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Adventitious Hyaloid Membrane Following Operation for Secondary Cataract
280
M. HAYWARD POST, JR.
rather abnormal children in other respects and should be given as much help as possible during the formative period. The general improvement, both physical and mental, in children where the operation has been resorted to about the tenth year in life has been truly remarkable. A case which I have at present under my care illustrates this point. The first operation was done upon the left eye about three years ago at the age of ten, at which time the patient was very inferior mentally, with about the development of a child of three. Since then she has been enabled, for the first time, to at-
tend school and will take her place in the near future with normal children to grow up as one of them. A consideration not to be overlooked. Therefore, in conclusion I believe that operation should be undertaken as early as practicable after the eyes have had the greater part of their growth, preferably about the eighth year, in order to lessen the possibility of retinal deterioration, to facilitate the operative procedure, to reduce to a minimum the danger due to anxiety neurosis, and to assist the child to grow up under as nearly normal conditions as possible.
A D V E N T I T I O U S HYALOID MEMBRANE FOLLOWING
OPERATION
FOR SECONDARY CATARACT. S. LEWIS ZIEGLER,
M.D.,
PHILADELPHIA.
After cataract extraction vision may remain impaired out of proportion to the pupillary membrane, and in spile of operation. This paper gives an explanation of such cases, and reports one as an illustration. Read before the Section of Ophthalmology of the A. M. A., June, 1919.
In my monograph on the "History of Iridotomy" presented before this section at Chicago, in 1908, I called attention to my method of V-shaped incision as practiced in two classes of 1 cases, (1) those with heavy iritic membrane and (2) those of more delicate secondary capsular cataract. Today I wish to call attention to an almost intangible filmlike membrane that may form over the vitreous surface after either of the operations named for secondary cataract and which requiresi similar treatment. This condition I have chosen to designate as "adventitious hyaloid membrane." SYMPTOMATOLOGY
The symptoms are both objective: and subjective. Objectively, oblique! illumination shows a faint iridescentf sheen covering the whole surface of the: vitreous body as exposed in the artificialI pupil, while direct illumination reveals> perfect and permanent transparency of: the cornea and vitreous media. The patient's subjective symptoms> are usually those of a distant vision ofI
from 20/30 to 20/50, but a reduced reading vision of from J-6 to J-12. The patient, therefore, grumbles because his good street vision is not accompanied by a correspondingly good reading vision, while the physician either blarnos a poor adjustment of glasses or charges stupidity on the part of the patient. This condition may appear in a week or two following the secondary operation, or may not occur until several years later, when the patient notices a sudden reduction in the ability to read, while the oculist finds it impossible to improve the near vision by refraction. ETIOLOGY
While no definite pathogenesis can be demonstrated in these cases, it is nevertheless my belief that the mildly corrosive action of a chemically perverted aqueous secretion is responsible for the formation of this filmy opalescent membrane. There is seldom any evidence of inflammatory reaction, altho in one or two cases I have noted the presence of slight ciliary con-
HYALOID MEMBRANE AFTER CATARACT OPERATIONS
gestion. As a rule, however, there has been an entire absence of disturbing factors, which fact has made the visual diminution the more disappointing. In the single case cited herewith there had been a history of iritis with plastic deposit on the lens capsule some twenty-five years before, and the possibility of some absorption of irritating lymph secretion from a marked aeneous eruption on the nose. This, however, is a complication that is most unusual. TREATMENT
There is only one thing to do in these cases, and that is to operate by the method of V-shaped capsulotomy, which should be performed pro forma by going thru all the manipulations in a classical way just as tho a heavy capsule were present. If one maintains a good oblique illumination of short focus one will note a wrinkling of the membrane as it presses before the knife, which will be pleasing to the operator because it will demonstrate to him that he has a real pathologic entity to deal with. One will often be surprised at the end of a week to ascertain by refraction that altho the distant vision has improved but slightly, the corrected near vision will now register J-l. REPORT
OF
CASE
Capt. T. F. I., aged 56, of Summerville, S. C , consulted me, Nov. 12, 1918, suffering from occlusion of the pupil in the right eye following cataract extraction performed in Charleston, Sept. 23, 1918. The eye was still red and irritable as a result of an infection which occurred two days after operation, and cleared slowly, leaving the pupil occluded and drawn upward. The tension appeared to be slightly below normal. I advised plus galvanism to drive out the congestion and prepare the eye for operation, Which result was secured in about ten days. The patient had suffered from an attack of iritis in both eyes twenty-five years before, which left capsular dePosits in the pupils of both eyes. The PUpil of the left eye showed seclusio HISTORY.
