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Keratoplasty for Herpetic Keratitis*
RETINAL CHANGES IN HYPERTENSION
179
REFERENCES
1. Evelyn, K. A.: A long-term study of the natural history of essential hypertension. Ann. Int. Med., 33:629-635, 1950. 2. : The course and prognosis of essential hypertension. Proc. Med. Sec. American Life Conven tion, 1954. 3. Wagener, H. P., Clay, G. E., and Gipner, J. F.: Classification of retinal lesions in the presence of vascular hypertension: Report submitted to the American Ophthalmological Society by the Committee on Classification of Hypertensive Disease of the Retina. Tr. Am. Ophth. Soc, 45 :57-73, 1947. 4. Page, I. H., and Corcoran, A. C.: Arterial Hypertension: Its Diagnosis and Treatment. Chicago, Year Book, 1949, pp. 81-88. 5. Leatham, A.: The retinal vessels in hypertension. Quart. J. Med., 18:203-215, 1949. 6. Keith, N. M., Wagener, H. P., and Barker, N. W.: Some different types of hypertension: Their cause and prognosis. Am. J. M. Sc, 197 :332-343, 1939. 7. Gowers, W. R.: A Manual and Atlas of Medical Ophthalmoscopy. London, 1890, ed. 3. 8. Nicholls, J. V. V., Turnbull, W., and Evelyn, K. A.: The caliber of the retinal arterioles in normal and hypertensive patients. Tr. Canad. Ophth. Soc, 7 :37-45, 1954-1955. 9. Bjork, S.: Hemodynamic factors and retinal changes in hypertensive diseases. Acta med. Scand., supp. 175, 1946. 10. Leishman, R.: The eye in general vascular disease: Hypertension and arteriosclerosis. Brit. J. Ophth., 41:641-701, 1957. KERATOPLASTY FOR HERPETIC H.
L.
ORMSBY,
KERATITIS*
M.D.
Toronto, Canada Herpes simplex virus infection of the cornea continues to be one of the most im portant problems in the field of ophthal mology. In spite of the introduction of many new therapeutic agents in the past decade, none has yet been found to be effective in this disease. W i t h the advent of the broad spectrum antibiotics, it was thought at first that an effective agent for the herpes simplex virus had been found in aureomycin. Braley and Sanders, 1 in initial studies, reported that this drug favorably influenced the course of her petic keratitis. Later, Braley and Alexander, 2 and MacKneson and Ormsby 3 reported that aureomycin had an inhibitory effect on this virus in vitro. Subsequently, however, clini cal trial failed to substantiate these early favorable reports, and it is now generally agreed that none of the antibiotics has any influence on herpetic disease. Cortisone and A C T H also were thought at first to have an important place in the treatment of herpetic keratitis. In all forms * From the Departments of Ophthalmology and Bacteriology, Faculty of Medicine, University of Toronto.
of stromal herpes, including disci form kera titis, the inflammatory reaction was sup pressed when steroids were administered, and patients experienced symptomatic re lief. Laboratory studies by Thygeson, Geller, and Schwartz," and by Ormsby, Demp ster, and van Rooyen, 5 conclusively showed that cortisone prolonged the acute phase of herpetic keratitis in rabbits, and caused per foration of the cornea in some instances. Clinical trial in humans subsequently showed that steroids had an unfavorable effect on the course of dendritic ulceration, and in some instances could activate a latent in fection. I t is now agreed by most authorities that steroids are to be avoided in all phases of the disease. T h e tendency for herpetic keratitis to recur, often after an interval of months or years, w a r r a n t s the conclusion that the virus lies latent in the cornea between attacks. T h e dendritic ulcer occurs in the epithelium and can be cured by cauterization and epi thelial denudation. This treatment fails to prevent recurrent attacks, however, and it must be assumed that the virus lies latent in the corneal stroma. Treatment by corneal
H. L. ORMSBY
180
transplantation should therefore be of value by removing tissues harboring latent virus, and at the same time improving vision. . KERATOFLASTY TECHNIQUE IN HERPETIC KERATITIS
Both lamellar and full-thickness grafts have been used by keratoplasty surgeons in the treatment of herpetic keratitis. When the corneal scar involves the deeper layers of the stroma and Descemet's membrane, full-thickness grafts are necessary if good vision is to result. Hogan 6 has shown, how ever, that when full-thickness grafts are used as a primary procedure in herpetic keratitis, clouding of the cornea due to antigen-antibody reaction is of frequent oc currence. When the present program of corneal grafting was instituted at the University of Toronto in 1954, it was decided to carry out all keratoplasties on herpetic eyes by means of the total (10-mm.) lamellar method, and to perform full-thickness opti cal grafts only as a secondary procedure. To date, 25 eyes with herpetic keratitis have been operated upon by the lamellar tech nique, and in two of these