit
There is probably no operation on the eye requiring a more careful attention to the details of each case than that for artificial pupil; and it is not often that we meet with two cases : consequently, no fixed rules can surgical treatment of each individual, a great deal of the manipulation being thus necessarily left to the judgment and experience of the surgeon. We can, however, I think, advantageously group our cases,
exactly identical
be laid down
as
in all respects to the precise
with reference to the treatment of each very similar series, than the minute details of minor complications in indi-
more
vidual
cases.
I will
proceed
reference to
some
to
give examples
of each group of cases, by a actually come under my
of those that have
observation and treatment in India, premising that there the performance of an artificial many others in which pupil such as the closure of the natural one after be necessary, may extraction or depression of the lens, adhesion of the iris to a own are
peripheral
or
central wound
due to iritis, &c.
or
ulcer of the cornea, closed pupil
Group 1.?One eye normal, central leucoma of the other, or opacity covering the two lower thirds of the cornea; pupil
the
dilatable by atropine. This is a sufficiently common case.
The patient comes to us eye perfectly healthy, whilst the vision of the opposite is very indifferent in a modified light, and in bright sunshine he We examine the eye cannot see at all with the affected organ. complained of, and find a dense central leucoma, the result of a ?previous ulcer in this situation ; the opacity is, as I have said, with
one
central, or extends over the lower two-thirds of the cornea, and, therefore, if of sufficient size, covers the pupil in whatever lighc the patient may be; if smaller, it is only when the pupil is cuu-
Mat
1,1878.] OPERATIVE PROCEEDINGS FOR ARTIFICIAL PUPIL.-BY F. ODEVAINE.
exposure to a strong glax-e, that vision is all but The instillation of atropine will, by dilating the pupil, give the patient more light, and inform us as to the existence or otherwise of any irregularity of its edges, due to adhesions either to the leucomu in front, or the lens behind. On
tracted
by
obliterated.
the presence or not of syuechiae our procedure must greatly depend. Should we find that, on full dilatation, the margins of the pupil are free from adhesions, and the lens and its capsule trans-
parent,
may, with great benefit to our patient, of excision of a portion of the iris.
we
operfition
perform
the
In the case under consideration, wherein one eye is normal, pupil should always be made in an upward or downward direction ; for, if made laterally, diplopia would result,
the artificial
obliging the patient ing in a squint, due
to to
close the eye operated upon, or eventuatthe confusion produced by the double
vision. The instruments usually employed in the operation of excision of a portion of iris are a broad needle, blunt hook, curved scissors, fixation forceps and stop speculum. The most suitable broad needle is one bent at an angle with the shaft, which is more easily
manipulated from above, and its blade, being of a triangular pretty broad at the base, permits of the opening being a sufficient size to easily admit the hook, and facilitates its withdrawal subsequently. I always insert the broad needle at the corneo-sclerotic junction, being careful to steady the eye of proper fixation forceps, just below the cornea by means audits sub-cellular tissue. of the a conjunctiva grasp taking good The needle, on entering the anterior chamber, has its point turned slightly forward towards the cornea, so as to avoid wounding the iris or lens : the former accident would, by filling the anterior chamber with blood, obscure the subsequent steps of the operation, and the latter give rise to a traumatic cataract. When the broad needle has advanced sufficiently to produce a wound large enough to permit of the easy passage in and out of the blunt hook, it should be gradually withdrawn, so as to retain if the pupil has been preas much aqueous as possible; and, viously fully dilated by atropine, it will remain large notwithstanding the partial drain of the aqueous humor, and thus allow of our seeing its margin from above. The position of the open end of the hook, with reference to the handle having been previously noted, it is introduced 011 the flat, gliding it gently along thesclerotic conjunctiva immediately above the wound, into which it is gently introduced in a direction downwards and forwards, until its open end passes beyond the pupillary margin, when the handle should receive a quarter turn, and the instrument be gradually withdrawn. This will cause the margin of the pupil to become engaged in the hook, which should then be cautiously and steadily removed from the anterior chamber, bringing with it a portion of the iris, which should be gently pulled upon, and divided close to the wound by means of a pair of scissors bent 011 the flat. The latter part of the operation I generally entrusted to an assistant, as I prefer myself keeping command of the globe by means of the fixation forceps in the various manipulations necessary to ensure the correct performance of this operation, which, I may here state, I most usually do without the employform and made of
ment
of any anaesthetic. withdrawing the hook
with the engaged piece of iris, it again turned on its flat, the end being directed somewhat forwards ; this manoeuvre will protect the lens from injury and more firmly secure the pupillary margin from off. In
should be
slipping point to attend to is that the back of the hook should be of the corneal puncture, so that its kept against either extremity
Another
curved end may not hitch in the wound on its withdrawal. Most full-sized cases of eye instruments contain two blunt hooks, fixed at either extremity of the same handle, and one is much longer than the other. In those instances in which the breadth of iris i3 considerable at the site of operation, I would recommend the use of the longer hook, as it will more
securely hold the edge
of the
pupil.