281
pupillae, with the lens more or less opaque in the exposed area. The tension was normal and iris color the same. The vision w a s : right eye, 1/200; left eye, 3/200. There was present lacrimal obstruction in both eyes and a marked aeneous eruption covering the nasal epidermis. November 22, I performed a Vshaped iridotomy with my knifeneedle, entering the anterior chamber above and making two free incisions in the iridocapsular membrane, from below upward. The first iritic puncture caused pain, the second did not. There was slight hemorrhage from a patch of plastic deposit at the edge of the old pupil, which was uncovered by the second incision, but this was quickly absorbed. There was a slight escape of semifluid vitreous at the point of incision, which exhibited some turbidity. I was able to obtain a nice, open pupil, somewhat triangular in form, with the base located downward. The blood quickly cleared away. At the end of two weeks the refraction in the right eye was S + l l . D C C + l.D Ax 110°=20/70, and S + 4.D added gave J-8, which subsequently became reduced to J-12. December 19, I showed the result before the Section on Ophthalmology of the College of Physicians of Philadelphia with the comment that "the slight iridescent reflex in the pupillary area of the right eye may indicate the formation of an adventitious hyaloid membrane and may call for further operative interference." December 28, this appearance had become so pronounced that a V-shaped incision was made in this membrane, which gave a distinct sense of yielding as the incision opened up. No reaction followed, and at the end of one week the refraction proved to be the same as before, but vision was now markedly improved, the distant vision with the same glass being 20/30 pt. and J-l for near. CONCLUSION
Adventitious hyaloid membrane, altho of rare occurence, is a distinct patho-
282
S. LEWIS
logic entity. During an experience of more than t h i r t y years, I have observed only seven or eight cases, altho o t h e r s m a y h a v e been overlooked by me in the hasty routine of practice. T h e cardinal s y m p t o m s as s t a t e d are (1) lowered visual a c u i t y ' f o r n e a r w h e n t h e d i s t a n t vision is good, and ( 2 ) the p r e s e n c e of an iridescent v i t r e o u s reflex as revealed by oblique illumination. A l t h o it occurs
ZIEGLER
as 1 a sequel of an o p e r a t i o n for seco n d a r y c a p s u l a r c a t a r a c t , its p r e s e n c e demands a pro forma repetition of the V-shaped incision in order to divide the lilm and restore normal vision. A cursory glance at the literature reveals nothing of' importance concerning this condition, and I have concluded, therefore, that the subject might stimulate thoughtful discussion and the reporting of similar cases.
C O M P L I C A T I O N S IN T H E I N T R A C A P S U L A R
EXTRACTION
OF
CATARACT. J O S E P H K. STERNMERG, BOSTON'.
From a personal experience with this method of operation this series of observations is drawn. It takes up the different steps of the procedure one by one and gives its authors' conclusions. Within recent years, much has been published in ophthalmic journals, relative to the advantages of removing cataract in its capsule. Papers have been read and discussed, but in very few of them have 1 been able to find reports dealing with postoperative developments, and the lessons learned therefrom. My personal experience with twentythree cases of intracapsular extraction, finds me most enthusiastic over the Smith cataract operation. I have been a close follower of Dr. Fisher's suggestions and technic, with most gratifying visual end results, in spite of the long delays of some of my cases healing, the cause of which I will touch on later. The twenty-three cases from which these d e d u c t i o n s are d r a w n w e r e ideal ones, careful examinations being made as to histories, light projection, blood p r e s s u r e , t e n s i o n , t e e t h , u r i n a l y s i s , and physical condition, ages varied from 5
I N C I S I O N , as
suggested by
Col.
