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Cataract Extraction in the Younger Age Group
586
EDITORIALS
blindness. T h e pursuit o f these goals is achieved in two ways : one, unique in the his tory o f international organizations o f oph thalmology, by maintaining an active, duespaying membership between congresses ; and two, by holding congresses every four years and interim meetings between congresses. The first, organizing congress was held in 1940 in Cleveland, Ohio. Subsequent con gresses under the presidency of Dr. Harry S. Gradle, were held in Montevideo, Uru guay, and Havana, Cuba. T h e fourth con gress, under the presidency o f Dr. Conrad Berens, was held in M e x i c o City. Dr. M o a c y r Alvaro will preside at the fifth congress. A n y o n e who has attended any o f these meetings knows that they are not only su perior from a scientific standpoint but that they are very pleasant social affairs as well. O n e has only to mention the magnificent fiesta in Havana or the television review of the folk dances in M e x i c o to recall the pleas ure o f those occasions. It is certain that our Chilean colleagues will plan something just as pleasant. Plans for the scientific program are well advanced. The official subjects o f the meet ing will be discussed in a series o f symposia which should be unusually rewarding. There v/ill be simultaneous translation in two o f the three official languages o f the organiza tion. Spanish and Portuguese will be trans lated into English and English will be trans lated into Spanish. It is noteworthy that the same system which will be used in Santiago was very successfully used for the first time at any medical meeting, at the interim meet ing of the Pan-American Association o f Ophthalmology held in Sao Paulo, Brazil, in June, 1954. It is worthwhile to point out that this o c casion presents a fine time to see South America. The official travel agent for the congress, M r . E . F. Noonan, representing Journeys International o f 6 East M o n r o e Street, Chicago, Illinois, has arranged a series o f tours that include all the main points of interest in South America. In addition,
M r . Noonan has agreed to modify any itin erary to suit the individual taste. Further more, the Internal Revenue Department has given assurances that the transportation costs to and from the Congress, as well as e x penses in Santiago while attending the Con gress, are deductible items in computing one's income tax. Inquiries concerning the program may be directed to Dr. James H . Allen, 1430 Tulane Avenue, N e w Orleans, Lousiana. Dr. J. W e s ley
M c K i n n e y , 921
Exchange
Building,
Memphis, Tennessee, is in charge o f scientific exhibits, and Dr. H . Saul Sugar, 28 W e s t Adams Street, Detroit 26, Michigan, is ar ranging for movies. Dr. Daniel Snydacker, 111 North Wabash Avenue, Chicago 2, Illi nois, is the acting secretary-treasurer
for
North
Dr.
America during
the illness o f
T h o m a s D . Allen and general inquiries may be directed to him. Daniel Snydacker.
CATARACT
EXTRACTION
IN T H E Y O U N G E R A G E G R O U P There is no question that, with the im provements in instrumentation, and anes thetic agents and their supplements, as well as more residency training programs, the re sults o f cataract surgery are probably better today than they ever have been before. A t least, more and more patients are being suc cessfully taken care of in their local c o m munities, and the complications encountered by the occasional but competent surgeon are decreasing in number. W i t h better anesthesia and akinesia, the intracapsular cataract extraction with or without a complete iridectomy is n o w the operation preferred b y most ophthalmolo gists. In fact, there are some w h o believe that extraction by any other method is never in dicated. Resident surgeons, in the enthusiasm of their first contact with surgery, frequently regard rupturing a capsule as serious a c o m plication as loss of vitreous. This is because
EDITORIALS
they see the grayish-white pupillary space in an injected eye and forget that a planned extracapsular extraction is a much better p r o cedure than that which results from uninten tional rupture o f the capsule. Unfortunately, many o f them have never been exposed to a well-executed extracapsular extraction. W h e n their chief operates and ruptures a capsule, he may deftly reach in, while his assistant irrigates the anterior chamber, and withdraw the remaining capsule with re sultant removal o f the capsule in toto, but, alas, when they execute the same maneuver that veritable large "bead" of vitreous pre sents. Vail in his article on the "Zonule mem brane and cataract expression" reviews the anatomy o f the zonule and points out the relationship between the zonule, hyaloid, and lens. A n y o n e w h o has employed the