"When there ia merely
a
115
iris, I introduce the short hook, which in such very well, and its point does not press on the ciliary attachment of the iris, as would otherwise occur if a longer hook were used, in which case also the instrument must necessarily be passed further into the anterior chamber, to permit of its open extremity passing beyond the pupillary margin rim of
narrow
cases answers
wilich
wish to
lay hold of. attention to these minor details that we are enabled to this operation with facility, and that exactness so necessary to success. At present, iridodialvsis and incarcerawe
It is
by perform
tion of iris, have been almost completely superseded by excision of the iris for the formation of artificial pupil. Liebreich baa invented a very useful forceps with fine curved points, which,
being passed, closed, through a small opening into the anterior are made to open sufficiently to seize the iris, without, at the same time, necessitating any divarication of the limbs of the forceps, which turn ou a horizontal axis. The abscission of the portion of iris drawn out by the hook most commonly leaves a triangular-shaped pnpil, the base below and the apex at the site of puncture, which is occasionally occupied by a small dark piece of iris, which, if at all projecting, I seize with a fine pair of forceps and snip off. Very soon after the operation, the new pupil may become obscured by blood effused from the cut edges of the iris. This is, however, soou absorbed, and the patient enjoys binocular and more extended lateral vision, as is the case in congenital colohoma iridis, in which no diplopia exists. It is well to warn the patient that he may for the first day or two get no increase of vision with the eye operated on ; for, as I have mentioned above, the new pupil is occasionally filled by effused blood, on the absorption of which much useful sight will be restored. After the operation, the eye should be kept bandaged down for a day or two, and atropine applied. In several instances, I have, some time after making the artificial pupil, tinted the leucoma in the manner detailed by me at page 291 of the Indian Medical Gazette for November, thus producing, not only an optical, but a cosmetic improvement, the latter being much appreciated by many. on
chamber,
Group 2.?One eye lost; leucoma and
a more or less nebulous the other eye. In this class of cases, if there are no synechiae, and the edge of the previously dilated pupil can be seen through the clear portion of cornea, it will be best to perform the operation of excision of a part of the iris as described above. The new pupil should be made behind any remaining clear cornea, taking particular care that the broad needle is entered well within the corneo-sclerotic junction, and not through the transparent cornea, as the wound would leave some opacity in this situation which is to be avoided. If we have a choice, the artificial
condition
of
the cornea
of
under the above circumstances, be made at the upper aud inner quadrant of the cornea, as giving better and more useful vision. The next site of election would be above, then below, and the most unfavorable externally ; the position of the new pupil must, however, depend upon the situation of the
pupil should,
corneal opacity. In making the excision of iris above, we should, particularly if the leucoma extends upwards, make a pretty large pupil by dragging the iris, seized by the hook, well through the wound, as the upper lid will cover the superior sharp angle of the new pupil, which will thus appear as a small oblong opening. Should we, ou the use of atropine, find that synechia) exist, or should the corneal opacity preclude our seeing the free edge
on its full dilatation, we cannot in such a case perform excision in the manner previously described, as the employment of the blunt hook would be attended by considerable
of the iris
danger
of laceration of the
cataract.
capsule
of the
lens, resulting
in
THE INDIAN MEDICAL GAZETTE.
116 This
brings
us
to
Group 3 ?One eye lost, the cornea of the opposite by a large leucoma with or ivithout synechice.
