The Experimental Approach to Cataract Surgery*

OSTEOPETROSIS

953

23. Roche, L., Ravoult, P. P., Vignon, G., Lejeune, E., Maitrepierre, J., and Lambert, R.: Deux nou­ velles observations d'osteopétrose fluorée. Arch, de maladies professionnelles, 21:356, I960. 24. Sjolin, S.: Studies on osteopetrosis: II. Investigations concerning the nature of the anemia. Acta. Paed., 48:529, 1959. 25. Pilgerstrofer, W.: Actions of cortisone in Albers-Schönberg disease (Osteopetrosis). Wien Ztschr. Inn. Med.,41:177, 1960. 26. Cohen, H. J., and Clark, A. L.: Osteopetrosis. Harlem Hosp. Bull., 8:12, 1955. 27. Steinberg, C. L.: Osteopetrosis. J. Lancet, 74:437, 1954.

THE EXPERIMENTAL APPROACH TO CATARACT SURGERY* R E S U L T S I N A SERIES OF 555

EXTRACTIONS DONE W I T H O U T C O N J U N C T I V A L FLAP III. A.

COMPLICATIONS

C. H I L D I N G ,

M.D.

Duluth, Minnesota

It is from the complications in cataract surgery that we learn the most. GLAUCOMA

Glaucoma runs through cataract surgery like the warp strand through the weaving. When these patients come to us with their cataracts, some have already been operated upon for glaucoma, some are on miotic treat­ ment, some have glaucoma of which they are as yet unaware and some have glaucoma in the fellow eye. Still others will develop glau­ coma postoperatively, either as a result of the operation or independent of it. Some will develop it in the fellow eye. PREOPERATIVE

GLAUCOMA

In 39 eyes (seven percent of this series), glaucoma was present when the patient pre­ sented himself for cataract extraction. Fif­ teen of the 39 had had previous surgical treatment for glaucoma. The previous opera­ tive field in 14 of these 15 eyes was left un­ disturbed in the cataract surgery, either by making the incision anterior in the cornea or centering it temporally or below.1 Twentyfour of these eyes had had no glaucoma sur­ gery (table 1). * From the Research Laboratory, St. Luke's Hospital. This work was supported by grants from the Louis W. and Maud Hill Family Foundation of Saint Paul, the Edward C. Congdon Memorial Trust, Miss Elisabeth Congdon and the Women's Service Guild of St. Luke's Hospital.

When patients with glaucoma come for cataract extraction, the surgeon is faced with a choice of three alternative procedures : ( 1 ) a preliminary glaucoma operation, (2) a simple cataract extraction, or (3) a com­ bination of the two. Since broad iridectomy and iridencleisis2 are so readily done, with a minimum of additional maneuvers, at the time of cataract surgery, one is tempted to do a combined operation. Some prefer a sub­ sequent cyclodialysis.3 In these 39 cases, a cataract extraction alone was done in 18. Some, as already noted, had had previous glaucoma surgery. A combined procedure was done in 23, in­ cluding two normotensive eyes because of glaucoma in the fellow eye (table 2). The decision to do a combined operation was disastrous in two cases: both patients were men over 80 years of age (82 and 85) ; TABLE 1 TYPE OF OPERATION THAT HAD BEEN DONE IN IS OF THE 3 9 CASES OF PRE-EXISTING GLAUCOMA

(1934-1954) Pre-existing glaucoma 39 Cases (Acute phacoanaphylactica—2 cases) Previous operation for glaucoma 15 By trephination 7 Iridencleisis 6 Unknown 2 Previous operation preserved in cata­ ract operation 14 By incision anterior to 3 By incision temporally 9 Unknown 2

A. C. HILDING

954 TABLE 2

TYPE OF CATARACT OPERATION DONE ON THE 3 9 EYES IN WHICH GLAUCOMA HAD BEEN DIAGNOSED

(1934-1954) Pre-existing glaucoma 39 Cases Surgery for Cataract Combined glaucoma-cataract operation 23* Iridencleisis 9 Broad iridectomy 14 Cataract operation alone, with no glaucoma operation 18 (some had previous operation) * Includes two normotensive on account of glau­ coma in fellow eye. Two lost from iris hemorrhage.

iridencleisis was done in both. Tn both, in­ tractable bleeding from the iris began at operation and both eyes were lost.''' The visual results in the group are given in Table 3 ; one third attained to vision of 20/200 or less and three eyes remained or became blind. PHACOANAPHYLACTICA