Smith a n d r e c o m m e n d e d by most others, should end within the liminis, from 1 to 2 m m . In m y first nine cases this m e t h o d w a s closely followed with ralher disappointing results, requiring from 10 d a y s to t w o w e e k s for the w o u n d to seal t i g h t l y . T h i s fact t e m p l e d me to t r y a slight conjunctival
Hap, with p l e a s i n g results. In the next live cases firm union w a s noticed at the end of the fourth day in t w o cases, mi the fifth day in the t h i r d and in the r e m a i n i n g two, on the sixth d a y . A l t h o c o n t r a r y to the prescribed r o u t i n e , eyes were inspected daily after the third day, to s t u d y the h e a l i n g progress. T H E liuni'-.croMy. T h i s c a n n o t be improved upon, as n o w p r a c t i s e d by m o s t o p e r a t o r s in their o w n m a n n e r , some d o i n g a p r e l i m i n a r y , o t h e r s d o i n g it at the time of the e x t r a c t i o n . I believe I hat unless the p a t i e n t is e x t r e m e l y restless a n d n e r v o u s , the iridectomy should be done at the time of the extraction, w o r k i n g on the supposition that e n t e r i n g an eye twice increases the d a n g e r two-fold. N o p r e l i m i n a r y iridectomies were m a d e in my cases. EXTRACTION
OE T H E
LENS.
To
in-
sure easy delivery, it is a b s o l u t e l y essential to m a k e a fairly large incision, a l m o s t half of the cornea to allow for a possible large lens. It is not only essential but of the u t m o s t i m p o r t a n c e to have an a s s i s t a n t who t h o r o l y und e r s t a n d s h o l d i n g the F i s h e r h o o k s . ()f the cases cited, v i t r e o u s w a s lost in only one ( t h e 2 2 n d ) , this b e i n g due to the faulty m a n i p u l a t i o n of the hooks at the crucial moment; the case how-
M. HAYWARD POST, JR.
rather abnormal children in other respects and should be given as much help as possible during the formative period. The general improvement, both physical and mental, in children where the operation has been resorted to about the tenth year in life has been truly remarkable. A case which I have at present under my care illustrates this point. The first operation was done upon the left eye about three years ago at the age of ten, at which time the patient was very inferior mentally, with about the development of a child of three. Since then she has been enabled, for the first time, to at-
tend school and will take her place in the near future with normal children to grow up as one of them. A consideration not to be overlooked. Therefore, in conclusion I believe that operation should be undertaken as early as practicable after the eyes have had the greater part of their growth, preferably about the eighth year, in order to lessen the possibility of retinal deterioration, to facilitate the operative procedure, to reduce to a minimum the danger due to anxiety neurosis, and to assist the child to grow up under as nearly normal conditions as possible.
A D V E N T I T I O U S HYALOID MEMBRANE FOLLOWING
OPERATION
FOR SECONDARY CATARACT. S. LEWIS ZIEGLER,
M.D.,
PHILADELPHIA.
After cataract extraction vision may remain impaired out of proportion to the pupillary membrane, and in spile of operation. This paper gives an explanation of such cases, and reports one as an illustration. Read before the Section of Ophthalmology of the A. M. A., June, 1919.
