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Cataract Extraction after Elliot Trephining Operation⋆
894
NOTES, CASES, INSTRUMENTS
discontined after four days, and the patient went home on the sixth day with the lesions healing well and no specific eye complaints. He was re-admitted to the hospital on March 21st, this time with definitely healed skin lesions, but with severe lid edema and definite eye involvement of one day's dura tion. On biomicroscopy, two fairly large herpetic infiltrations were noted in the left cornea away from the pupillary area at the 11- and 5-o'clock positions. The iris was muddy and the light reflex was slow; the eye was soft. Local treatment consisted of one drop of two-percent atropine, four times daily, hot packs for 20 minutes every hour, aureomycin ophthalmic solution (two drops every hour). Treatment by mouth was aureomycin (250 mg. every four hours around the clock) and empirin compound with 0.5 gr of codeine for pain. A magnesium sulfatfc purge was prescribed on admission. Improvement was steady with a sharp decline in pain and noticeable change in the corneal lesions in three days. The lower and smaller lesion healed first, leaving a fine nebulous scar. Both lesions were healed by the third week. The aureomycin by mouth was discon tinued on the 14th day, but the aureomycin drops were continued four times daily until the day of discharge on the 21st day. The atropine was withheld after the 14th day. The iris was clear. The resultant fine corneal opacities do not affect visual function. The patient had received 21 gm. of aureo mycin by mouth over a 14-day period with out any gastrointestinal complaints and with total effective healing of the corneal lesions with a minimum of scarring. Talcott Building.
CATARACT EXTRACTION AFTER ELLIOT TREPHINING OPERATION* HENRY F. JACOBIUS,
M.D.
New York It is often difficult to remove a cataractous lens in the presence of a large overhanging bleb following glaucoma surgery, especially when there is also a secluded pupil from a chronic iritis of long duration. History. A Negro, aged 58 years, who ap peared much older, entered the Metropolitan Hospital on October 30,1949. Vision in the right eye was light projection only. The patient gave a history of treatment for chronic primary glaucoma for many years. In 1948, an Elliot trephining operation was performed upon the right eye at the Metropolitan Hospital. For the past year, there had been a gradual diminishing of vi sion, until now he was unable to get about without assistance. The left eye had been totally blind fol lowing a perforating injury at the age of six years. The eyeball was degenerated and soft to touch. The cornea showed old, diffuse infiltrates. The lens appeared to be calcareous and opaque. Eye examination. There was a large filter ing bleb in the right eye which overhung the upper fourth of the cornea. The slitlamp microscope showed numerous old keratic pre cipitates, as well as a small irregular pupil which was bound down concentrically at the pupillary border by ring synechias. There was a hypermature senile cataract. Tension was 18 mm. Hg (Schi^tz). Operation. At operation on October 4, 1949, the pupil was small and did not dilate with two-percent homatropine, 10-percent solution of neosynephrin, and one-percent solution of atropine sulfate. Since it seemed inadvisable to disturb the larger filtering bleb, a conjunctival flap was made at the temporal half of the eyeball. * From the Metropolitan Hospital, eye service of Dr. Charles A. Turtz.