Glaucoma due to lens sensitization was di­ agnosed in three eyes.4'5 In the first, a cata­ ract had been discovered 10 years previously and in the meantime had become grade IV, hypermature and shrunken. Glaucoma devel­ oped and an iridencleisis had been performed 15 months before cataract surgery. In ex­ tracting the lens, the incision was centered temporally to avoid the area of the iriden­ cleisis. The lens was flat and disclike and was TABLE 3 VISUAL RESULTS IN EYES WITH PRE-EXISTING GLAUCOMA

(1934-1954) Pre-existing glaucoma 20/20 20/30

39 Cases 5 10

20/40 20/50 20/100

3 6 3

20/200 <20/200

4 6

Blind

3

t Ironically, one patient had come 2,000 miles to be operated on and the other was an intimate friend of the family, whose fellow eye was almost useless.

delivered by grasping at the equator. Mild pain and questionable clinical iritis of one day's duration characterized the postopera­ tive period. Thereafter the eye healed well and vision of 20/30 was attained. The second patient came with acute glau­ coma and a diagnosis of phacoanaphylactica was made. Tension at that time was 65 mm. Hg (Schipitz) and was reduced to 25 mm. Hg preoperatlvely. After cataract extrac­ tion, tension increased for two days then it became normalized. Final vision, however, was only 20/200 due to vitreous pathology. The vitreous was thickly filled with opacities. In the third instance, cataract had been diagnosed nine years previously and, when the patient presented herself, it was hyper­ mature, grade IV. Acute glaucoma had de­ veloped and paracentesis with trephination had been done elsewhere six weeks prior to cataract extraction. Tension was normalized after cataract surgery and the immediate vision was 20/50. Final visual result was not obtained. POSTOPERATIVE GLAUCOMA

The incidence of postoperative glaucoma in this series was less than that of pre-exist­ ing glaucoma and the results were better. Seventeen eyes in the series (three percent) developed glaucoma postoperatively, four within 10 days, and 15 within six months. In one eye the glaucoma followed a blow from a fist some eight and one-half months after operation. In three it was associated with iritis and in 12 followed the collapse of the anterior chamber. It did not occur in any eye having a shallow chamber that did not empty entirely, even when shallow for a long period of time. These 12 cases developed in eyes in which the chamber was completely collapsed for from two to 14 days (table 4 ) . Thirteen of the 17 eyes were operated upon secondarily for glaucoma; four were controlled without any operation. The types of operation used appear in Table 5. The visual results (table 6) were fairly good. Ten of the 17 attained to normal vision.

EXPERIMENTAL APPROACH TO CATARACT SURGERY A record of late change in visual results was had in eight cases. COLLAPSE OF ANTERIOR CHAMBER

Loss of the anterior chamber or failure to reform is a common complication and may lead to serious consequences.6"9 A flat an­ terior chamber was found 91 times in this series, representing 16.5 percent of the total. Many undoubtedly were due to leak, some to delayed aqueous formation.9'10 Of these 91, 26 (about one fourth) followed immediately after removal of sutures. Fifty-six (about two thirds) were empty for not more than three days, 28 for only one day or less (in one case for only a half hour after removal of sutures). None of those that were empty for a single day were followed by glaucoma. Seventeen were collapsed for two days ; two of these were followed by glaucoma. In 35 there was no chamber for from four to 26 days and it was following these longer periods that glaucoma occurred. LEAK

AFTER SUTURE REMOVAL

Collapse following suture removal oc­ curred in 26 eyes (4.7 percent of the total series). These instances were probably due to leak. In addition, some chambers became shallow without collapse ; some of these also might have been due to leak. EFFECT UPON THE PUPIL

The precautions taken in making the inciTABLE 4 CONDITIONS ASSOCIATED WITH POSTOPERATIVE GLAUCOMA AND TIME INTERVAL BEFORE GLAUCOMA DEVELOPED

(1934-1954) Postoperative glaucoma Associated-with or following col­ lapsed anterior chamber Associated with iritis

17 Cases 12 3

Interval from operation to de­ velopment of glaucoma Within 10 da 10-30 da 2nd-6th mo More than 6 mo No record

4 6 5 1 1

955

TABLE 5 T Y P E S OF OPERATIVE PROCEDURES USED IN EYES HAVING POSTOPERATIVE GLAUCOMA

(1934-1954) Postoperative glaucoma—17 Cases Secondary glaucoma operation used Cyclodialysis 1 Peripheral iridectomies 3 Iridencleisis 4 Full iridectomy 1 Trephination with iridectomy 1 Trephination with iridencleisis 1 Incision reopened 1 (Died 2 wk.) No glaucoma operation

