- Email: [email protected]
Conservative Treatment of Massive Cystoid Following Cataract Extraction
CONSERVATIVE TREATMENT OF MASSIVE CYSTOID FOLLOWING CATARACT EXTRACTION BURTON CHANCE, M.D. PHILADELPHIA
Three cases are reported to show the results of an operation for the reduction of enormous cystoid ectases which developed after cataract extraction. The ectases had been produced by the accumulation of aqueous, the anterior and posterior chambers in the affected eyes having been cut off from each other by the iris membrane. The cystoids were treated by lacerating the lower portion of the iridocapsular membrane with a Ziegler knife needle, thereby establishing communication between the chambers. In a few weeks the bulgings of the irides decreased and shrank—in one case entirely—and all three eyes now have useful sight. Read before the Section on Ophthalmology, College of Physicians in Philadelphia, February IS, 1934.
On April 11, 1932, I extracted the right crystalline lens by ordinary com bined procedures and without accident. Recovery followed without incident. On May 18, I attempted in the left eye an iridocapsulotomy with a Ziegler knife needle. There was not sufficient depth to the chamber to permit the in sertion of the blade without lacerating the membranous sheet. The membrane was very dense and difficult to incise even with the perfect blade employed; however, finally, a more or less purpose ful incision was made, and a rhomboidal opening secured. For several days the aqueous chamber was filled with blood and capsulolenticular debris, but, by June 7, there was a clear opening which allowed some view of the fundus. Be fore the end of the month a plus 10 lens was given with addition for near. A remarkable change had taken place in the patient's morale and a great in crease in her general strength. She went off to the seaside until September. On her return I was astonished to see that the ectasis had shrunk to a remarkable extent, that the patient could read easily with each eye small types and the news paper, and that vision was 4/3 fully. The opening in the iris in the left eye en abled me to explore the fundus, which was healthy. When last examined in November, 1933, full 4/4 and small types could be read with each eye, while in the left eye only a slight elevation of the cystoid was visible and the globe had been free from pain. The second case to be detailed is that of F.B., a male, aged 63 years, who con sulted me on August 30, 1932. 929
In 1932, three persons consulted me because of exactly similar conditions, namely, mature senile cataract in the right eye, and discomfort in the left eye occasioned by a staphylomatous cystoid supervening on a previously performed extraction of cataract. Each person was blind and helpless, greatly depressed psychically because of hopelessness, having in mind the recollection of many weeks of infirmity after the former cata ract operation. Today, each, after the extraction of cataract in the second eye, is able to see well and is capable of carrying on the accustomed daily oc cupations, having been afforded useful sight in the eye with the ectasia, also. In March, 1932, Mrs. R.M.C., aged 76 years, in a state of marked decrepi tude, querulous, unkempt, and blind, was all but carried into my office. Her right eye contained a mature cataract; the left, presented chronic blepharoconjunctivitis and injection of the globe, the upper one fourth displaying a huge sausagelike ectasis. Singularly, there was no pain; and the eye was not ten der. Light and shadows only, could be appreciated. The patient had had failing sight be cause of cataracts since 1920. In 1929, the left eye had been operated on, but, at the second dressing, she was told a prolapse of the iris had occurred. Hospitalization was continued for two months, during which time she was urged repeatedly to have the eyeball removed. About four weeks after hospitalization another surgeon performed some operation, necessitating the inser tion of stitches; no further treatment was given.