In my monograph on the "History of Iridotomy" presented before this section at Chicago, in 1908, I called attention to my method of V-shaped incision as practiced in two classes of 1 cases, (1) those with heavy iritic membrane and (2) those of more delicate secondary capsular cataract. Today I wish to call attention to an almost intangible filmlike membrane that may form over the vitreous surface after either of the operations named for secondary cataract and which requiresi similar treatment. This condition I have chosen to designate as "adventitious hyaloid membrane." SYMPTOMATOLOGY
The symptoms are both objective: and subjective. Objectively, oblique! illumination shows a faint iridescentf sheen covering the whole surface of the: vitreous body as exposed in the artificialI pupil, while direct illumination reveals> perfect and permanent transparency of: the cornea and vitreous media. The patient's subjective symptoms> are usually those of a distant vision ofI
from 20/30 to 20/50, but a reduced reading vision of from J-6 to J-12. The patient, therefore, grumbles because his good street vision is not accompanied by a correspondingly good reading vision, while the physician either blarnos a poor adjustment of glasses or charges stupidity on the part of the patient. This condition may appear in a week or two following the secondary operation, or may not occur until several years later, when the patient notices a sudden reduction in the ability to read, while the oculist finds it impossible to improve the near vision by refraction. ETIOLOGY
While no definite pathogenesis can be demonstrated in these cases, it is nevertheless my belief that the mildly corrosive action of a chemically perverted aqueous secretion is responsible for the formation of this filmy opalescent membrane. There is seldom any evidence of inflammatory reaction, altho in one or two cases I have noted the presence of slight ciliary con-
HYALOID MEMBRANE AFTER CATARACT OPERATIONS
gestion. As a rule, however, there has been an entire absence of disturbing factors, which fact has made the visual diminution the more disappointing. In the single case cited herewith there had been a history of iritis with plastic deposit on the lens capsule some twenty-five years before, and the possibility of some absorption of irritating lymph secretion from a marked aeneous eruption on the nose. This, however, is a complication that is most unusual. TREATMENT
There is only one thing to do in these cases, and that is to operate by the method of V-shaped capsulotomy, which should be performed pro forma by going thru all the manipulations in a classical way just as tho a heavy capsule were present. If one maintains a good oblique illumination of short focus one will note a wrinkling of the membrane as it presses before the knife, which will be pleasing to the operator because it will demonstrate to him that he has a real pathologic entity to deal with. One will often be surprised at the end of a week to ascertain by refraction that altho the distant vision has improved but slightly, the corrected near vision will now register J-l. REPORT
OF
CASE
Capt. T. F. I., aged 56, of Summerville, S. C , consulted me, Nov. 12, 1918, suffering from occlusion of the pupil in the right eye following cataract extraction performed in Charleston, Sept. 23, 1918. The eye was still red and irritable as a result of an infection which occurred two days after operation, and cleared slowly, leaving the pupil occluded and drawn upward. The tension appeared to be slightly below normal. I advised plus galvanism to drive out the congestion and prepare the eye for operation, Which result was secured in about ten days. The patient had suffered from an attack of iritis in both eyes twenty-five years before, which left capsular dePosits in the pupils of both eyes. The PUpil of the left eye showed seclusio HISTORY.
281
pupillae, with the lens more or less opaque in the exposed area. The tension was normal and iris color the same. The vision w a s : right eye, 1/200; left eye, 3/200. There was present lacrimal obstruction in both eyes and a marked aeneous eruption covering the nasal epidermis. November 22, I performed a Vshaped iridotomy with my knifeneedle, entering the anterior chamber above and making two free incisions in the iridocapsular membrane, from below upward. The first iritic puncture caused pain, the second did not. There was slight hemorrhage from a patch of plastic deposit at the edge of the old pupil, which was uncovered by the second incision, but this was quickly absorbed. There was a slight escape of semifluid vitreous at the point of incision, which exhibited some turbidity. I was able to obtain a nice, open pupil, somewhat triangular in form, with the base located downward. The blood quickly cleared away. At the end of two weeks the refraction in the right eye was S + l l . D C C + l.D Ax 110°=20/70, and S + 4.D added gave J-8, which subsequently became reduced to J-12. December 19, I showed the result before the Section on Ophthalmology of the College of Physicians of Philadelphia with the comment that "the slight iridescent reflex in the pupillary area of the right eye may indicate the formation of an adventitious hyaloid membrane and may call for further operative interference." December 28, this appearance had become so pronounced that a V-shaped incision was made in this membrane, which gave a distinct sense of yielding as the incision opened up. No reaction followed, and at the end of one week the refraction proved to be the same as before, but vision was now markedly improved, the distant vision with the same glass being 20/30 pt. and J-l for near. CONCLUSION
Adventitious hyaloid membrane, altho of rare occurence, is a distinct patho-
282
S. LEWIS
logic entity. During an experience of more than t h i r t y years, I have observed only seven or eight cases, altho o t h e r s m a y h a v e been overlooked by me in the hasty routine of practice. T h e cardinal s y m p t o m s as s t a t e d are (1) lowered visual a c u i t y ' f o r n e a r w h e n t h e d i s t a n t vision is good, and ( 2 ) the p r e s e n c e of an iridescent v i t r e o u s reflex as revealed by oblique illumination. A l t h o it occurs
ZIEGLER
as 1 a sequel of an o p e r a t i o n for seco n d a r y c a p s u l a r c a t a r a c t , its p r e s e n c e demands a pro forma repetition of the V-shaped incision in order to divide the lilm and restore normal vision. A cursory glance at the literature reveals nothing of' importance concerning this condition, and I have concluded, therefore, that the subject might stimulate thoughtful discussion and the reporting of similar cases.