eyes, secondary five mm. full-thickness grafts have been per formed to give normal vision. Radiation has not been used preoperatively, since most of the vessels could be removed by the dissection. Postoperatively, vascularization of the graft has not been a problem, and has been controlled to a large extent by the use of topical steroids. In removing the host tissues, the 10-mm. Castroviejo trephine was set at a depth of 0.6 mm., and the corneal incision carried out by rotating the trephine with the fingers. The edge of the corneal lip was grasped in its healthiest portion with Saint-Martin forceps and the incision carried more deeply with a No. 15 Bard-Parker blade. By keep ing the field absolutely dry, and by lifting the cornea upward with tension, the corneal stromal fibers could be seen to separate and assume a vertical striation. By peeling off these fibers at their base with the knife, a
very deep dissection could be performed, close to Descemet's membrane. Perforation during the course of this deep dissection occurred in four eyes with Descemetocoeles. The resultant lowering of in traocular pressure aided the placement of the graft, and did not appear to hinder the healing processes in any way. However, some stromal edema persisted for three to five weeks in the grafts in these cases, and some permanent deep scar was formed over the area of perforation. All grafts were fixed by eight 6-0, edgeto-edge fine silk sutures. Healing was rapid in all herpetic corneas, and the sutures were removed in most instances between the seventh and 10th days. Atropine was ap plied with each dressing, and hydrocortisone ointment was started after the seventh post operative day. After the removal of the sutures, the eye was left uncovered and the hydrocortisone ointment was applied four times daily by the nursing staff. Following discharge from hospital, the patient used hyoscine drops morning and night in the eye until all signs of iritis had subsided, and hydrocortisone was used topi cally for another four to eight weeks. As a result of this treatment no graft reactions occurred, and vascularization of the bed, and of the graft itself, has been minimal. In the the first six cases, however, when hydro cortisone was not used postoperatively be cause of the fear that herpetic infection might be activated, vascularization in the bed was extensive, and two grafts developed antigen-antibody reactions with subsequent clouding. RESULTS
In this series, all cases have been surgi cally successful. Healing has been rapid and postoperative complications have been minimal. Six eyes have been operated upon because of the danger of perforation of descemetoceles. One of these eyes perforated follow ing admission of the patient to hospital, and a bubble of air was seen in the anterior
KERATOPLASTY FOR HERPETIC KERATITIS chamber. In four eyes, rupture occurred during the dissection. In all six eyes, heal ing of the graft was satisfactory, but residual edema persisted for some weeks, and is still present in one graft five months after opera tion. In 10 eyes, surgery was performed to terminate a long period of active keratitis which had failed to respond to the usual methods of treatment. These patients ex perienced relief of their symptoms within 48 hours after operation, and did not exhibit any undue postoperative reaction in the graft. The remaining eight eyes were op erated upon during the quiescent phase of the disease. The visual results were gratifying in all eyes in which the scar tissue did not ex tend to Descemet's membrane. In those pa tients in whom only one eye had been in volved in the disease process, we have done no subsequent full-thickness grafts. Patients have usually been satisfied with the visual result and with freedom from symptoms. In two patients who had suffered from bilateral herpes, and had had bilateral lamellar grafts, subsequent six-mm. full-thickness grafts have been performed on the eye with the poorer vision. These grafts have remained clear. Recurrence of herpetic infection has not appeared in any of the grafted eyes, in spite of the postoperative use of hydrocortisone. One patient operated upon in August, 1954, to cure an active infection of four months' duration, had 20/20 vision in the operated eye. In August, 1957, he returned with a dendritic ulcer on the other eye. This was the initial infection in this eye and developed during an attack of lobar pneumonia. The ulcer was terminated by iodine cauterization. The previously grafted eye did not show any signs of activity. DISCUSSION
The lamellar technique would appear to offer many advantages over full-thickness procedures in the treatment of herpetic kera titis. Although the proper performance of
181