sliding technique with a complete iridectomy has seen ample evidence o f the zonular hyaloid adherence. In cases with a tough zonule, after the zonule has been ruptured above, a pull on the lens will produce a protrusion o f the hyaloid into the lips o f the wound. W i t h re lease o f this pull the hyaloid falls back. D e livery o f the lens in these cases may take five to 10 minutes ( b y the c l o c k ) . T h e zonule seems to separate fiber b y fiber and the hya loid to peel off the back o f the lens. T h e presentation o f the hyaloid during the p r o cedure may be thought at first to be due to positive pressure, but following delivery o f the lens the hyaloid can be seen to fall back and present a flat or, at times, a concave ap pearance. Even though no vitreous is lost, traction on the tough zonule may d o unseen damage to the retina in the region o f the ora serrata. The phenomenon decribed above is not seen when one uses the tumbling p r o cedure, but may account for the occasional unexplained loss o f vitreous in a soft eye when a technically satisfactory maneuver is being executed. It is well known that it is difficult to assess the strength o f the zonule before operation. There are some individuals o f three score
587
years and 10 w h o have surprisingly tough zonules. Then some o f those much younger have a fairly fragile zonule. A s a general rule, however, the younger the individual the tougher the zonule. T h e etiologic basis for cataracts in young people is usually con genital, traumatic, degenerative, a n d / o r in flammatory. In the latter group, excluding frank uveitis, are those individuals w h o show peripheral retinal degenerative changes and whose first evidence o f a cataract is a posterior subcapsular sheen suggesting a "Cataracta complicata." T h e treatment o f congenital cataracts has for years been a discission followed b y linear extraction if necessary. T h e methods des cribed by Barkan and Cordes have in my hands been more satisfactory than a simple discission. Traumatic cataracts, especially those following an intraocular foreign body, are frequently associated with a disturbance o f the vitreous and attempted removal in the capsule results in loss o f vitreous. In the third category, intracapsular extraction is frequently attempted because it is considered the "ideal" operation or, because o f the pos terior subcapsular opacities, to avoid a sub sequent discission o f a secondary cataract. I was brought u p in the intracapsular school and have seen and helped with a fair amount o f surgery in a large ophthalmic in stitution. T h e planned extracapsular pro cedure is not very frequently performed, but those w h o are adept at it and loosen the an terior capsule with a cystotome and then re move it with posterior tooth capsule forceps, followed by adequate drainage, seldom have to readmit their patients for a secondary discission. T h e early disadvantages o f the extra capsular extraction a r e : slow absorption o f lens material with delayed use o f the eye, phacoanaphylactica, and secondary glaucoma due to retention o f cortical material. T h e late complications are poor transparency o f the posterior capsule, formation o f Elschnig pearls, and poor visibility o f the peripheral fundus in case o f a subsequent retinal detach-
EDITORIALS
588
OPHTHALMOLOGY UNDER ATTACK*
ment. Most of these complications can be avoided with adequate
removal o f the an
terior lens capsule and irrigation. T h e post
During the last quarter of a century there
operative reaction to lens proteins can n o w be
have been, as everyone knows, great advances
adequately controlled by the use o f one o f the corticosteroids.
in applied science generally and medicine particularly.
This is not a plea to return to the extra
Together
with
these,
some extent, as a result o f them,
and
capsular extraction but it is a suggestion that
legal, economic, and
there is a time and a place for everything
have developed as people have learned
and that a well-executed extracapsular cata ract extraction can at times be utilized to advantage. Those w h o do a large amount o f surgery in teaching institutions might d o well to instruct their residents in this procedure even though in their o w n hands an intra capsular extraction may be spectacular and successful. Residents completing their surgi cal training are highly skilled but most o f them will be in practice five to 10 years be fore they have done as man\' operations as they did during their training. During this period of famine, they may be on their own in a general hospital with a nurse assistant and no coach at their elbow. T h e y should know how to perform the extracapsular e x traction satisfactorily, if it is indicated. One must never lose sight of the fact that the patient is being operated on to have his vision restored.
