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The Adhesion of the Lens Capsule to the Hyaloid Membrane*
THE ADHESION OF T H E LENS CAPSULE TO HYALOID MEMBRANE*
THE
A N D ITS RELATION TO INTRACAPSULAR CATARACT EXTRACTION ALGERNON
B.
R E E S E , M.D.,
A N D J O S E P H A.
C.
WADSWORTH,
M.D.
New York A great deal of attention has been given to the role which the zonules play in fixing the lens. There is little in the literature on the part played by adhesions between the anterior hyaloid membrane and the capsule in securing the lens. Wieger 1 first described the occurrence of some degree of normal adhesion of the lens capsule to the hyaloid and gave it the name ligamentum hyaloideocapsulare. However, Duke-Elder 2 felt that this attachment is of little clinical importance. Goldsmith 3 ob served the adhesion of the hyaloid to the lens capsule, and Vail* in his excellent dis cussion stated: " T h e posterior capsule of the lens is closely connected with the anterior surface of the vitreous through capillary attraction in the retrolental fossa, to adhe sions formed by the ligamentum hyaloideo capsulare, by embryonic fibers joining the posterior lens capsule to the anterior hya loid, or by all three." Vail 5 also states: The smooth, moist convex surface of the lens is in intimate contact with the smooth, moist concave surface of the anterior hyaloid membrane, in Berger's* retrolental space, the latter, however, being only potential. There is, therefore, capillary attrac tion, which is strong. In addition, if the ligamentum hyaloideocapsulare of Wieger is an actual structure, and there is evidence that it is, then there is an actual adhesion between the posterior capsule of the lens and the hyaloid membrane. In addition, there is evidence that embryonic adhesions may also be present. Thus, a rough pull upon the lens can tear the anterior hyaloid membrane and produce char acteristic holes, seen many times with the biomicroscope after operation, and lead to herniation of vitreous mass into the anterior chamber.
the time of operation on supposedly uncom plicated cataracts. W h e n such an "adhesion syndrome" was noted at the time of an ex traction, we made it a practice to section the lens to see if we could detect any hyaloid elements which were adhering to the pos terior capsule. Figures 1, 2, and 3 are ex amples of the findings we encountered. Bel lows 7 states that the presence of the pigmented ring on the posterior lens surface is due to pigment in the patellar fossa after injury or inflammation. Its ring shape is due to the normal adhesion of the lens to the anterior hyaloid. After extracapsular extractions on three eyes in which the lens remained firmly ad herent to the hyaloid, even when the zonules were obviously ruptured, there was noted postoperatively an opaque circle with a clear center on the face of the vitreous (fig. 4 ) . This circle represents, in our opinion, firm adhesion between the capsule and the hyaloid at the site of the ligamentum hyaloideocap sulare. I n an attempt to determine the extent of the adhesion between the capsule and the hyaloid and its possible significance in cat aract extraction, we performed extractions on 20 fresh eyes which we believed to be normal or at least normal for our purposes in the anterior sector. 8 A m o n g the 20 eyes available, nine had melanomas of the choroid. T h e other 11 were obtained at autopsy or because of an exenteration for an orbital new growth. In each eye the cornea was excised and the iris removed at its base, thereby exposing the lens and its zonular membrane. T h e lens was then grasped with A r r u g a forceps, and by gentle traction it was removed in its capsule. I n 15 (75 per cent) of the eyes the zonular membrane rup-
O u r attention was directed to the adhe sions between the capsule and the hyaloid at • * Presented at the 93rd annual meeting of the American Ophthalmological Society, Hot Springs, Virginia, June, 1957. 495
4%
ALGERNON B. REESE AND JOSEPH A. C. WADSWORTH
1W-V
^M
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m
-*^
Figs. 1 to 4 (Reese and Wadsworth). (1) This photomicrograph of an adherent lens removed in cap sule shows a splitting of the posterior capsule (A) or a lamination of the hyaloid membrane adherent to the capsule. (2) An adherent lens removed in capsule shows a thickened posterior capsule (A). Scat tered pigment granules are present. (3) An adherent lens removed in capsule shows a cellular deposit with pigment granules on the posterior capsule. There is also an irregularity in the thickness of the cap sule. This patient had iritis a number of years previous to extraction. (4) An opaque circle with a clear center on the face of the vitreous representing adhesion between the capsule and the hyaloid at the site of the ligamentum hyaloideocapsulare. The sketch was made on the 14th day following an extracapsular extraction of a lens which was too firmly adherent to the hyaloid to permit an intracapsular extraction. tured, easily permitting the lens to be de livered without evidence of any adhesion of it to the vitreous (fig. 5 ) . In five (25 per cent) of the eyes studied the hyaloid was so firmly adherent that it came forward with the lens after the zonular membrane was broken. W h e n the capsule was peeled off, the hyaloid snapped back to its normal position. The various degrees of adhesion between the hyaloid and capsule are shown in Figures 6, 7A, and 7B. W h e n the adhesion was firm, the lens could be drawn far away from the globe before the hyaloid separated; and, in one instance, the adhesion was so firm that a round, punched-out hole was left in the hyaloid (fig. 8 ) . It is possible that an adhesion of the hyaloid and capsule may be fostered by a