a 10-mm. lamellar graft, carried to the deep stromal level, requires much surgical skill and practice, there is less hazard involved in the operation, and healing is more rapid. Even though the final visual result with a lamellar graft may not be equal to that of a successful full-thickness graft, most pa tients seem satisfied with the result, and post operative complications are rare. While many ophthalmologists would hesi tate to recommend full-thickness grafts in vascularized corneas, and relatively few surgeons have the necessary training to per form them, most would agree that after some opportunity to practice on animal or eyebank eyes, the lamellar technique could be performed with the same hope of success as cataract extraction. It has been our experience that steroids have greatly reduced the postoperative re action in these eyes. Since we have not had any recurrence of herpetic infection as a result of this procedure, it seems likely that all latent virus has been removed. In our hands, the 10-mm. lamellar graft is no more difficult to perform than the smaller seven-mm. lamellar grafts which we have been doing in eyes with superficial corneal scars and in corneal dystrophies. The proximity of the limbal tissues in large grafts may be a factor in the rapid healing which we have experienced. SUMMARY AND CONCLUSIONS
1. At the present time no therapeutic agent is available which will eliminate latent herpes simplex virus from infected corneal tissues. 2. Total lamellar (10 mm.) deep trans plantation removes invading blood vessels and scar tissue from all but the deepest stromal layers, and probably removes all the latent virus. 3. Twenty-five total lamellar grafts in eyes with severe recurrent herpetic keratitis have resulted in relief of symptoms, and in varying degrees of improved vision. 4. Secondary full-thickness grafts (six mm.) in two of these eyes developed no
182
H. L. ORMSBY
surgical complications and have remained clear. 5. N o re-infections with simplex virus have yet occurred in any of the grafted eyes.
6. T h e use of corticosteroids postoperatively has not resulted in the exacerbation of infection, has reduced postoperative reaction, and has contributed to a better visual result. 3050 Yonge Street at Lawrence.
REFERENCES
1. Braley, A. E., and Sanders, M.: Aureomycin in ocular infections. J.A.M.A., 138:426-427 (Oct.) 1948. 2. Braley, A. E., and Alexander, R. C.: Experimental and clinical use of aureomycin in herpes simplex. Tr. Am. Ophth. Soc, 47 :33S-348, 1949. 3. MacKneson, R. G., and Ormsby, H. L.: The effect of the broad- and medium-spectrum antibiotics on the virus of herpes simplex. Am. J. Ophth., 39 :689-690, 19SS. 4. Thygeson, P., Geller, H. O., and Schwartz, A.: Effect of cortisone on experimental herpes-simplex keratitis of the rabbit. Am. J. Ophth., 34:88S, 1951. 5. Ormsby, H. L., Dempster, G., and van Rooyen, S. E.: Effect of cortisone on experimentally induced herpetic keratitis of the rabbit. Am. J. Ophth., 34:1687, 1951. 6. Hogan, M. J.: Corneal transplantation in the treatment of herpetic disease of the cornea. Am. J. Ophth., 43:147-160 (Apr. Pt. II) 1957.
EPITHELIZATION OF THE ANTERIOR
SEGMENT
A F T E R CATARACT EXTRACTIONS B R I T T A I N FORD P A Y N E ,
M.D.
Neiv York Epithelial invasion of the anterior cham ber following cataract operations appears to be increasing, as shown by a further study of enucleated eyes in the E n o Laboratory of the New York Eye and E a r Infirmary. O u t of the 31 specimens sent to the lab oratory from within the hospital and outside sources for the two years following a joint report 1 before the 1955 meeting of the American Ophthalmological Society, five of these exhibited epithelization. Microscopic evidence of extracapsular op erative technique was present in only one globe. This follows the trend as shown in the last five years of the joint report 1 on the causes of enucleation. T h e report extended for a quarter of a century and included 333 specimens. Approximately 25 percent of the "postcataract" eyes were affected in the latter period. It was during this time that the ef fects of intracapsular technique became evi dent. It is not the purpose of these observations
to indict the intracapsular technique as pre disposing to epithelial downgrowths but to call attention to these complications and guard against them, if possible. In a recent presentation, Maumenee 2 stated that 14.3 percent of the eyes enucleated after cataract extractions showed the complica tion of epithelial inclusions. No reference was made as to the type of operation em ployed but the incidence of one out of every seven enucleated eyes affected by this com plication is startling. Although many reasons have been given for downgrowths, none has been accepted as final. T h e loss of vitreous at the time of operation followed by poor union of the wound may prove to be the most important factors. Collapse of the anterior chamber, prolapse of the iris, buckling of the operative wound, and invasion of the suture tract have been noted. Which factor will prove to be the major underlying cause remains to be determined,