being occupied
For the reasons given above, we are obliged to remove a piece of iris from behind the remaining clear portion of cornea by some other means than tlie blunt hook ; and, unless we employ Liebreich's forceps previously alluded to, we are obliged to make an opening through the cornea of a size proportionate to that of the intended pupil. The patient being placed in the recumbent position opposite means of a a good light, the lids are kept apart by proper speculum ; the fixation forceps should be applied close to the to the point of intended puncture, cornea and exactly opposite which, if above or internally, I make by means of a mediumsized angular iridectomy knife, which is entered at the corneosclerotic junction, keeping its point directed slightly forwards, and advancing the instrument into the anterior chamber by steady pressure, so as to keep the wound filled by the blade, and prevent the escape of aqueous until the opening is of the size we wish to make it, when the knife is carefully withdrawn with the same precaution as on its entrance. Should there be no synechioe, the rapid removal of the instrument from the anterior chamber is followed by a rush of aqueous which prolapses the iris, which can be thus more easily seized by a pair of fine curved iridectomy forceps, and excised by angular or curved scissors. If the iris does not spontaneously protrude, the forceps are introduced a very short distance within the wound, and the iris caught midway between its pupillary margin and ciliary attachment and gently drawn out. I generally divide the iris at one angle of the incision ; and, by gently pulling on the portion held by the forceps, tear it away, as far as the opposite angle, at which it is again divided. During the excision of the iris, I entrust the fixation forceps to an assistant. When the artificial pupil is made above, we may safely uo a pretty large iridectomy ; when, however, the operation is performed below or laterally we must be careful not to take too large a piece of iris away, as in such a case unpleasant dazzling would result. In those cases in which the iridectomy is made inferiorly or externally, it will be found more convenient to use a straight iridectomy knife, and the artificial pupil can be made by simply snipping off the portion of iris within the grasp of the forceps by one stroke of the scissors ; this usually leaves a triangular pupil of sufficient size. Occasionally, the anterior chamber becomes partly filled by blood effused from the divided conjunctiva in making the first puncture, thus obscuring the iris. It is advisable to remove the blood before it coagulates. This is done by gently pulling on the fixation forceps, or very lightly pressing on the surface of the cornea by a smooth curette in a direction towards the wound. In this way we clear the anterior chamber and again see the iris before its being caught by the forceps. In cases in which the ocular conjunctiva is lax, a flap of this membrane is formed by the entrance of the knife through the sclera; before seizing the iris, we should, with the same forceps, be careful to turn this small flap towards the cornea ; otherwise we may lay hold of it instead of the iris. After the operation, any small clot lodged between the edges of the wound should be gently removed by a fine pair of forceps. I generally keep a soft pad of moistened cotton wool applied to the eye by means of a bandage. This is kept on for a few days; and, by retaining the edges of the wound in apposition, prevents the formation of a cystoid cicatrix. ,
4.?Both eyes with large leucomata covering the pupils, smaller central ones with or without synechia;.
Giioup or
In the first instance, if the artificial pupils can be made in corresponding portions of each cornea, such as above, below or internally, owing to the existence of clear cornea in the-e situations, we may operate on either eye, with an interval of
[May 1,
1878.
a few days between the two operations. "When, however, the corneal opacities are so situated that the artificial pupils cannot be made through corresponding portions of the iris, it is better
to operate on one eye only, taking advantage of the most clear portion of cornea, provided it be large enough, and bearing in
mind the most eligible sites for the new pupil, as previously detailed under " Group 2." Should synechias exist, or the edge of the natural pupil be obscured, we must iridectomize ; otherwise, the
operation by In
excision will answer
admirably.
instance I had lately to operate for entropium
on both eyes, and subsequently make an artificial pupil upwards on either side, on account of a leucomatous state of the lower two-thirds of both cornese with a very good result.
of
one
Group 5.?One eye lost; in the other, leucoma cornea ; synechia; anterior ; capsular cataract.
of
lower
half
The above are rather complicated cases ; yet, if the patient has perception of light, and can make out the shadow of the hand passed between the eye and an open window, very useful sight may be restored by proper operative measures. In a young man coming under this group, I first made a large iridectomy upwards, and then removed the thickened and opaque capsule, which was adherent below, by means of an ordinary pair of finely pointed curved forceps, and some cheesy lenticular matter was taken away by a scoop. The patient, who a
had been all but blind for fifteen years, recovered very useful In the absence of canula forceps, the fine iridectomy ones answer {very well for removing opaque capsule from the anterior chamber. This is best done by seizing the vision indeed.