previous inflammation, and we have some evidence to support this. In Figures 3 and 4 we see what seems to be evidence of se quelae from a previous iridocyclitis. Fur thermore, several times when extracting a cataract complicating a past iridocyclitis, we have noted firm adhesions between the cap sule and the hyaloid; in one eye the adhe sions were so firm that the two structures could not be separated. More often, though, the adhesion seems to be on a developmental basis. As the pri mary vitreous and the tunica vasculosa lentis disappear with the development of the secon dary vitreous, small remnants of the mesodermal tissue may remain along the pos terior capsule of the lens. 9 At about the same time the zonular membrane (tertiary vitre-
ADHESION OF LENS CAPSULE
497
Figs. S to 8 (Reese and Wadsworth). (S) Experimental cataract extraction with lens delivered without evidence of adhesion to the hyaloid. (6) A drawing of an experimental cataract extraction demonstrating adhesion of the lens to the hyaloid. (7) Experimental cataract extraction showing adherence of the capsule to the hyaloid. (A) and (B) are different stages in the same extraction. (8) A punched-out round hole in the hyaloid following experimental extraction of an adherent lens. ous) develops from the ciliary epithelium and extends to encompass a portion of the lens capsule. At the junction where the sec ondary vitreous and the zonular membrane meet there may be remnants of the mesodermal tissue from the primary vitreous or tunica vasculosa lentis. 10 Fusion of these three layers with the posterior lens capsule occurs at the ligainentum hyaloideocapsulare ( E g g e r s ' line). 1 1 W e have not been able to detect, with the biomicroscope, adhesions
between the two structures at the so-called ligainentum hyaloideocapsulare. Redslob 12 believes that small fibers extend from the pos terior lens capsule into the vitreous. An undue adherence of the hyaloid to the capsule may manifest itself in several ways at the time of the cataract extraction. First, the surgeon appreciates the presence of ad hesions when the lens remains deep in the eye and does not show a tendency to come forward, either as a whole or at the equator
498
ALGERNON B. REESE AND JOSEPH A. C. VVADSWORTH
below, if a tumbling is attempted. The lens lends to slip behind the posterior lip of the wound. When the zonules at the lens equa tor below are obviously broken, the lens still will not tumble or present itself in the wound, or the lens hangs in the wound even with the equator presenting. When the lens is teased forward with the forceps, one can sometimes see the hyaloid peel off the pos terior capsule of the lens. After the hyaloid finally becomes completely free of the cap sule, one feels or sees the vitreous body sink back suddenly. If the adhesion is too strong to separate the two structures and one per severes with forceps, the capsule may be broken or vitreous lost. Failure to appreciate the adhesion between these two structures at the time of extraction is one important cause of capsule rupture or vitreous loss. The adhesion between the posterior cap sule and the hyaloid probably causes the pull on the lens at the time of the extraction to be transmitted to the base of the vitreous which is adherent to the periphery of the re tina. This may be a factor in producing re tinal detachment following cataract extrac tion. W h e n this adhesion syndrome is appreci ated, it is sometimes possible to tease the two structures apart by wedging a spoon between the hyaloid and the capsule with the cornea intervening.
The difficulty of separating the adhesion between the two structures with forceps is that the lens cannot be adequately everted without so stretching the capsule that it rup tures. This can be obviated by the use of an erisophake. W e believe the erisophake has particular virtues in combating this adhesion syndrome. The instrument can be rotated so that the lens can be gradually, and if neces sary completely, everted and in this way gradually peeled away from the hyaloid membrane. Even when the lens lies in the wound and is practically delivered, the last remaining adhesions between capsule and hyaloid may be sufficiently strong to tear a hole in the hyaloid if delivery is done pre cipitously. Vannas 1 3 found that eight percent of eyes on which intracapsular extractions without vitreous loss had been done showed a tear in the hyaloid membrane immediately fol lowing the operation. These were probably rents caused by firm adhesion of the ligamentum hyaloideocapsulare. SUMMARY
Evidence is presented that an adherence between the posterior lens capsule and the anterior hyaloid occurs sufficiently in degree and frequency to be reckoned with in per forming an intracapsular cataract extraction. 73 East 71st Street (21).