13

4

sions to prevent iris prolapse were very ef­ fective. Prolapse did not occur in any of the 91, nor did any visible incarceration. Among the 91 eyes, four pupils were pear shaped, one was oval and six were slightly eccentric. It could be that these abnormal shapes were due to collapse, but such pupils occurred also in eyes in which the chamber remained full. EFFECT OF COLLAPSE ON VISION

There was no demonstrable effect upon final visual result in any eye due directly to loss of chamber. Sixty-nine (71.4 percent) attained to normal vision—somewhat less than for the group as a whole. Three of those that developed glaucoma attained to less than normal vision ; one of these was a glaucoma secondary to iritis. It is possible that in the other two the vision was some­ what compromised by the collapse of the anterior chamber, acting indirectly through TABLE 6 VISUAL RESULTS IN CASES OF POSTOPERATIVE GLAUCOMA

(1934-1954) Postoperative glaucoma—17 Late Cases Immediate 20/15. 1 Better 20/20. 2 Worse 20/30. 7 Unchanged 20/40. 2 No record 20/50. 1 Died <20/200 2 Blind 1 No record 1

2 4 2 8 1

A. C. HILDING

956

the glaucoma that followed. The vision in these two cases was 20/50 and 20/40. SHALLOW

ANTERIOR CHAMBER NOT

WHICH

DID

COLLAPSE

Shallow anterior chambers that were never seen completely empty were recorded in 57 eyes. There were probably more, because in the first 200 no great importance was at­ tached to mere shallowness. Tn none of these 57 did there seem to be any deleterious effect and glaucoma developed in none. No matter how shallow the chamber became, or how long it persisted, glaucoma did not develop as long as there was a film of aqueous be­ tween the iris and the cornea. BLOOD

IN

ANTERIOR

CHAMBER

One of the greatest objections to conjunctival flaps is the frequent development of a more or less silent hyphema of considerable extent between the third and seventh post­ operative days. 11 " 14 Limbal incisions, avoid­ ance of flaps, and the types of closure used all but eliminated this type of bleeding in my series. HYPHEMA

In three instances only did a grade I I I hyphema develop. In one a broad, full iridectomy had been done because the fellow eye had been lost from glaucoma. This chamber was irrigated because of the hyphema—the only one in the entire 555. In the second in­ stance, the standard limbal incision with four corneoscleral sutures and one peripheral iridectomy had been used and I do not know why the eye bled. It could have been from the iris and latent glaucoma might have been a factor. A third eye developed a grade I I I hyphema but this eye also suffered from iritis, grade I I I vitreous loss, and iris pro­ lapse (listed under all four complications). Convalescence was stormy but a visual acuity of 20/15 was eventually had. Five others had a "slight amount" "streak" of blood for one or two days.

or

TRAUMATIC

BLEEDING

Nine eyes developed a little bleeding from directly applied trauma during the immediate postoperative period. T w o were grade II and the rest minimal or grade I. (Eight of these are discussed under postoperative accidents.) The ninth was in a restless, unco-operative patient who got out of bed and was most difficult to control. All of the 16 eyes discussed in these cate­ gories attained to 20/30 vision or better with one exception. Poor vision ( 2 0 / 2 0 0 ) in this eye was due to vitreous pathology. BLOOD STREAKS FROM SUTURE REMOVAL

One to three hairlike streaks of blood were seen to course over the upper iris in five eyes at the time of suture removal. This could hardly be classed as hyphema. Nothing happened in any. POSTOPERATIVE ACCIDENTS

Twelve eyes were accidentally injured dur­ ing the convalescent period. Although pain­ ful and, in some instances causing consider­ able deformation of the pupil, all 12 attained vision of 20/30 or better. Eight of the 12 showed a little blood in the anterior chamber (see above). One patient struck her eye in sleep dur­ ing the seventh night, a second did the same on the sixth night and tore out a suture. T w o developed sudden, severe pain the sixth and eighth nights, respectively, and had probably struck the eyes. O n e man, also in sleep, stuck his thumb under the dressing the sixth night and scratched the cornea. Blood appeared in the anterior chamber and required four days to absorb. A woman poked her finger into her eye while sleeping the fifth night. O n the 12th postoperative day, during play, the granddaughter of a clergyman patient poked her finger into his eye collapsing the anterior chamber. O n e patient was being shaved by his brother on the sixth day, when the brother's hand slipped and struck the newly operated eye with his finger. A woman