930
BURTON CHANCE
In October, 1931, his left eye had been operated on for cataract, and had be come so inflamed that he was kept in the hospital for many weeks, having been told that erysipelas had set in, inflaming the skin of his face and eyelids. He was advised to have the eye removed, but would not consent. In the succeeding months he was in miserable health and despondent because of his helplessness, the right eye being reduced to light per ception. When examined by me, there was a hypermature cataract in the right eye, through which light was perceived and projection obtained promptly in all fields. The left globe presented a dense ly leucomatous cornea with slight vascularity. At the upper sclerocorneal juncture, were two large cystic ectases projecting from a whitish line, as though from a dense cicatrix. Light could be perceived in all directions. The iris seemed to be adherent to the leucoma, thus abolishing the anterior chamber. The appearance of the globe resembled a ciliary staphyloma. The eye was con stantly irritated by the lashes" from a deeply in-turned lower lid. There was marked eczematous dermatitis, aggra vated by the constant flow of tears from the irritated eye. On September 14, 1932, after making a small peripheral iridectomy, I reremoved the crystalline lens from the right eye, the extraction being com pleted with the aid of capsule forceps. The patient was highly nervous, and required sedatives. On the third night he became wild and pulled off his dress ings, yet his recovery was entirely satis factory, except that mydriasis could not be maintained because of the painful dermatitis that was set up by the use of atropine and other allied solutions. The ectasis in the left eye was judged to be dependent upon the pressure on the iris from the accumulation of aque ous in the posterior chamber, as noted in the first case. It appeared probable that drainage of the fluid might be se cured by effecting the formation of a channel into the anterior chamber. Therefore, on October 10, an iridotomy was attempted with a Ziegler knife in serted at the outer limbus. The blade
having been insinuated across the stretched iris, a puncture was made near the bottom of the vertical meridian, and an upward slit effected, followed by a cross cut. The thick and fibrous iridocapsular sheet was incised with diffi culty. Much thin vitreous flowed out into the aqueous through the aperture and through the external knife punc ture, followed by free hemorrhage. Only slight reaction supervened so that by the fifth day the eye had become quiet, the hyphemia translucent, and, to my astonishment, the two ectases had be come umbilicated. Soon thereafter, they rapidly collapsed, so that by the end of December they had shrunk markedly. In November, an attempt was made to sever the fibrous strands spanning the "hole" in the iridocapsular membrane. For several weeks, the skin of the lids and cheeks continued to be rough and fissured. In December, several punc tures were made in the left lower lid with the galvanic needle, resulting in a satisfactory eversion of the cilia so that the globe was no longer irritated by them. In the meantime, the bloody de tritus in the aqueous had become ab sorbed, and, by March, 1933, it was possible to make out details of the fundus. In May, great comfort was af forded by an aphakic correction, which, by the end of June, enabled the man to see 4/22. By this time the ectases had become flattened to their present ap pearance, the dermatitis had healed, the entropion had been greatly relieved, and the patient could go about alone and live an enjoyable existence. Some time be fore Christmas the patient was not well, perhaps it was the grip, since when the sight of the left eye has not been as acute as formerly. Without doubt, what was regarded as "erysipelas," which set in after the first cataract was operated upon, was in reality an atropine dermatitis. When it was repeated during my care of the man, its manifestations were indeed alarming to the nurses, who believed it indicated erysipelas, and who, because there were obstetric patients in the house, pleaded that the man should be taken away. Each subsequent use of even a weak solution, or oily suspension was fol-
CYSTOID FOLLOWING CATARACT EXTRACTION lowed by redness and edema of the skin. The third case presented local condi tions quite similar to those in the first case. A cataract extraction was per formed on the right eye, and the iris sheet of the left eye slit, with visual and pathological sequences quite like those observed in that case. The details of this history will be related in a future com munication. These cases as presented are based on the features which each offered at the first glance. So massive were the ectases, and so feeble the patients, that anyone would with reason have hesi tated to expose them to the strains which arise during plastic operations de vised for the obliteration of extrusions in the ciliary regions, such as in the re duction of a staphyloma. On closer study, however, it appeared that in no case was there thinning of the ciliary region, the ectasis being confined to iris tissue, over which was spread a deli
931
cate conjunctival membrane. In effect, the condition was like that found in iris bombe, where the anterior chamber is cut off from the posterior, in conse quence of which the accumulated humor distends and bulges the thinned iris membrane. It was deemed wise, there fore, not to attempt an excision of the bladderlike ectasis, nor yet to puncture it. Accordingly, my design sought to make an opening in the iris membrane within the chamber, hoping thereby that the ectasis might collapse and shrink in a short while. My expectations were fulfilled by the simple procedures instituted. The re moval of the cataract from the right eye and the effects of what was done on the left so promptly revived the exhausted morale of each of the afflicted persons that one may regret that the procedure had not been carried out earlier. 315 South Fifteenth Street.