membrane about its upper or lower third as the case may be, and giving the instrument a twist between the fingers should any adiiesions exist; for if, under these circumstances, it is pulled
directly, there would be some choroidal attachment of the iris. on
danger
of
separating
the
Group 6.? One eye lost, a large leucoma leaving only outer and quadrants of other cornea clear ; lens opaque. In these cases, owing to the natural pupil being quite obscured by the large corneal opacity in front, we are very often unable upper
to say whether the lens is opaque or not, until the artificial pupil has been made, and allows of our thus getting a view of the deeper part of the eye. Under the conditions included in the above group, we should first
perform a very careful iridectomy, making our puncture beyond the clear cornea, with the double object of not encroaching upon it, and of permitting of the iridectomy being complete np to the ciliary attachment of the iris. Inmeaiatelv after the operation, we may not, on account of the flow of well
blood into the anterior chamber, be able to state whether cataract This will, however, be ascertained by oblique or not. illumination assoonas the effusedblood has been absorbed. Should exists
patient then be able to count fingers at a few inches from his face, or to aiseern large objects placed further off. we should refrain from attempting the removal of the lens, for its margin may be only slightly opaque, and the cataract may not ripen or the
very gradually, leaving a mere perception of light, when would be fully justified in performing extraction. I need scarcely say that with only a small portion of clear cornea left,
do
so
we
the latter operation is very difficult, as we cannot of course see the lens, and the various manipulations must be done under the leucoma. In a case coming under the sixth group, and in which I made an artificial pupil upwards and outwards, the
operation a perception of light only, fingers at 16", and make out large objects at a considerable distance, notwithstanding the existence of an opaque lens. I told this old man that his sight was likely to diminish as the cataract matured, and that in that case I would attempt the removal of the lens. The opposite eye was collapsed and painful on light pressure; and, as I feared its
patient, having was
before the
afterwards able to count
May 1,
DO YOU BELIEVE IN PRESENTIMENT ?-BY W. CURRAN.
1878.]
sympathetically affecting the atrophied globe.
the one
operated
upon, I enucleated
Group 7.?One eye in which the pupillary closed
pupil;
a
lost, the other with a large central leucoma margin is entirely engaged, constituting nebulous condition of the whole cornea existing as
well. A very difficult case
to manage; and, when comparatively requiring early |operative interference to prevent glaucomatous changes within the eye, eventuating in atrophy. A case of this description was lately under my care, in which a large ulcer had perforated the cornea, causing prolapse at the pupillary margin of the iris, and its entanglement in the cicatrix, with a more or less nebulous condition of the whole cornea. A small iridectomy was made upwards and inwards, not only with a view to its optica], but also therapeutical, effects. For the former, we should have a clear portion of cornea ; but, as the pupil was closed, and the natural communication between the chambers of the eye shut off, it was essential to anticipate pathological changes which would eventuate in disorganization of this poor man's only eye. The ulcerative keratitis, which originally gave rise to the leucoma, &c., having been, recent, I had every hope that the nebulous condition of the cornea would clear away, and thus allow of more light passing through the artificial pupil. My anticipations are being realized, for I now find that, although it is but six months since the operation, the patient, a learned "Kazee," can now distinguish letters corresponding to No. 18 of Jaeger's test type, although previously he had only a perception of light.
speaking
recent,
The above seven groups of cases
are
a
notes, and I hope they may prove useful of treatment most
requiring operation,
likely
to
the formation of
few taken from my indicating the line
as
be successful in similar instances an artificial pupil, for which
it will be observed, I have confined my proceedings through a small puncture,
to the removal of a portion of the iris or a more extensive excision with
separation of its ciliary through a larger wound, constituting iridectomy. conclusion, remark that whenever, in cases requiring an artificial pupil, we find the globe preternaturally hard, or that extensive synechise exist likely to induce recurrent iritis, we should iridectomize with a view to preventing morbid changes destructive of the eye, and at the same time to admit li"ht to the fundus; in other words we should, in such cases, make a large artificial pupil by iridectomy, even if some dazzling should result in consequence, and the latter may be subsequently modified by tinting the cornea corresponding to, and encroaching slightly on, the margin of the new pupil, and thus cutiiug off a portion of light. In making the artificial pupil above, we need not fear its being too large, as the lid covers the much light from upper portion of the cornea, and prevents too v reaching the fundus. Sehoke, C. I., February 1878. attachment I would, in
)
By Surgeon-Major F. Odevaine, F.Il.C.S., JBhopal Battalion 8c Political Agency. In a country like India, in which diseases of the eye are at once so common and so frequently neglected or mismanaged, owing to the ignorance of the people and the', comparatively speaking, few hospitals or dispensaries within easy reach of avast number of the population, very many suffer from dense leucomata, witli or without partial staphyloma, the consequence of deep ulceration of the cornea. The density and extent of these corneal opacities are frequently much aggravated by the practice of using locally so common amongst the natives phool," or oxide of zinc, which they apply for all forms of ophthalmia ; and, should abrasion or ulcer of the cornea exist, an indelible white patch is left at the site of the previous ulceration. It is in cases of leucoma, whe ther complicated or not with synechia), staphyloma, and perhaps opacity of the lens or its thickened capsule, that we are so frequently called upon to attempt the restoration of useful vision by the performance of some operation with a viesv to the admission of light to the "
fundus of the eye. Within the last eleven months, out of a total of 312 operations on the eye and its appendages, I find from my notes that 72 of these were for artificial pupil, but this number does not include many applicants, in whom, from there being no clear cornea, or owing to the existence of complications, such as extensive glaucomatous changes, atrophy of the discs or retina,
presumed
or
detachment of the
refuse any operative the patient.