179
REFERENCES
1. Evelyn, K. A.: A long-term study of the natural history of essential hypertension. Ann. Int. Med., 33:629-635, 1950. 2. : The course and prognosis of essential hypertension. Proc. Med. Sec. American Life Conven tion, 1954. 3. Wagener, H. P., Clay, G. E., and Gipner, J. F.: Classification of retinal lesions in the presence of vascular hypertension: Report submitted to the American Ophthalmological Society by the Committee on Classification of Hypertensive Disease of the Retina. Tr. Am. Ophth. Soc, 45 :57-73, 1947. 4. Page, I. H., and Corcoran, A. C.: Arterial Hypertension: Its Diagnosis and Treatment. Chicago, Year Book, 1949, pp. 81-88. 5. Leatham, A.: The retinal vessels in hypertension. Quart. J. Med., 18:203-215, 1949. 6. Keith, N. M., Wagener, H. P., and Barker, N. W.: Some different types of hypertension: Their cause and prognosis. Am. J. M. Sc, 197 :332-343, 1939. 7. Gowers, W. R.: A Manual and Atlas of Medical Ophthalmoscopy. London, 1890, ed. 3. 8. Nicholls, J. V. V., Turnbull, W., and Evelyn, K. A.: The caliber of the retinal arterioles in normal and hypertensive patients. Tr. Canad. Ophth. Soc, 7 :37-45, 1954-1955. 9. Bjork, S.: Hemodynamic factors and retinal changes in hypertensive diseases. Acta med. Scand., supp. 175, 1946. 10. Leishman, R.: The eye in general vascular disease: Hypertension and arteriosclerosis. Brit. J. Ophth., 41:641-701, 1957. KERATOPLASTY FOR HERPETIC H.
L.
ORMSBY,
KERATITIS*
M.D.
Toronto, Canada Herpes simplex virus infection of the cornea continues to be one of the most im portant problems in the field of ophthal mology. In spite of the introduction of many new therapeutic agents in the past decade, none has yet been found to be effective in this disease. W i t h the advent of the broad spectrum antibiotics, it was thought at first that an effective agent for the herpes simplex virus had been found in aureomycin. Braley and Sanders, 1 in initial studies, reported that this drug favorably influenced the course of her petic keratitis. Later, Braley and Alexander, 2 and MacKneson and Ormsby 3 reported that aureomycin had an inhibitory effect on this virus in vitro. Subsequently, however, clini cal trial failed to substantiate these early favorable reports, and it is now generally agreed that none of the antibiotics has any influence on herpetic disease. Cortisone and A C T H also were thought at first to have an important place in the treatment of herpetic keratitis. In all forms * From the Departments of Ophthalmology and Bacteriology, Faculty of Medicine, University of Toronto.
of stromal herpes, including disci form kera titis, the inflammatory reaction was sup pressed when steroids were administered, and patients experienced symptomatic re lief. Laboratory studies by Thygeson, Geller, and Schwartz," and by Ormsby, Demp ster, and van Rooyen, 5 conclusively showed that cortisone prolonged the acute phase of herpetic keratitis in rabbits, and caused per foration of the cornea in some instances. Clinical trial in humans subsequently showed that steroids had an unfavorable effect on the course of dendritic ulceration, and in some instances could activate a latent in fection. I t is now agreed by most authorities that steroids are to be avoided in all phases of the disease. T h e tendency for herpetic keratitis to recur, often after an interval of months or years, w a r r a n t s the conclusion that the virus lies latent in the cornea between attacks. T h e dendritic ulcer occurs in the epithelium and can be cured by cauterization and epi thelial denudation. This treatment fails to prevent recurrent attacks, however, and it must be assumed that the virus lies latent in the corneal stroma. Treatment by corneal
H. L. ORMSBY
180
transplantation should therefore be of value by removing tissues harboring latent virus, and at the same time improving vision. . KERATOFLASTY TECHNIQUE IN HERPETIC KERATITIS
Both lamellar and full-thickness grafts have been used by keratoplasty surgeons in the treatment of herpetic keratitis. When the corneal scar involves the deeper layers of the stroma and Descemet's membrane, full-thickness grafts are necessary if good vision is to result. Hogan 6 has shown, how ever, that when full-thickness grafts are used as a primary procedure in herpetic keratitis, clouding of the cornea due to antigen-antibody reaction is of frequent oc currence. When the present program of corneal grafting was instituted at the University of Toronto in 1954, it was decided to carry out all keratoplasties on herpetic eyes by means of the total (10-mm.) lamellar method, and to perform full-thickness opti cal grafts only as a secondary procedure. To date, 25 eyes with herpetic keratitis have been operated upon by the lamellar tech nique, and in two of these eyes, secondary five mm. full-thickness grafts have been per