Three cases are reported to show the results of an operation for the reduction of enormous cystoid ectases which developed after cataract extraction. The ectases had been produced by the accumulation of aqueous, the anterior and posterior chambers in the affected eyes having been cut off from each other by the iris membrane. The cystoids were treated by lacerating the lower portion of the iridocapsular membrane with a Ziegler knife needle, thereby establishing communication between the chambers. In a few weeks the bulgings of the irides decreased and shrank—in one case entirely—and all three eyes now have useful sight. Read before the Section on Ophthalmology, College of Physicians in Philadelphia, February IS, 1934.
On April 11, 1932, I extracted the right crystalline lens by ordinary com bined procedures and without accident. Recovery followed without incident. On May 18, I attempted in the left eye an iridocapsulotomy with a Ziegler knife needle. There was not sufficient depth to the chamber to permit the in sertion of the blade without lacerating the membranous sheet. The membrane was very dense and difficult to incise even with the perfect blade employed; however, finally, a more or less purpose ful incision was made, and a rhomboidal opening secured. For several days the aqueous chamber was filled with blood and capsulolenticular debris, but, by June 7, there was a clear opening which allowed some view of the fundus. Be fore the end of the month a plus 10 lens was given with addition for near. A remarkable change had taken place in the patient's morale and a great in crease in her general strength. She went off to the seaside until September. On her return I was astonished to see that the ectasis had shrunk to a remarkable extent, that the patient could read easily with each eye small types and the news paper, and that vision was 4/3 fully. The opening in the iris in the left eye en abled me to explore the fundus, which was healthy. When last examined in November, 1933, full 4/4 and small types could be read with each eye, while in the left eye only a slight elevation of the cystoid was visible and the globe had been free from pain. The second case to be detailed is that of F.B., a male, aged 63 years, who con sulted me on August 30, 1932. 929
In 1932, three persons consulted me because of exactly similar conditions, namely, mature senile cataract in the right eye, and discomfort in the left eye occasioned by a staphylomatous cystoid supervening on a previously performed extraction of cataract. Each person was blind and helpless, greatly depressed psychically because of hopelessness, having in mind the recollection of many weeks of infirmity after the former cata ract operation. Today, each, after the extraction of cataract in the second eye, is able to see well and is capable of carrying on the accustomed daily oc cupations, having been afforded useful sight in the eye with the ectasia, also. In March, 1932, Mrs. R.M.C., aged 76 years, in a state of marked decrepi tude, querulous, unkempt, and blind, was all but carried into my office. Her right eye contained a mature cataract; the left, presented chronic blepharoconjunctivitis and injection of the globe, the upper one fourth displaying a huge sausagelike ectasis. Singularly, there was no pain; and the eye was not ten der. Light and shadows only, could be appreciated. The patient had had failing sight be cause of cataracts since 1920. In 1929, the left eye had been operated on, but, at the second dressing, she was told a prolapse of the iris had occurred. Hospitalization was continued for two months, during which time she was urged repeatedly to have the eyeball removed. About four weeks after hospitalization another surgeon performed some operation, necessitating the inser tion of stitches; no further treatment was given.