EXPERTMENTAL APPROACH TO CATARACT SURGERY reached out of bed for something on the 10th day, striking the operated eye squarely on the corner of the bed table. The wound opened and the pupil became hammock shaped. One patient became startled during a dressing, jumped suddenly and developed severe pain in the eye and the same side of the head and also a grade II hyphema that required five days to absorb. One pa­ tient jerked suddenly during suture removal while I held the suture with a forceps. My rule is not to grasp a suture until it has al­ ready been cut.15 The wound gaped, vitreous presented and the iris folded back above the vitreous, making a keyhole pupil. Another patient jerked suddenly during suture re­ moval but nothing happened except that the anterior chamber emptied. EPITHELIAL DOWNGROWTH

This is a frightening turn of events, about which there is an extensive literature.16"23 Fear of this uncommon complication has had a profound influence on the present opera­ tive methods. I am not sure that it developed in any eye of this series. It was diagnosed, with question, once in a 75-year-old man in whom a narrow, sharp, iciclelike, grayish point was seen on the 21st postoperative day. It extended from the incision at the 11o'clock position vertically downward to the pupillary level. It did not change appreciably over a period of some months. Neither its appearance nor the time interval involved was typical. Three weeks after operation is very early for the development of epithelial invasion. The literature indicates that many months are required. Nor did the iciclelike shape bear any resemblance to the crescent covering the upper third of the posterior cornea, as described in the literature. After two years its appearance was essentially un­ changed and vision was 20/100. A macular lesion was also found that had an "orange peel" appearance and this might have caused the reduction of vision. The diagnosis in this instance was doubtful. A woman, operated upon in 1937, re­

957

turned in 1940 with 20/20 vision. In 1942, at the end of five and one-half years, the eye was greatly irritated and vision had dropped to counting fingers. There was clouding of the upper portion of the cornea, with a cyst in the anterior chamber. The cyst contained a white, granular crescent that showed a fluid level with change of position. The patient died without a definite ocular diagnosis hav­ ing been made and the eye was not recovered for examination. Five years seems a very long time lapse before the onset of epithelial downgrowth, if such it was. The record of a third patient, a 62-yearold man, upon review 17 years after opera­ tion, contained findings suggestive of downgrowth. The eye had remained irritated for about two years ; Descemet's membrane was clouded in the upper third and a thin line was seen at the lower margin. This line disap­ peared, however, and, after two and a half years, the cloudiness lessened and final vision was 20/100. The diagnosis remains un­ certain. CLINICAL IRITIS

This is a serious complication.24 Tt was recorded in 31 eyes (5.6 percent). L. 20 of these 31 eyes, the capsule ruptured during attempted intracapsular delivery of the lens ; in one the capsule was purposely opened. Iritis occurred also in 10 eyes in which the lens had been delivered successfully intracapsularly. Grading the severity of the iritis on a basis of I to IV, three eyes were classified as questionable, 14 as grade I, seven as grade II, four as grade III and three were not graded. The visual results were as follows: 14 (about half) attained 20/30 or better; five, 20/40 to 20/100; two 20/200; three, less than 20/200, and six became blind. In one there was no record. Of the 17 eyes classified as questionable or grade I, 13 attained to a vision of 20/30 or better. Only one of the seven in grade II attained to normal vision and none of the

A. C. HILDING

958

four in grade III. In fact, three of the grade III eyes became blind. In 14 eyes (almost half), the visual re­ sult was 20/100 or less. The cause of poor vision in one was a late vitreous hemorrhage and in one a diabetic retinitis. A third devel­ oped a postoperative psychosis from which he did not recover. Immediately after opera­ tion, he repeatedly poked his eye with his finger, traumatizing it severely. In all of the other 11, the iritis seemed to be the major cause of poor vision. Four of the eyes developed pupillary mem­ branes or exudate. One of these also devel­ oped anterior synechias in the upper third of the anterior chamber, with clouding and vascularization of the corresponding area of the cornea. The most unfortunate results of all oc­ curred in two patients in whom both eyes were lost. In the first of these patients, the eyes were operated upon six days apart and seemed to do well for two months, then both developed a chronic, low-grade iridocyclitis that eventually reduced vision to counting fingers. Since this experience, one to several months' time has been allowed to elapse be­ tween operations. The other of these two pa­ tients had suffered from repeated attacks of iritis over a period of 20 years. Posterior synechias with iris bombé and glaucoma had developed in both eyes and both had been operated upon for this condition. This man's cataracts became so dense that he was prac­ tically helpless, and one eye, with a vision of only light perception, was operated upon. Plastic iridocyclitis promptly lighted up and, after a stormy course, the eye was lost. Nine months later, after taking what was thought to be proper precautions, the second eye (vision 3/200) was operated upon, but, de­ spite every effort, followed the same stormy course to complete blindness. POSTOPERATIVE HYPOTONY