interference,
latter, as
not
I have been
being likely
obliged to
to
benefit
There is probably no operation on the eye requiring a more careful attention to the details of each case than that for artificial pupil; and it is not often that we meet with two cases : consequently, no fixed rules can surgical treatment of each individual, a great deal of the manipulation being thus necessarily left to the judgment and experience of the surgeon. We can, however, I think, advantageously group our cases,
exactly identical
be laid down
as
in all respects to the precise
with reference to the treatment of each very similar series, than the minute details of minor complications in indi-
more
vidual
cases.
I will
proceed
reference to
some
to
give examples
of each group of cases, by a actually come under my
of those that have
observation and treatment in India, premising that there the performance of an artificial many others in which pupil such as the closure of the natural one after be necessary, may extraction or depression of the lens, adhesion of the iris to a own are
peripheral
or
central wound
due to iritis, &c.
or
ulcer of the cornea, closed pupil
Group 1.?One eye normal, central leucoma of the other, or opacity covering the two lower thirds of the cornea; pupil
the
dilatable by atropine. This is a sufficiently common case.
The patient comes to us eye perfectly healthy, whilst the vision of the opposite is very indifferent in a modified light, and in bright sunshine he We examine the eye cannot see at all with the affected organ. complained of, and find a dense central leucoma, the result of a ?previous ulcer in this situation ; the opacity is, as I have said, with
one
central, or extends over the lower two-thirds of the cornea, and, therefore, if of sufficient size, covers the pupil in whatever lighc the patient may be; if smaller, it is only when the pupil is cuu-
Mat
1,1878.] OPERATIVE PROCEEDINGS FOR ARTIFICIAL PUPIL.-BY F. ODEVAINE.
exposure to a strong glax-e, that vision is all but The instillation of atropine will, by dilating the pupil, give the patient more light, and inform us as to the existence or otherwise of any irregularity of its edges, due to adhesions either to the leucomu in front, or the lens behind. On
tracted
by
obliterated.
the presence or not of syuechiae our procedure must greatly depend. Should we find that, on full dilatation, the margins of the pupil are free from adhesions, and the lens and its capsule trans-
parent,
may, with great benefit to our patient, of excision of a portion of the iris.
we
operfition
perform
the
In the case under consideration, wherein one eye is normal, pupil should always be made in an upward or downward direction ; for, if made laterally, diplopia would result,
the artificial
obliging the patient ing in a squint, due
to to
close the eye operated upon, or eventuatthe confusion produced by the double
vision. The instruments usually employed in the operation of excision of a portion of iris are a broad needle, blunt hook, curved scissors, fixation forceps and stop speculum. The most suitable broad needle is one bent at an angle with the shaft, which is more easily
manipulated from above, and its blade, being of a triangular pretty broad at the base, permits of the opening being a sufficient size to easily admit the hook, and facilitates its withdrawal subsequently. I always insert the broad needle at the corneo-sclerotic junction, being careful to steady the eye of proper fixation forceps, just below the cornea by means audits sub-cellular tissue. of the a conjunctiva grasp taking good The needle, on entering the anterior chamber, has its point turned slightly forward towards the cornea, so as to avoid wounding the iris or lens : the former accident would, by filling the anterior chamber with blood, obscure the subsequent steps of the operation, and the latter give rise to a traumatic cataract. When the broad needle has advanced sufficiently to produce a wound large enough to permit of the easy passage in and out of the blunt hook, it should be gradually withdrawn, so as to retain if the pupil has been preas much aqueous as possible; and, viously fully dilated by atropine, it will remain large notwithstanding the partial drain of the aqueous humor, and thus allow of our seeing its margin from above. The position of the open end of the hook, with reference to the handle having been previously noted, it is introduced 011 the flat, gliding it gently along thesclerotic conjunctiva immediately above the wound, into which it is gently introduced in a direction downwards and forwards, until its open end passes beyond the pupillary margin, when the handle should receive a quarter turn, and the instrument be gradually withdrawn. This will cause the margin of the pupil to become engaged in the hook, which should then be cautiously and steadily removed from the anterior chamber, bringing with it a portion of the iris, which should be gently pulled upon, and divided close to the wound by means of a pair of scissors bent 011 the flat. The latter part of the operation I generally entrusted to an assistant, as I prefer myself keeping command of the globe by means of the fixation forceps in the various manipulations necessary to ensure the correct performance of this operation, which, I may here state, I most usually do without the employform and made of
ment
of any anaesthetic. withdrawing the hook
with the engaged piece of iris, it again turned on its flat, the end being directed somewhat forwards ; this manoeuvre will protect the lens from injury and more firmly secure the pupillary margin from off. In
should be
slipping point to attend to is that the back of the hook should be of the corneal puncture, so that its kept against either extremity
Another
curved end may not hitch in the wound on its withdrawal. Most full-sized cases of eye instruments contain two blunt hooks, fixed at either extremity of the same handle, and one is much longer than the other. In those instances in which the breadth of iris i3 considerable at the site of operation, I would recommend the use of the longer hook, as it will more
securely hold the edge
of the
pupil.