930
BURTON CHANCE
In October, 1931, his left eye had been operated on for cataract, and had be come so inflamed that he was kept in the hospital for many weeks, having been told that erysipelas had set in, inflaming the skin of his face and eyelids. He was advised to have the eye removed, but would not consent. In the succeeding months he was in miserable health and despondent because of his helplessness, the right eye being reduced to light per ception. When examined by me, there was a hypermature cataract in the right eye, through which light was perceived and projection obtained promptly in all fields. The left globe presented a dense ly leucomatous cornea with slight vascularity. At the upper sclerocorneal juncture, were two large cystic ectases projecting from a whitish line, as though from a dense cicatrix. Light could be perceived in all directions. The iris seemed to be adherent to the leucoma, thus abolishing the anterior chamber. The appearance of the globe resembled a ciliary staphyloma. The eye was con stantly irritated by the lashes" from a deeply in-turned lower lid. There was marked eczematous dermatitis, aggra vated by the constant flow of tears from the irritated eye. On September 14, 1932, after making a small peripheral iridectomy, I reremoved the crystalline lens from the right eye, the extraction being com pleted with the aid of capsule forceps. The patient was highly nervous, and required sedatives. On the third night he became wild and pulled off his dress ings, yet his recovery was entirely satis factory, except that mydriasis could not be maintained because of the painful dermatitis that was set up by the use of atropine and other allied solutions. The ectasis in the left eye was judged to be dependent upon the pressure on the iris from the accumulation of aque ous in the posterior chamber, as noted in the first case. It appeared probable that drainage of the fluid might be se cured by effecting the formation of a channel into the anterior chamber. Therefore, on October 10, an iridotomy was attempted with a Ziegler knife in serted at the outer limbus. The blade
having been insinuated across the stretched iris, a puncture was made near the bottom of the vertical meridian, and an upward slit effected, followed by a cross cut. The thick and fibrous iridocapsular sheet was incised with diffi culty. Much thin vitreous flowed out into the aqueous through the aperture and through the external knife punc ture, followed by free hemorrhage. Only slight reaction supervened so that by the fifth day the eye had become quiet, the hyphemia translucent, and, to my astonishment, the two ectases had be come umbilicated. Soon thereafter, they rapidly collapsed, so that by the end of December they had shrunk markedly. In November, an attempt was made to sever the fibrous strands spanning the "hole" in the iridocapsular membrane. For several weeks, the skin of the lids and cheeks continued to be rough and fissured. In December, several punc tures were made in the left lower lid with the galvanic needle, resulting in a satisfactory eversion of the cilia so that the globe was no longer irritated by them. In the meantime, the bloody de tritus in the aqueous had become ab sorbed, and, by March, 1933, it was possible to make out details of the fundus. In May, great comfort was af forded by an aphakic correction, which, by the end of June, enabled the man to see 4/22. By this time the ectases had become flattened to their present ap pearance, the dermatitis had healed, the entropion had been greatly relieved, and the patient could go about alone and live an enjoyable existence. Some time be fore Christmas the patient was not well, perhaps it was the grip, since when the sight of the left eye has not been as acute as formerly. Without doubt, what was regarded as "erysipelas," which set in after the first cataract was operated upon, was in reality an atropine dermatitis. When it was repeated during my care of the man, its manifestations were indeed alarming to the nurses, who believed it indicated erysipelas, and who, because there were obstetric patients in the house, pleaded that the man should be taken away. Each subsequent use of even a weak solution, or oily suspension was fol-
CYSTOID FOLLOWING CATARACT EXTRACTION lowed by redness and edema of the skin. The third case presented local condi tions quite similar to those in the first case. A cataract extraction was per formed on the right eye, and the iris sheet of the left eye slit, with visual and pathological sequences quite like those observed in that case. The details of this history will be related in a future com munication. These cases as presented are based on the features which each offered at the first glance. So massive were the ectases, and so feeble the patients, that anyone would with reason have hesi tated to expose them to the strains which arise during plastic operations de vised for the obliteration of extrusions in the ciliary regions, such as in the re duction of a staphyloma. On closer study, however, it appeared that in no case was there thinning of the ciliary region, the ectasis being confined to iris tissue, over which was spread a deli
931
cate conjunctival membrane. In effect, the condition was like that found in iris bombe, where the anterior chamber is cut off from the posterior, in conse quence of which the accumulated humor distends and bulges the thinned iris membrane. It was deemed wise, there fore, not to attempt an excision of the bladderlike ectasis, nor yet to puncture it. Accordingly, my design sought to make an opening in the iris membrane within the chamber, hoping thereby that the ectasis might collapse and shrink in a short while. My expectations were fulfilled by the simple procedures instituted. The re moval of the cataract from the right eye and the effects of what was done on the left so promptly revived the exhausted morale of each of the afflicted persons that one may regret that the procedure had not been carried out earlier. 315 South Fifteenth Street.