REFERENCES
1. Wieger, G.: Ueber den Canalis Petiti und ein Ligamentum Hyaloideocapsulare. Strassburg, 1883. 2. Duke-Elder, W. S.: Textbook of Ophthalmology. London, Kingston, 1933, v. 1, p. 119. 3. Goldsmith, J.: Slitlamp observations during intracapsular extraction of cataract. Arch. Ophth., 22: 792-808, 1939. 4. Vail, I).: Intracapsular extraction: Mechanics, technic, variations. Tr. Am. Acad. Ophth., 58:367-370, 1954. 5. : Zonule membrane and cataract expression. Arch. Ophth., 48:405-413, 1952. 6. Berger, E.: Beitrage zur Anatomie der Zonula Zinni. Arch. f. Ophth., 28:28, 1882. 7. Bellows, J. G.: Cataract and Anomalies of the Lens. St. Louis, Mosby, 1944. 8. Verhoeff, F. H.: The consideration of the ocular structures immediately after removal of the lens in capsule, as determined by microscopic examination, Tr. Am. Ophth. Soc, 29:184, 1931. 9. Cordes, F. C.: Types of congenital cataract, Am. J. Ophth., 30:397-420, 1947. 10. Mann, I. C.: The Development of the Human Eye. London, Cambridge, 1928, p. 205. 11. E«cers. A.: The zonule of Zinn of man according to the investigation of the cadavtr eye with biomicroscopy. Arch. f. Ophth., 113:1, 1924. 12. Redslob, E., et al.: Traitt d'ophthalmologie. Paris, Masson & Cie, 1939, v. 1, p. 573. 13. Vannas, M.: Klinische und experimentelle Untersuchungen ueber die vordern Teile des Glaskorper inshesondere nach intrakapsularen Linsenextraktion, Klin. Monatshl. f. Augenh., 89:318, 1932.
THE
A N D ITS RELATION TO INTRACAPSULAR CATARACT EXTRACTION ALGERNON
B.
R E E S E , M.D.,
A N D J O S E P H A.
C.
WADSWORTH,
M.D.
New York A great deal of attention has been given to the role which the zonules play in fixing the lens. There is little in the literature on the part played by adhesions between the anterior hyaloid membrane and the capsule in securing the lens. Wieger 1 first described the occurrence of some degree of normal adhesion of the lens capsule to the hyaloid and gave it the name ligamentum hyaloideocapsulare. However, Duke-Elder 2 felt that this attachment is of little clinical importance. Goldsmith 3 ob served the adhesion of the hyaloid to the lens capsule, and Vail* in his excellent dis cussion stated: " T h e posterior capsule of the lens is closely connected with the anterior surface of the vitreous through capillary attraction in the retrolental fossa, to adhe sions formed by the ligamentum hyaloideo capsulare, by embryonic fibers joining the posterior lens capsule to the anterior hya loid, or by all three." Vail 5 also states: The smooth, moist convex surface of the lens is in intimate contact with the smooth, moist concave surface of the anterior hyaloid membrane, in Berger's* retrolental space, the latter, however, being only potential. There is, therefore, capillary attrac tion, which is strong. In addition, if the ligamentum hyaloideocapsulare of Wieger is an actual structure, and there is evidence that it is, then there is an actual adhesion between the posterior capsule of the lens and the hyaloid membrane. In addition, there is evidence that embryonic adhesions may also be present. Thus, a rough pull upon the lens can tear the anterior hyaloid membrane and produce char acteristic holes, seen many times with the biomicroscope after operation, and lead to herniation of vitreous mass into the anterior chamber.