Providing he can see, he is not
particularly concerned with the shape o f his pupil or the presence of a posterior capsule. O n e must weigh the advantages
and dis
advantages. T h e loss o f viscid vitreous is a most serious complication and if the honest surgeon feels that it can be avoided by an extracapsular extraction he should be pre pared to do it and not give as an excuse, fol lowing the loss o f vitreous, " W e l l , it was a young patient and I particularly wanted an intracapsular extraction with a round pupil." It behooves us all to reflect on our abilities and do what is easiest for us and best for the patient.
appreciate
the
to
certain
ethical complications
tremendous
to
influence upon
economics which political power can exert. Thus, today, state legislatures and congress are battle-grounds in which pressure groups strive for political control for their o w n eco nomic advantage. Medicine has held aloof from this process and has sought no special preferment,
and
indeed, in general, has, by working f o r ade quate control o f disease, attempted
to de
stroy the reason for its o w n existence. In recent years, however, this selfless viewpoint has been challenged by fringe groups who have attempted,
without
adequate
medical
education, to "muscle in" on the practice of medicine; this, of course, not with any idea of being o f service to the public, but, basi cally, with the idea of sharing in the monetary rewards. Ophthalmology, as one of the
important
medical specialties, has, until comparatively recent years, along with the rest of the medi cal world, been permitted to develop its field and services without limitation or
interfer
ence by legislative bodies. This condition, however, no longer obtains because, at the present time, a well-organized eifort is being made not only to limit ophthalmology in its field, but
also to extend legally to other
groups part of the traditional
duties
and
privileges of the ophthalmologist. In this we have the first real attempt to limit medical science by legislative enactment, a proposal which must be resisted vigorously by oph
P. R o b b McDonald.
thalmology in the interest of public health and well being. * Reprinted from the Transaclums of tlie Penn sylvania Academy of Ophthalmalogy and Otolaryn gology, Directory Issue, Spring, 1955.
EDITORIALS
blindness. T h e pursuit o f these goals is achieved in two ways : one, unique in the his tory o f international organizations o f oph thalmology, by maintaining an active, duespaying membership between congresses ; and two, by holding congresses every four years and interim meetings between congresses. The first, organizing congress was held in 1940 in Cleveland, Ohio. Subsequent con gresses under the presidency of Dr. Harry S. Gradle, were held in Montevideo, Uru guay, and Havana, Cuba. T h e fourth con gress, under the presidency o f Dr. Conrad Berens, was held in M e x i c o City. Dr. M o a c y r Alvaro will preside at the fifth congress. A n y o n e who has attended any o f these meetings knows that they are not only su perior from a scientific standpoint but that they are very pleasant social affairs as well. O n e has only to mention the magnificent fiesta in Havana or the television review of the folk dances in M e x i c o to recall the pleas ure o f those occasions. It is certain that our Chilean colleagues will plan something just as pleasant. Plans for the scientific program are well advanced. The official subjects o f the meet ing will be discussed in a series o f symposia which should be unusually rewarding. There v/ill be simultaneous translation in two o f the three official languages o f the organiza tion. Spanish and Portuguese will be trans lated into English and English will be trans lated into Spanish. It is noteworthy that the same system which will be used in Santiago was very successfully used for the first time at any medical meeting, at the interim meet ing of the Pan-American Association o f Ophthalmology held in Sao Paulo, Brazil, in June, 1954. It is worthwhile to point out that this o c casion presents a fine time to see South America. The official travel agent for the congress, M r . E . F. Noonan, representing Journeys International o f 6 East M o n r o e Street, Chicago, Illinois, has arranged a series o f tours that include all the main points of interest in South America. In addition,
M r . Noonan has agreed to modify any itin erary to suit the individual taste. Further more, the Internal Revenue Department has given assurances that the transportation costs to and from the Congress, as well as e x penses in Santiago while attending the Con gress, are deductible items in computing one's income tax. Inquiries concerning the program may be directed to Dr. James H . Allen, 1430 Tulane Avenue, N e w Orleans, Lousiana. Dr. J. W e s ley
M c K i n n e y , 921
Exchange
Building,
Memphis, Tennessee, is in charge o f scientific exhibits, and Dr. H . Saul Sugar, 28 W e s t Adams Street, Detroit 26, Michigan, is ar ranging for movies. Dr. Daniel Snydacker, 111 North Wabash Avenue, Chicago 2, Illi nois, is the acting secretary-treasurer
for
North
Dr.