formed to give normal vision. Radiation has not been used preoperatively, since most of the vessels could be removed by the dissection. Postoperatively, vascularization of the graft has not been a problem, and has been controlled to a large extent by the use of topical steroids. In removing the host tissues, the 10-mm. Castroviejo trephine was set at a depth of 0.6 mm., and the corneal incision carried out by rotating the trephine with the fingers. The edge of the corneal lip was grasped in its healthiest portion with Saint-Martin forceps and the incision carried more deeply with a No. 15 Bard-Parker blade. By keep ing the field absolutely dry, and by lifting the cornea upward with tension, the corneal stromal fibers could be seen to separate and assume a vertical striation. By peeling off these fibers at their base with the knife, a
very deep dissection could be performed, close to Descemet's membrane. Perforation during the course of this deep dissection occurred in four eyes with Descemetocoeles. The resultant lowering of in traocular pressure aided the placement of the graft, and did not appear to hinder the healing processes in any way. However, some stromal edema persisted for three to five weeks in the grafts in these cases, and some permanent deep scar was formed over the area of perforation. All grafts were fixed by eight 6-0, edgeto-edge fine silk sutures. Healing was rapid in all herpetic corneas, and the sutures were removed in most instances between the seventh and 10th days. Atropine was ap plied with each dressing, and hydrocortisone ointment was started after the seventh post operative day. After the removal of the sutures, the eye was left uncovered and the hydrocortisone ointment was applied four times daily by the nursing staff. Following discharge from hospital, the patient used hyoscine drops morning and night in the eye until all signs of iritis had subsided, and hydrocortisone was used topi cally for another four to eight weeks. As a result of this treatment no graft reactions occurred, and vascularization of the bed, and of the graft itself, has been minimal. In the the first six cases, however, when hydro cortisone was not used postoperatively be cause of the fear that herpetic infection might be activated, vascularization in the bed was extensive, and two grafts developed antigen-antibody reactions with subsequent clouding. RESULTS
In this series, all cases have been surgi cally successful. Healing has been rapid and postoperative complications have been minimal. Six eyes have been operated upon because of the danger of perforation of descemetoceles. One of these eyes perforated follow ing admission of the patient to hospital, and a bubble of air was seen in the anterior
KERATOPLASTY FOR HERPETIC KERATITIS chamber. In four eyes, rupture occurred during the dissection. In all six eyes, heal ing of the graft was satisfactory, but residual edema persisted for some weeks, and is still present in one graft five months after opera tion. In 10 eyes, surgery was performed to terminate a long period of active keratitis which had failed to respond to the usual methods of treatment. These patients ex perienced relief of their symptoms within 48 hours after operation, and did not exhibit any undue postoperative reaction in the graft. The remaining eight eyes were op erated upon during the quiescent phase of the disease. The visual results were gratifying in all eyes in which the scar tissue did not ex tend to Descemet's membrane. In those pa tients in whom only one eye had been in volved in the disease process, we have done no subsequent full-thickness grafts. Patients have usually been satisfied with the visual result and with freedom from symptoms. In two patients who had suffered from bilateral herpes, and had had bilateral lamellar grafts, subsequent six-mm. full-thickness grafts have been performed on the eye with the poorer vision. These grafts have remained clear. Recurrence of herpetic infection has not appeared in any of the grafted eyes, in spite of the postoperative use of hydrocortisone. One patient operated upon in August, 1954, to cure an active infection of four months' duration, had 20/20 vision in the operated eye. In August, 1957, he returned with a dendritic ulcer on the other eye. This was the initial infection in this eye and developed during an attack of lobar pneumonia. The ulcer was terminated by iodine cauterization. The previously grafted eye did not show any signs of activity. DISCUSSION
The lamellar technique would appear to offer many advantages over full-thickness procedures in the treatment of herpetic kera titis. Although the proper performance of
181