"When there ia merely
a
115
iris, I introduce the short hook, which in such very well, and its point does not press on the ciliary attachment of the iris, as would otherwise occur if a longer hook were used, in which case also the instrument must necessarily be passed further into the anterior chamber, to permit of its open extremity passing beyond the pupillary margin rim of
narrow
cases answers
wilich
wish to
lay hold of. attention to these minor details that we are enabled to this operation with facility, and that exactness so necessary to success. At present, iridodialvsis and incarcerawe
It is
by perform
tion of iris, have been almost completely superseded by excision of the iris for the formation of artificial pupil. Liebreich baa invented a very useful forceps with fine curved points, which,
being passed, closed, through a small opening into the anterior are made to open sufficiently to seize the iris, without, at the same time, necessitating any divarication of the limbs of the forceps, which turn ou a horizontal axis. The abscission of the portion of iris drawn out by the hook most commonly leaves a triangular-shaped pnpil, the base below and the apex at the site of puncture, which is occasionally occupied by a small dark piece of iris, which, if at all projecting, I seize with a fine pair of forceps and snip off. Very soon after the operation, the new pupil may become obscured by blood effused from the cut edges of the iris. This is, however, soou absorbed, and the patient enjoys binocular and more extended lateral vision, as is the case in congenital colohoma iridis, in which no diplopia exists. It is well to warn the patient that he may for the first day or two get no increase of vision with the eye operated on ; for, as I have mentioned above, the new pupil is occasionally filled by effused blood, on the absorption of which much useful sight will be restored. After the operation, the eye should be kept bandaged down for a day or two, and atropine applied. In several instances, I have, some time after making the artificial pupil, tinted the leucoma in the manner detailed by me at page 291 of the Indian Medical Gazette for November, thus producing, not only an optical, but a cosmetic improvement, the latter being much appreciated by many. on
chamber,
Group 2.?One eye lost; leucoma and
a more or less nebulous the other eye. In this class of cases, if there are no synechiae, and the edge of the previously dilated pupil can be seen through the clear portion of cornea, it will be best to perform the operation of excision of a part of the iris as described above. The new pupil should be made behind any remaining clear cornea, taking particular care that the broad needle is entered well within the corneo-sclerotic junction, and not through the transparent cornea, as the wound would leave some opacity in this situation which is to be avoided. If we have a choice, the artificial
condition
of
the cornea
of
under the above circumstances, be made at the upper aud inner quadrant of the cornea, as giving better and more useful vision. The next site of election would be above, then below, and the most unfavorable externally ; the position of the new pupil must, however, depend upon the situation of the
pupil should,
corneal opacity. In making the excision of iris above, we should, particularly if the leucoma extends upwards, make a pretty large pupil by dragging the iris, seized by the hook, well through the wound, as the upper lid will cover the superior sharp angle of the new pupil, which will thus appear as a small oblong opening. Should we, ou the use of atropine, find that synechia) exist, or should the corneal opacity preclude our seeing the free edge
on its full dilatation, we cannot in such a case perform excision in the manner previously described, as the employment of the blunt hook would be attended by considerable
of the iris
danger
of laceration of the
cataract.
capsule
of the
lens, resulting
in
THE INDIAN MEDICAL GAZETTE.