the time of operation on supposedly uncom plicated cataracts. W h e n such an "adhesion syndrome" was noted at the time of an ex traction, we made it a practice to section the lens to see if we could detect any hyaloid elements which were adhering to the pos terior capsule. Figures 1, 2, and 3 are ex amples of the findings we encountered. Bel lows 7 states that the presence of the pigmented ring on the posterior lens surface is due to pigment in the patellar fossa after injury or inflammation. Its ring shape is due to the normal adhesion of the lens to the anterior hyaloid. After extracapsular extractions on three eyes in which the lens remained firmly ad herent to the hyaloid, even when the zonules were obviously ruptured, there was noted postoperatively an opaque circle with a clear center on the face of the vitreous (fig. 4 ) . This circle represents, in our opinion, firm adhesion between the capsule and the hyaloid at the site of the ligamentum hyaloideocap sulare. I n an attempt to determine the extent of the adhesion between the capsule and the hyaloid and its possible significance in cat aract extraction, we performed extractions on 20 fresh eyes which we believed to be normal or at least normal for our purposes in the anterior sector. 8 A m o n g the 20 eyes available, nine had melanomas of the choroid. T h e other 11 were obtained at autopsy or because of an exenteration for an orbital new growth. In each eye the cornea was excised and the iris removed at its base, thereby exposing the lens and its zonular membrane. T h e lens was then grasped with A r r u g a forceps, and by gentle traction it was removed in its capsule. I n 15 (75 per cent) of the eyes the zonular membrane rup-
O u r attention was directed to the adhe sions between the capsule and the hyaloid at • * Presented at the 93rd annual meeting of the American Ophthalmological Society, Hot Springs, Virginia, June, 1957. 495
4%
ALGERNON B. REESE AND JOSEPH A. C. WADSWORTH
1W-V
^M
fcfr"
frVpfr
m
-*^
Figs. 1 to 4 (Reese and Wadsworth). (1) This photomicrograph of an adherent lens removed in cap sule shows a splitting of the posterior capsule (A) or a lamination of the hyaloid membrane adherent to the capsule. (2) An adherent lens removed in capsule shows a thickened posterior capsule (A). Scat tered pigment granules are present. (3) An adherent lens removed in capsule shows a cellular deposit with pigment granules on the posterior capsule. There is also an irregularity in the thickness of the cap sule. This patient had iritis a number of years previous to extraction. (4) An opaque circle with a clear center on the face of the vitreous representing adhesion between the capsule and the hyaloid at the site of the ligamentum hyaloideocapsulare. The sketch was made on the 14th day following an extracapsular extraction of a lens which was too firmly adherent to the hyaloid to permit an intracapsular extraction. tured, easily permitting the lens to be de livered without evidence of any adhesion of it to the vitreous (fig. 5 ) . In five (25 per cent) of the eyes studied the hyaloid was so firmly adherent that it came forward with the lens after the zonular membrane was broken. W h e n the capsule was peeled off, the hyaloid snapped back to its normal position. The various degrees of adhesion between the hyaloid and capsule are shown in Figures 6, 7A, and 7B. W h e n the adhesion was firm, the lens could be drawn far away from the globe before the hyaloid separated; and, in one instance, the adhesion was so firm that a round, punched-out hole was left in the hyaloid (fig. 8 ) . It is possible that an adhesion of the hyaloid and capsule may be fostered by a
previous inflammation, and we have some evidence to support this. In Figures 3 and 4 we see what seems to be evidence of se quelae from a previous iridocyclitis. Fur thermore, several times when extracting a cataract complicating a past iridocyclitis, we have noted firm adhesions between the cap sule and the hyaloid; in one eye the adhe sions were so firm that the two structures could not be separated. More often, though, the adhesion seems to be on a developmental basis. As the pri mary vitreous and the tunica vasculosa lentis disappear with the development of the secon dary vitreous, small remnants of the mesodermal tissue may remain along the pos terior capsule of the lens. 9 At about the same time the zonular membrane (tertiary vitre-
ADHESION OF LENS CAPSULE
497
Figs. S to 8 (Reese and Wadsworth). (S) Experimental cataract extraction with lens delivered without evidence of adhesion to the hyaloid. (6) A drawing of an experimental cataract extraction demonstrating adhesion of the lens to the hyaloid. (7) Experimental cataract extraction showing adherence of the capsule to the hyaloid. (A) and (B) are different stages in the same extraction. (8) A punched-out round hole in the hyaloid following experimental extraction of an adherent lens. ous) develops from the ciliary epithelium and extends to encompass a portion of the lens capsule. At the junction where the sec ondary vitreous and the zonular membrane meet there may be remnants of the mesodermal tissue from the primary vitreous or tunica vasculosa lentis. 10 Fusion of these three layers with the posterior lens capsule occurs at the ligainentum hyaloideocapsulare ( E g g e r s ' line). 1 1 W e have not been able to detect, with the biomicroscope, adhesions
