Technique Associated with Intracapsular Cataract Extraction*

NOTES, CASES, INSTRUMENTS Flap technique: A superior-rectus suture is placed to aid in holding the eye down, since a general anesthetic is used. A horseshoe incision is made around the cornea leaving about six millimeters at the lower pole for fixation of the globe during the primary corneal incision. A thin flap is dissected well back all around the cornea, avoiding the subconjunctival tissue. The suture is started in the undissected bridge and carried over and over the margin of the flap, ending about four millimeters from its origin and here the first step of the knot is made and left loose. The flap is pushed back from the

TECHNIQUE ASSOCIATED WITH INTRACAPSULAR CATARACT EXTRACTION* JOSEPHINE

K.

DIRION, M.D.

Cleveland

The use of a conjunctival flap in cases of cataract extraction is always a subject for much discussion at any meeting of ophthalmologists. Undoubtedly the reason there are so many types of flaps is because each one is satisfactory only in the hands of its creator. Since I have confined myself, following my Indian experience, to intra-

Circumcision

Dissection and Suture

Flap tied

Fig. 1 (Dirion). Steps in preparation and closure of conjunctival flap.

capsular extraction in most patients suffering from senile cataract, I have felt more and more the need for a secure support for the large wound required. I found in some cases a delay in the reestablishment of the anterior chamber which necessitated the patient's remaining in bed longer than if there had been extracapsular extraction with a smaller wound. Rapid union of the wound has many other advantages than the shorter recovery period; advantages such as avoiding a late incarceration of the iris with an associated low-grade iritis and all its related sequelae and a high degree of astigmatism.

* Presented before the Huron Road Hospital staff meeting in February, 1936. 299

cornea and the eye is ready for the corneal incision (which is kept entirely in the cornea) and the lens extraction. Recently I have effected my extractions without an iridectomy, making only a small puncture in the iris with the cataract knife parallel to the corneal wound at the upper pole after the extraction. After the usual toilet of the eye the flap is pulled down and tied over the bridge below where the knot remains fixed in the undissected tissue. The cornea is completely covered by the flap. The first dressing is done after four days, when the suture is removed. The flap in retracting usually remains adherent to the corneal wound for ten days or two weeks before finally slipping back

300

NOTES, CASES, INSTRUMENTS

to position. The conjunctiva remains red slightly longer but the security of the flap more than compensates for this. The ultimate scar is a fine white line at the site of the pericorneal incision. Before developing my own flap, I tried the Kuhnt flap, in which there is a dissection of the upper portion of the conjunctiva, which is held in position by two lateral sutures. Because of the uneven tension created by the position, I discarded it. The Wiirdemann flap, in which there is a circumcision of the cornea and a purse-string suture tied over the center, offered two difficulties: first, after making the flap there was no means of securing a firm fixation of the globe during the primary incision, and second, a suture tied over the center of the cornea resulted in a central keratitis which took some time to clear. The anesthetic: Having performed many extractions under local, and several in which a general anesthetic was absolutely necessary under chloroform (at the risk of consequent nausea and vomiting), it was not difficult for Dr. W. H. Phillips to convince me that an anesthetic without preoperative excitement and without postoperative nausea and vomiting would be an ideal procedure for cataract work. Dr. Phillips has used avertin for more than six years with practically all his general anesthetics. I operated on six patients under evipal and in most instances the anesthesia was quite satisfactory except for the excitement associated with the intravenous administration. Now I have used avertin for a year with very satisfactory results. There is no preoperative excitement, in fact many times the patient is not aware he is being anesthetized, and the twentyfour hours following the operation are quiet and restful. The only contraindication we have found is diabetes, and thus

far I still hesitate to use it even with wellguided insulin administration. 835 Rose Building. ANOTHER TEST FOR MALINGERING HARRY

S.

GRADLE,

M.D.

Chicago

Any device that can reduce the visual acuity of an eye without detection is of help in unmasking a malingerer who professes marked decrease in the visual acuity of an injured eye. The greater the variety of such devices available the greater the reduction of chances that a malingerer may obtain unjust compensation. If the malingerer is very clever and claims the loss of visual acuity in both eyes, there are a few methods of disproving the claim. But the average malingering patient claims loss of visual acuity only in the injured eye and it is in this type of case that the following test is of value. In the past, polarization of light has been accomplished by means of a Nicol prism, which is made by cutting Iceland spar along one of the two faces and cementing the two halves together again with Canada balsam. A beam of light transmitted through such a prism progresses in only one plane of vibration. If the beam is then passed through a second Nicol prism whose axis is parallel to that of the first prism, there is no interference. But if the axis of the second prism is at right angles to that of the first prism, the light is completely stopped. Nicol prisms are expensive, clumsy, and unwieldy unless set in some fixed optical instrument. A substitute has recently been developed by the Polaroid Corporation, that from the practical standpoint forms a perfect polarizing element. It is inex-