116 This
brings
us
to
Group 3 ?One eye lost, the cornea of the opposite by a large leucoma with or ivithout synechice.
being occupied
For the reasons given above, we are obliged to remove a piece of iris from behind the remaining clear portion of cornea by some other means than tlie blunt hook ; and, unless we employ Liebreich's forceps previously alluded to, we are obliged to make an opening through the cornea of a size proportionate to that of the intended pupil. The patient being placed in the recumbent position opposite means of a a good light, the lids are kept apart by proper speculum ; the fixation forceps should be applied close to the to the point of intended puncture, cornea and exactly opposite which, if above or internally, I make by means of a mediumsized angular iridectomy knife, which is entered at the corneosclerotic junction, keeping its point directed slightly forwards, and advancing the instrument into the anterior chamber by steady pressure, so as to keep the wound filled by the blade, and prevent the escape of aqueous until the opening is of the size we wish to make it, when the knife is carefully withdrawn with the same precaution as on its entrance. Should there be no synechioe, the rapid removal of the instrument from the anterior chamber is followed by a rush of aqueous which prolapses the iris, which can be thus more easily seized by a pair of fine curved iridectomy forceps, and excised by angular or curved scissors. If the iris does not spontaneously protrude, the forceps are introduced a very short distance within the wound, and the iris caught midway between its pupillary margin and ciliary attachment and gently drawn out. I generally divide the iris at one angle of the incision ; and, by gently pulling on the portion held by the forceps, tear it away, as far as the opposite angle, at which it is again divided. During the excision of the iris, I entrust the fixation forceps to an assistant. When the artificial pupil is made above, we may safely uo a pretty large iridectomy ; when, however, the operation is performed below or laterally we must be careful not to take too large a piece of iris away, as in such a case unpleasant dazzling would result. In those cases in which the iridectomy is made inferiorly or externally, it will be found more convenient to use a straight iridectomy knife, and the artificial pupil can be made by simply snipping off the portion of iris within the grasp of the forceps by one stroke of the scissors ; this usually leaves a triangular pupil of sufficient size. Occasionally, the anterior chamber becomes partly filled by blood effused from the divided conjunctiva in making the first puncture, thus obscuring the iris. It is advisable to remove the blood before it coagulates. This is done by gently pulling on the fixation forceps, or very lightly pressing on the surface of the cornea by a smooth curette in a direction towards the wound. In this way we clear the anterior chamber and again see the iris before its being caught by the forceps. In cases in which the ocular conjunctiva is lax, a flap of this membrane is formed by the entrance of the knife through the sclera; before seizing the iris, we should, with the same forceps, be careful to turn this small flap towards the cornea ; otherwise we may lay hold of it instead of the iris. After the operation, any small clot lodged between the edges of the wound should be gently removed by a fine pair of forceps. I generally keep a soft pad of moistened cotton wool applied to the eye by means of a bandage. This is kept on for a few days; and, by retaining the edges of the wound in apposition, prevents the formation of a cystoid cicatrix. ,
4.?Both eyes with large leucomata covering the pupils, smaller central ones with or without synechia;.
Giioup or
In the first instance, if the artificial pupils can be made in corresponding portions of each cornea, such as above, below or internally, owing to the existence of clear cornea in the-e situations, we may operate on either eye, with an interval of
[May 1,
1878.
a few days between the two operations. "When, however, the corneal opacities are so situated that the artificial pupils cannot be made through corresponding portions of the iris, it is better
to operate on one eye only, taking advantage of the most clear portion of cornea, provided it be large enough, and bearing in
mind the most eligible sites for the new pupil, as previously detailed under " Group 2." Should synechias exist, or the edge of the natural pupil be obscured, we must iridectomize ; otherwise, the
operation by In
excision will answer
admirably.
instance I had lately to operate for entropium
on both eyes, and subsequently make an artificial pupil upwards on either side, on account of a leucomatous state of the lower two-thirds of both cornese with a very good result.
of
one
Group 5.?One eye lost; in the other, leucoma cornea ; synechia; anterior ; capsular cataract.
of
lower
half
The above are rather complicated cases ; yet, if the patient has perception of light, and can make out the shadow of the hand passed between the eye and an open window, very useful sight may be restored by proper operative measures. In a young man coming under this group, I first made a large iridectomy upwards, and then removed the thickened and opaque capsule, which was adherent below, by means of an ordinary pair of finely pointed curved forceps, and some cheesy lenticular matter was taken away by a scoop. The patient, who a
had been all but blind for fifteen years, recovered very useful In the absence of canula forceps, the fine iridectomy ones answer {very well for removing opaque capsule from the anterior chamber. This is best done by seizing the vision indeed.