between the two structures at the so-called ligainentum hyaloideocapsulare. Redslob 12 believes that small fibers extend from the pos terior lens capsule into the vitreous. An undue adherence of the hyaloid to the capsule may manifest itself in several ways at the time of the cataract extraction. First, the surgeon appreciates the presence of ad hesions when the lens remains deep in the eye and does not show a tendency to come forward, either as a whole or at the equator
498
ALGERNON B. REESE AND JOSEPH A. C. VVADSWORTH
below, if a tumbling is attempted. The lens lends to slip behind the posterior lip of the wound. When the zonules at the lens equa tor below are obviously broken, the lens still will not tumble or present itself in the wound, or the lens hangs in the wound even with the equator presenting. When the lens is teased forward with the forceps, one can sometimes see the hyaloid peel off the pos terior capsule of the lens. After the hyaloid finally becomes completely free of the cap sule, one feels or sees the vitreous body sink back suddenly. If the adhesion is too strong to separate the two structures and one per severes with forceps, the capsule may be broken or vitreous lost. Failure to appreciate the adhesion between these two structures at the time of extraction is one important cause of capsule rupture or vitreous loss. The adhesion between the posterior cap sule and the hyaloid probably causes the pull on the lens at the time of the extraction to be transmitted to the base of the vitreous which is adherent to the periphery of the re tina. This may be a factor in producing re tinal detachment following cataract extrac tion. W h e n this adhesion syndrome is appreci ated, it is sometimes possible to tease the two structures apart by wedging a spoon between the hyaloid and the capsule with the cornea intervening.
The difficulty of separating the adhesion between the two structures with forceps is that the lens cannot be adequately everted without so stretching the capsule that it rup tures. This can be obviated by the use of an erisophake. W e believe the erisophake has particular virtues in combating this adhesion syndrome. The instrument can be rotated so that the lens can be gradually, and if neces sary completely, everted and in this way gradually peeled away from the hyaloid membrane. Even when the lens lies in the wound and is practically delivered, the last remaining adhesions between capsule and hyaloid may be sufficiently strong to tear a hole in the hyaloid if delivery is done pre cipitously. Vannas 1 3 found that eight percent of eyes on which intracapsular extractions without vitreous loss had been done showed a tear in the hyaloid membrane immediately fol lowing the operation. These were probably rents caused by firm adhesion of the ligamentum hyaloideocapsulare. SUMMARY
Evidence is presented that an adherence between the posterior lens capsule and the anterior hyaloid occurs sufficiently in degree and frequency to be reckoned with in per forming an intracapsular cataract extraction. 73 East 71st Street (21).
REFERENCES
1. Wieger, G.: Ueber den Canalis Petiti und ein Ligamentum Hyaloideocapsulare. Strassburg, 1883. 2. Duke-Elder, W. S.: Textbook of Ophthalmology. London, Kingston, 1933, v. 1, p. 119. 3. Goldsmith, J.: Slitlamp observations during intracapsular extraction of cataract. Arch. Ophth., 22: 792-808, 1939. 4. Vail, I).: Intracapsular extraction: Mechanics, technic, variations. Tr. Am. Acad. Ophth., 58:367-370, 1954. 5. : Zonule membrane and cataract expression. Arch. Ophth., 48:405-413, 1952. 6. Berger, E.: Beitrage zur Anatomie der Zonula Zinni. Arch. f. Ophth., 28:28, 1882. 7. Bellows, J. G.: Cataract and Anomalies of the Lens. St. Louis, Mosby, 1944. 8. Verhoeff, F. H.: The consideration of the ocular structures immediately after removal of the lens in capsule, as determined by microscopic examination, Tr. Am. Ophth. Soc, 29:184, 1931. 9. Cordes, F. C.: Types of congenital cataract, Am. J. Ophth., 30:397-420, 1947. 10. Mann, I. C.: The Development of the Human Eye. London, Cambridge, 1928, p. 205. 11. E«cers. A.: The zonule of Zinn of man according to the investigation of the cadavtr eye with biomicroscopy. Arch. f. Ophth., 113:1, 1924. 12. Redslob, E., et al.: Traitt d'ophthalmologie. Paris, Masson & Cie, 1939, v. 1, p. 573. 13. Vannas, M.: Klinische und experimentelle Untersuchungen ueber die vordern Teile des Glaskorper inshesondere nach intrakapsularen Linsenextraktion, Klin. Monatshl. f. Augenh., 89:318, 1932.