NOTES, CASES, INSTRUMENTS
895
The following technique has been used for the so-called complicated cataract includ ing "cataracta uveitica," caused by repeated irido-cyclo-uveitis, and the "cataract of the glaucomatous eye," as well as cataracts due to the different diseases of the retina or to other ocular or systemic diseases. It is an accepted rule that increased or improved vision by a cataract operation may be anticipated only if light sensitivity and light projection of the eye to be operated upon is satisfactory. There are of course, exceptions—in cases of chronic glaucoma, advanced pigmentary degeneration of the retina, and other alterations of the fundus, despite faulty projection of light because of contraction of the visual field, the operation may result in quite satisfactory visual acuity. The following case is noteworthy: A man suffering from advanced retinitis pigmentosa had perception of light at three meters in each eye. Projection of light was limited to the center. Several ophthalmologists refus ing, I undertook the intracapsular and round-pupil operation and obtained a post operative visual acuity for each eye of 5/5 with suitable correction. Bad perception and especially faulty pro jection of light do not invariably mean con traindication to cataract operation. The prob lem, as to whether or not the cataract should be extracted in cases of deficient projection, is to be considered individually in each case. Cataracts due to uveitis or other inflamma tions should not be operated on until the in MODIFICATIONS O F flammation has been quiet for sufficient time OPERATIVE METHODS O F so that it will not recur and the eye be de COMPLICATED CATARACTS* stroyed by it. This is especially true of the cataracts following sympathetic ophthalmia. F. PAPOLCZY, M.D. To perform a cataract operation on a blind Budapest, Hungary eye for cosmetic reasons only is a considera Operation of senile cataract has been ad ble risk. If blindness is due to cataract fol vanced to such a degree of perfection that lowing uveitis, the operation may result in this progress should influence favorably the recurrence of the inflammation, and phthisis operative technique of other kinds of cata bulbi frequently follows. In absolute glau racts as well. coma the danger of expulsive hemorrhage * From the Department of Ophthalmology, St. is to be considered, especially if the ocular Stephen's Hospital. tension is high. If an old detachment of the
Corneal sutures were introduced at the 8and 10-o'clock positions. A keratome incision was made at the 9o'clock position and enlarged with McQuire scissors. A peripheral iridectomy was made at the 9-o'clock position, a spatula was in troduced and, with some difficulty, the ad hesions were broken up. Tooth forceps were introduced, and a large piece of capsule was removed. The lens was delivered in the usual man ner through the temporal incision without any loss of vitreous. The incision was brought together, and some gelatinous cor tex was irrigated with saline. A remaining loose piece of capsule was removed with smooth capsule forceps. The iris pillars were replaced. The corneal sutures were tied, and two cc. of air were introduced into the anterior chamber. Interrupted silk sutures were used for the conjunctival flap. Atropine was in stilled, and a bilateral patch was applied. The postoperative course was uneventful. The anterior chamber reformed on the sec ond day. Most of the keratic precipitates were absorbed, and the eye was white about 10 days after operation. With a +10.0 D sph., vision in the right eye is 20/30—, and, oddly enough, the filter ing bleb has become smaller in size. 300 West 23rd Street (11).
NOTES, CASES, INSTRUMENTS
discontined after four days, and the patient went home on the sixth day with the lesions healing well and no specific eye complaints. He was re-admitted to the hospital on March 21st, this time with definitely healed skin lesions, but with severe lid edema and definite eye involvement of one day's dura tion. On biomicroscopy, two fairly large herpetic infiltrations were noted in the left cornea away from the pupillary area at the 11- and 5-o'clock positions. The iris was muddy and the light reflex was slow; the eye was soft. Local treatment consisted of one drop of two-percent atropine, four times daily, hot packs for 20 minutes every hour, aureomycin ophthalmic solution (two drops every hour). Treatment by mouth was aureomycin (250 mg. every four hours around the clock) and empirin compound with 0.5 gr of codeine for pain. A magnesium sulfatfc purge was prescribed on admission. Improvement was steady with a sharp decline in pain and noticeable change in the corneal lesions in three days. The lower and smaller lesion healed first, leaving a fine nebulous scar. Both lesions were healed by the third week. The aureomycin by mouth was discon tinued on the 14th day, but the aureomycin drops were continued four times daily until the day of discharge on the 21st day. The atropine was withheld after the 14th day. The iris was clear. The resultant fine corneal opacities do not affect visual function. The patient had received 21 gm. of aureo mycin by mouth over a 14-day period with out any gastrointestinal complaints and with total effective healing of the corneal lesions with a minimum of scarring. Talcott Building.
CATARACT EXTRACTION AFTER ELLIOT TREPHINING OPERATION* HENRY F. JACOBIUS,
M.D.