membrane about its upper or lower third as the case may be, and giving the instrument a twist between the fingers should any adiiesions exist; for if, under these circumstances, it is pulled
directly, there would be some choroidal attachment of the iris. on
danger
of
separating
the
Group 6.? One eye lost, a large leucoma leaving only outer and quadrants of other cornea clear ; lens opaque. In these cases, owing to the natural pupil being quite obscured by the large corneal opacity in front, we are very often unable upper
to say whether the lens is opaque or not, until the artificial pupil has been made, and allows of our thus getting a view of the deeper part of the eye. Under the conditions included in the above group, we should first
perform a very careful iridectomy, making our puncture beyond the clear cornea, with the double object of not encroaching upon it, and of permitting of the iridectomy being complete np to the ciliary attachment of the iris. Inmeaiatelv after the operation, we may not, on account of the flow of well
blood into the anterior chamber, be able to state whether cataract This will, however, be ascertained by oblique or not. illumination assoonas the effusedblood has been absorbed. Should exists
patient then be able to count fingers at a few inches from his face, or to aiseern large objects placed further off. we should refrain from attempting the removal of the lens, for its margin may be only slightly opaque, and the cataract may not ripen or the
very gradually, leaving a mere perception of light, when would be fully justified in performing extraction. I need scarcely say that with only a small portion of clear cornea left,
do
so
we
the latter operation is very difficult, as we cannot of course see the lens, and the various manipulations must be done under the leucoma. In a case coming under the sixth group, and in which I made an artificial pupil upwards and outwards, the
operation a perception of light only, fingers at 16", and make out large objects at a considerable distance, notwithstanding the existence of an opaque lens. I told this old man that his sight was likely to diminish as the cataract matured, and that in that case I would attempt the removal of the lens. The opposite eye was collapsed and painful on light pressure; and, as I feared its
patient, having was
before the
afterwards able to count
May 1,
DO YOU BELIEVE IN PRESENTIMENT ?-BY W. CURRAN.
1878.]
sympathetically affecting the atrophied globe.
the one
operated
upon, I enucleated
Group 7.?One eye in which the pupillary closed
pupil;
a
lost, the other with a large central leucoma margin is entirely engaged, constituting nebulous condition of the whole cornea existing as
well. A very difficult case
to manage; and, when comparatively requiring early |operative interference to prevent glaucomatous changes within the eye, eventuating in atrophy. A case of this description was lately under my care, in which a large ulcer had perforated the cornea, causing prolapse at the pupillary margin of the iris, and its entanglement in the cicatrix, with a more or less nebulous condition of the whole cornea. A small iridectomy was made upwards and inwards, not only with a view to its optica], but also therapeutical, effects. For the former, we should have a clear portion of cornea ; but, as the pupil was closed, and the natural communication between the chambers of the eye shut off, it was essential to anticipate pathological changes which would eventuate in disorganization of this poor man's only eye. The ulcerative keratitis, which originally gave rise to the leucoma, &c., having been, recent, I had every hope that the nebulous condition of the cornea would clear away, and thus allow of more light passing through the artificial pupil. My anticipations are being realized, for I now find that, although it is but six months since the operation, the patient, a learned "Kazee," can now distinguish letters corresponding to No. 18 of Jaeger's test type, although previously he had only a perception of light.
speaking
recent,
The above seven groups of cases
are
a
notes, and I hope they may prove useful of treatment most
requiring operation,
likely
to
the formation of
few taken from my indicating the line
as
be successful in similar instances an artificial pupil, for which
it will be observed, I have confined my proceedings through a small puncture,
to the removal of a portion of the iris or a more extensive excision with
separation of its ciliary through a larger wound, constituting iridectomy. conclusion, remark that whenever, in cases requiring an artificial pupil, we find the globe preternaturally hard, or that extensive synechise exist likely to induce recurrent iritis, we should iridectomize with a view to preventing morbid changes destructive of the eye, and at the same time to admit li"ht to the fundus; in other words we should, in such cases, make a large artificial pupil by iridectomy, even if some dazzling should result in consequence, and the latter may be subsequently modified by tinting the cornea corresponding to, and encroaching slightly on, the margin of the new pupil, and thus cutiiug off a portion of light. In making the artificial pupil above, we need not fear its being too large, as the lid covers the much light from upper portion of the cornea, and prevents too v reaching the fundus. Sehoke, C. I., February 1878. attachment I would, in
)