a 10-mm. lamellar graft, carried to the deep stromal level, requires much surgical skill and practice, there is less hazard involved in the operation, and healing is more rapid. Even though the final visual result with a lamellar graft may not be equal to that of a successful full-thickness graft, most pa tients seem satisfied with the result, and post operative complications are rare. While many ophthalmologists would hesi tate to recommend full-thickness grafts in vascularized corneas, and relatively few surgeons have the necessary training to per form them, most would agree that after some opportunity to practice on animal or eyebank eyes, the lamellar technique could be performed with the same hope of success as cataract extraction. It has been our experience that steroids have greatly reduced the postoperative re action in these eyes. Since we have not had any recurrence of herpetic infection as a result of this procedure, it seems likely that all latent virus has been removed. In our hands, the 10-mm. lamellar graft is no more difficult to perform than the smaller seven-mm. lamellar grafts which we have been doing in eyes with superficial corneal scars and in corneal dystrophies. The proximity of the limbal tissues in large grafts may be a factor in the rapid healing which we have experienced. SUMMARY AND CONCLUSIONS
1. At the present time no therapeutic agent is available which will eliminate latent herpes simplex virus from infected corneal tissues. 2. Total lamellar (10 mm.) deep trans plantation removes invading blood vessels and scar tissue from all but the deepest stromal layers, and probably removes all the latent virus. 3. Twenty-five total lamellar grafts in eyes with severe recurrent herpetic keratitis have resulted in relief of symptoms, and in varying degrees of improved vision. 4. Secondary full-thickness grafts (six mm.) in two of these eyes developed no
182
H. L. ORMSBY
surgical complications and have remained clear. 5. N o re-infections with simplex virus have yet occurred in any of the grafted eyes.
6. T h e use of corticosteroids postoperatively has not resulted in the exacerbation of infection, has reduced postoperative reaction, and has contributed to a better visual result. 3050 Yonge Street at Lawrence.
REFERENCES
1. Braley, A. E., and Sanders, M.: Aureomycin in ocular infections. J.A.M.A., 138:426-427 (Oct.) 1948. 2. Braley, A. E., and Alexander, R. C.: Experimental and clinical use of aureomycin in herpes simplex. Tr. Am. Ophth. Soc, 47 :33S-348, 1949. 3. MacKneson, R. G., and Ormsby, H. L.: The effect of the broad- and medium-spectrum antibiotics on the virus of herpes simplex. Am. J. Ophth., 39 :689-690, 19SS. 4. Thygeson, P., Geller, H. O., and Schwartz, A.: Effect of cortisone on experimental herpes-simplex keratitis of the rabbit. Am. J. Ophth., 34:88S, 1951. 5. Ormsby, H. L., Dempster, G., and van Rooyen, S. E.: Effect of cortisone on experimentally induced herpetic keratitis of the rabbit. Am. J. Ophth., 34:1687, 1951. 6. Hogan, M. J.: Corneal transplantation in the treatment of herpetic disease of the cornea. Am. J. Ophth., 43:147-160 (Apr. Pt. II) 1957.
EPITHELIZATION OF THE ANTERIOR
SEGMENT
A F T E R CATARACT EXTRACTIONS B R I T T A I N FORD P A Y N E ,
M.D.
Neiv York Epithelial invasion of the anterior cham ber following cataract operations appears to be increasing, as shown by a further study of enucleated eyes in the E n o Laboratory of the New York Eye and E a r Infirmary. O u t of the 31 specimens sent to the lab oratory from within the hospital and outside sources for the two years following a joint report 1 before the 1955 meeting of the American Ophthalmological Society, five of these exhibited epithelization. Microscopic evidence of extracapsular op erative technique was present in only one globe. This follows the trend as shown in the last five years of the joint report 1 on the causes of enucleation. T h e report extended for a quarter of a century and included 333 specimens. Approximately 25 percent of the "postcataract" eyes were affected in the latter period. It was during this time that the ef fects of intracapsular technique became evi dent. It is not the purpose of these observations
to indict the intracapsular technique as pre disposing to epithelial downgrowths but to call attention to these complications and guard against them, if possible. In a recent presentation, Maumenee 2 stated that 14.3 percent of the eyes enucleated after cataract extractions showed the complica tion of epithelial inclusions. No reference was made as to the type of operation em ployed but the incidence of one out of every seven enucleated eyes affected by this com plication is startling. Although many reasons have been given for downgrowths, none has been accepted as final. T h e loss of vitreous at the time of operation followed by poor union of the wound may prove to be the most important factors. Collapse of the anterior chamber, prolapse of the iris, buckling of the operative wound, and invasion of the suture tract have been noted. Which factor will prove to be the major underlying cause remains to be determined,