America during
the illness o f
T h o m a s D . Allen and general inquiries may be directed to him. Daniel Snydacker.
CATARACT
EXTRACTION
IN T H E Y O U N G E R A G E G R O U P There is no question that, with the im provements in instrumentation, and anes thetic agents and their supplements, as well as more residency training programs, the re sults o f cataract surgery are probably better today than they ever have been before. A t least, more and more patients are being suc cessfully taken care of in their local c o m munities, and the complications encountered by the occasional but competent surgeon are decreasing in number. W i t h better anesthesia and akinesia, the intracapsular cataract extraction with or without a complete iridectomy is n o w the operation preferred b y most ophthalmolo gists. In fact, there are some w h o believe that extraction by any other method is never in dicated. Resident surgeons, in the enthusiasm of their first contact with surgery, frequently regard rupturing a capsule as serious a c o m plication as loss of vitreous. This is because
EDITORIALS
they see the grayish-white pupillary space in an injected eye and forget that a planned extracapsular extraction is a much better p r o cedure than that which results from uninten tional rupture o f the capsule. Unfortunately, many o f them have never been exposed to a well-executed extracapsular extraction. W h e n their chief operates and ruptures a capsule, he may deftly reach in, while his assistant irrigates the anterior chamber, and withdraw the remaining capsule with re sultant removal o f the capsule in toto, but, alas, when they execute the same maneuver that veritable large "bead" of vitreous pre sents. Vail in his article on the "Zonule mem brane and cataract expression" reviews the anatomy o f the zonule and points out the relationship between the zonule, hyaloid, and lens. A n y o n e w h o has employed the sliding technique with a complete iridectomy has seen ample evidence o f the zonular hyaloid adherence. In cases with a tough zonule, after the zonule has been ruptured above, a pull on the lens will produce a protrusion o f the hyaloid into the lips o f the wound. W i t h re lease o f this pull the hyaloid falls back. D e livery o f the lens in these cases may take five to 10 minutes ( b y the c l o c k ) . T h e zonule seems to separate fiber b y fiber and the hya loid to peel off the back o f the lens. T h e presentation o f the hyaloid during the p r o cedure may be thought at first to be due to positive pressure, but following delivery o f the lens the hyaloid can be seen to fall back and present a flat or, at times, a concave ap pearance. Even though no vitreous is lost, traction on the tough zonule may d o unseen damage to the retina in the region o f the ora serrata. The phenomenon decribed above is not seen when one uses the tumbling p r o cedure, but may account for the occasional unexplained loss o f vitreous in a soft eye when a technically satisfactory maneuver is being executed. It is well known that it is difficult to assess the strength o f the zonule before operation. There are some individuals o f three score
587
years and 10 w h o have surprisingly tough zonules. Then some o f those much younger have a fairly fragile zonule. A s a general rule, however, the younger the individual the tougher the zonule. T h e etiologic basis for cataracts in young people is usually con genital, traumatic, degenerative, a n d / o r in flammatory. In the latter group, excluding frank uveitis, are those individuals w h o show peripheral retinal degenerative changes and whose first evidence o f a cataract is a posterior subcapsular sheen suggesting a "Cataracta complicata." T h e treatment o f congenital cataracts has for years been a discission followed b y linear extraction if necessary. T h e methods des cribed by Barkan and Cordes have in my hands been more satisfactory than a simple discission. Traumatic cataracts, especially those following an intraocular foreign body, are frequently associated with a disturbance o f the vitreous and attempted removal in the capsule results in loss o f vitreous. In the third category, intracapsular extraction is frequently attempted because it is considered the "ideal" operation or, because o f the pos terior subcapsular opacities, to avoid a sub sequent discission o f a secondary cataract. I was brought u p in the intracapsular school and have seen and helped with a fair amount o f surgery in a large ophthalmic in stitution. T h e planned