New York It is often difficult to remove a cataractous lens in the presence of a large overhanging bleb following glaucoma surgery, especially when there is also a secluded pupil from a chronic iritis of long duration. History. A Negro, aged 58 years, who ap peared much older, entered the Metropolitan Hospital on October 30,1949. Vision in the right eye was light projection only. The patient gave a history of treatment for chronic primary glaucoma for many years. In 1948, an Elliot trephining operation was performed upon the right eye at the Metropolitan Hospital. For the past year, there had been a gradual diminishing of vi sion, until now he was unable to get about without assistance. The left eye had been totally blind fol lowing a perforating injury at the age of six years. The eyeball was degenerated and soft to touch. The cornea showed old, diffuse infiltrates. The lens appeared to be calcareous and opaque. Eye examination. There was a large filter ing bleb in the right eye which overhung the upper fourth of the cornea. The slitlamp microscope showed numerous old keratic pre cipitates, as well as a small irregular pupil which was bound down concentrically at the pupillary border by ring synechias. There was a hypermature senile cataract. Tension was 18 mm. Hg (Schi^tz). Operation. At operation on October 4, 1949, the pupil was small and did not dilate with two-percent homatropine, 10-percent solution of neosynephrin, and one-percent solution of atropine sulfate. Since it seemed inadvisable to disturb the larger filtering bleb, a conjunctival flap was made at the temporal half of the eyeball. * From the Metropolitan Hospital, eye service of Dr. Charles A. Turtz.
NOTES, CASES, INSTRUMENTS
895
The following technique has been used for the so-called complicated cataract includ ing "cataracta uveitica," caused by repeated irido-cyclo-uveitis, and the "cataract of the glaucomatous eye," as well as cataracts due to the different diseases of the retina or to other ocular or systemic diseases. It is an accepted rule that increased or improved vision by a cataract operation may be anticipated only if light sensitivity and light projection of the eye to be operated upon is satisfactory. There are of course, exceptions—in cases of chronic glaucoma, advanced pigmentary degeneration of the retina, and other alterations of the fundus, despite faulty projection of light because of contraction of the visual field, the operation may result in quite satisfactory visual acuity. The following case is noteworthy: A man suffering from advanced retinitis pigmentosa had perception of light at three meters in each eye. Projection of light was limited to the center. Several ophthalmologists refus ing, I undertook the intracapsular and round-pupil operation and obtained a post operative visual acuity for each eye of 5/5 with suitable correction. Bad perception and especially faulty pro jection of light do not invariably mean con traindication to cataract operation. The prob lem, as to whether or not the cataract should be extracted in cases of deficient projection, is to be considered individually in each case. Cataracts due to uveitis or other inflamma tions should not be operated on until the in MODIFICATIONS O F flammation has been quiet for sufficient time OPERATIVE METHODS O F so that it will not recur and the eye be de COMPLICATED CATARACTS* stroyed by it. This is especially true of the cataracts following sympathetic ophthalmia. F. PAPOLCZY, M.D. To perform a cataract operation on a blind Budapest, Hungary eye for cosmetic reasons only is a considera Operation of senile cataract has been ad ble risk. If blindness is due to cataract fol vanced to such a degree of perfection that lowing uveitis, the operation may result in this progress should influence favorably the recurrence of the inflammation, and phthisis operative technique of other kinds of cata bulbi frequently follows. In absolute glau racts as well. coma the danger of expulsive hemorrhage * From the Department of Ophthalmology, St. is to be considered, especially if the ocular Stephen's Hospital. tension is high. If an old detachment of the
Corneal sutures were introduced at the 8and 10-o'clock positions. A keratome incision was made at the 9o'clock position and enlarged with McQuire scissors. A peripheral iridectomy was made at the 9-o'clock position, a spatula was in troduced and, with some difficulty, the ad hesions were broken up. Tooth forceps were introduced, and a large piece of capsule was removed. The lens was delivered in the usual man ner through the temporal incision without any loss of vitreous. The incision was brought together, and some gelatinous cor tex was irrigated with saline. A remaining loose piece of capsule was removed with smooth capsule forceps. The iris pillars were replaced. The corneal sutures were tied, and two cc. of air were introduced into the anterior chamber. Interrupted silk sutures were used for the conjunctival flap. Atropine was in stilled, and a bilateral patch was applied. The postoperative course was uneventful. The anterior chamber reformed on the sec ond day. Most of the keratic precipitates were absorbed, and the eye was white about 10 days after operation. With a +10.0 D sph., vision in the right eye is 20/30—, and, oddly enough, the filter ing bleb has become smaller in size. 300 West 23rd Street (11).