C O M P L I C A T I O N S IN T H E I N T R A C A P S U L A R
EXTRACTION
OF
CATARACT. J O S E P H K. STERNMERG, BOSTON'.
From a personal experience with this method of operation this series of observations is drawn. It takes up the different steps of the procedure one by one and gives its authors' conclusions. Within recent years, much has been published in ophthalmic journals, relative to the advantages of removing cataract in its capsule. Papers have been read and discussed, but in very few of them have 1 been able to find reports dealing with postoperative developments, and the lessons learned therefrom. My personal experience with twentythree cases of intracapsular extraction, finds me most enthusiastic over the Smith cataract operation. I have been a close follower of Dr. Fisher's suggestions and technic, with most gratifying visual end results, in spite of the long delays of some of my cases healing, the cause of which I will touch on later. The twenty-three cases from which these d e d u c t i o n s are d r a w n w e r e ideal ones, careful examinations being made as to histories, light projection, blood p r e s s u r e , t e n s i o n , t e e t h , u r i n a l y s i s , and physical condition, ages varied from 5
I N C I S I O N , as
suggested by
Col.
Smith a n d r e c o m m e n d e d by most others, should end within the liminis, from 1 to 2 m m . In m y first nine cases this m e t h o d w a s closely followed with ralher disappointing results, requiring from 10 d a y s to t w o w e e k s for the w o u n d to seal t i g h t l y . T h i s fact t e m p l e d me to t r y a slight conjunctival
Hap, with p l e a s i n g results. In the next live cases firm union w a s noticed at the end of the fourth day in t w o cases, mi the fifth day in the t h i r d and in the r e m a i n i n g two, on the sixth d a y . A l t h o c o n t r a r y to the prescribed r o u t i n e , eyes were inspected daily after the third day, to s t u d y the h e a l i n g progress. T H E liuni'-.croMy. T h i s c a n n o t be improved upon, as n o w p r a c t i s e d by m o s t o p e r a t o r s in their o w n m a n n e r , some d o i n g a p r e l i m i n a r y , o t h e r s d o i n g it at the time of the e x t r a c t i o n . I believe I hat unless the p a t i e n t is e x t r e m e l y restless a n d n e r v o u s , the iridectomy should be done at the time of the extraction, w o r k i n g on the supposition that e n t e r i n g an eye twice increases the d a n g e r two-fold. N o p r e l i m i n a r y iridectomies were m a d e in my cases. EXTRACTION
OE T H E
LENS.
To
in-
sure easy delivery, it is a b s o l u t e l y essential to m a k e a fairly large incision, a l m o s t half of the cornea to allow for a possible large lens. It is not only essential but of the u t m o s t i m p o r t a n c e to have an a s s i s t a n t who t h o r o l y und e r s t a n d s h o l d i n g the F i s h e r h o o k s . ()f the cases cited, v i t r e o u s w a s lost in only one ( t h e 2 2 n d ) , this b e i n g due to the faulty m a n i p u l a t i o n of the hooks at the crucial moment; the case how-