extracapsular pro cedure is not very frequently performed, but those w h o are adept at it and loosen the an terior capsule with a cystotome and then re move it with posterior tooth capsule forceps, followed by adequate drainage, seldom have to readmit their patients for a secondary discission. T h e early disadvantages o f the extra capsular extraction a r e : slow absorption o f lens material with delayed use o f the eye, phacoanaphylactica, and secondary glaucoma due to retention o f cortical material. T h e late complications are poor transparency o f the posterior capsule, formation o f Elschnig pearls, and poor visibility o f the peripheral fundus in case o f a subsequent retinal detach-
EDITORIALS
588
OPHTHALMOLOGY UNDER ATTACK*
ment. Most of these complications can be avoided with adequate
removal o f the an
terior lens capsule and irrigation. T h e post
During the last quarter of a century there
operative reaction to lens proteins can n o w be
have been, as everyone knows, great advances
adequately controlled by the use o f one o f the corticosteroids.
in applied science generally and medicine particularly.
This is not a plea to return to the extra
Together
with
these,
some extent, as a result o f them,
and
capsular extraction but it is a suggestion that
legal, economic, and
there is a time and a place for everything
have developed as people have learned
and that a well-executed extracapsular cata ract extraction can at times be utilized to advantage. Those w h o do a large amount o f surgery in teaching institutions might d o well to instruct their residents in this procedure even though in their o w n hands an intra capsular extraction may be spectacular and successful. Residents completing their surgi cal training are highly skilled but most o f them will be in practice five to 10 years be fore they have done as man\' operations as they did during their training. During this period of famine, they may be on their own in a general hospital with a nurse assistant and no coach at their elbow. T h e y should know how to perform the extracapsular e x traction satisfactorily, if it is indicated. One must never lose sight of the fact that the patient is being operated on to have his vision restored.
Providing he can see, he is not
particularly concerned with the shape o f his pupil or the presence of a posterior capsule. O n e must weigh the advantages
and dis
advantages. T h e loss o f viscid vitreous is a most serious complication and if the honest surgeon feels that it can be avoided by an extracapsular extraction he should be pre pared to do it and not give as an excuse, fol lowing the loss o f vitreous, " W e l l , it was a young patient and I particularly wanted an intracapsular extraction with a round pupil." It behooves us all to reflect on our abilities and do what is easiest for us and best for the patient.
appreciate
the
to
certain
ethical complications
tremendous
to
influence upon
economics which political power can exert. Thus, today, state legislatures and congress are battle-grounds in which pressure groups strive for political control for their o w n eco nomic advantage. Medicine has held aloof from this process and has sought no special preferment,
and
indeed, in general, has, by working f o r ade quate control o f disease, attempted
to de
stroy the reason for its o w n existence. In recent years, however, this selfless viewpoint has been challenged by fringe groups who have attempted,
without
adequate
medical
education, to "muscle in" on the practice of medicine; this, of course, not with any idea of being o f service to the public, but, basi cally, with the idea of sharing in the monetary rewards. Ophthalmology, as one of the
important
medical specialties, has, until comparatively recent years, along with the rest of the medi cal world, been permitted to develop its field and services without limitation or
interfer
ence by legislative bodies. This condition, however, no longer obtains because, at the present time, a well-organized eifort is being made not only to limit ophthalmology in its field, but
also to extend legally to other
groups part of the traditional
duties
and
privileges of the ophthalmologist. In this we have the first real attempt to limit medical science by legislative enactment, a proposal which must be resisted vigorously by oph
P. R o b b McDonald.
thalmology in the interest of public health and well being. * Reprinted from the Transaclums of tlie Penn sylvania Academy of Ophthalmalogy and Otolaryn gology, Directory Issue, Spring, 1955.