The postoperative intraocular pressure re­ mained very low in many eyes, although many also returned to normal reasonably

soon. In the absence of leak, this hypotony was presumed to be due to operative trauma suffered by the aqueous-producing mecha­ nism, similar in nature to that following a blow upon the intact eye, when the tension remains low for a more or less extended period. In those measured, the mean time re­ quired for a return to the preoperative level was about one month. This subject was dis­ cussed in detail in a previous paper.10 VITREOUS DYNAMICS AND STATE OF HYALOID

In extracapsular removal of the lens, the anterior support to the vitreous body is par­ tially lost. If the extraction is done intracapsularly, still more support is lost and, in addition, the normal attachments between the hyaloid and lens are severed.25·26 These con­ sist mainly in a ringlike attachment some­ times referred to as Eggers' line.27'28 After loss of anterior support, the anteroposterior diameter of the vitreous is increased and the physiologic slack in the fibrillar structure partially taken up. These changes alter the stresses in external and internal vitreous at­ tachments and structure and, for instance, make retinal detachment and macular irrita­ tion more likely than in the phakic eye.26 VITREOUS COMPLICATIONS

A total of 18 (3.8 percent) suffered some degree of vitreous loss. Fourteen of these were only grade I, two were grade II, and two were grade III. VITREOUS LOSS

From the vitreous loss itself, there seemed to be little or no direct effect upon the visual result. Of the 14 having grade I loss, 11 attained to vision of 20/30 or better, and the other three attained 20/50, 20/100, and 20/200. The two eyes with grade I loss that saw 20/50 and 20/200 were both in the same individual. Both eyes developed a corneal dystrophy (clouding of the anterior layers), iritis and pupillary membrane. Eventually the vision became very poor in both eyes (counted fingers). The eye with 20/100

EXPERIMENTAL APPROACH TO CATARACT SURGERY

959

vision was highly myopic and had a fluid vitreous and degeneration of the retina. Both eyes having a grade II loss attained 20/20 vision and the two with a grade III attained 20/30 and 20/15. Thus, of the 18, 15 saw 20/30 or better. Two of those that at first attained normal vision later lost some visual acuity. One, in which the vision was 20/30 after operation, developed a hole in the macula and a detachment and the vision was lost. The other, with initial 20/20 vision, after two years saw only 20/100. Macular disease was present. 26 · 29

ous loss, therefore, tended to occur more fre­ quently among the younger patients—a point favoring use of alpha chymotrypsin in younger patients. The method of lens delivery in these 18 was as follows: 11 were delivered intracapsularly, four were begun intracapsularly and finished extracapsularly, two were done by capsulotomy, and one was a spontaneous precipitate delivery, in which the capsule ruptured and was recovered in its entirety.

VITREOUS ADHESIONS: RELATION TO

In this group of cataract operations, there were no prolapses of the large, ballooning type that was common before the days of sutures and peripheral iridectomies.31 This complication has been virtually eliminated. Incarceration or small prolapse occurred 14 times ; eight were classified as incarcerations only, and six as prolapse ; four of the latter were grade I and two were grade II (table 7)· As far as could be determined, this com­ plication did not materially affect the visual results in most instances. Nine of the 14 attained to a vision of 20/30 or better. Three of those with vision of 20/50 or poorer ex­ hibited retinal disease to explain the poor vision. For the remaining two, no definite cause was found. Repair was successfully carried out at a secondary operation in ten. In the other four, the complication was so minor that it was thought no repair was necessary.

MACULAR DISEASE

Two other eyes, which did not suffer vit­ reous loss, should be mentioned here because of macular disease quite definitely due to vit­ reous adhesions. Both developed horse-tail adhesions to the incision and a macular dis­ turbance that was objectively visible with the ophthalmoscope. For a time vision be­ came reduced, then, after some weeks or months, improved in both. Presumably the vitreous attachment at the macular area had let go, thus relieving the macula of the irrita­ tion from tugging. In these two eyes, the relation of the macular disease to the vitre­ ous seemed quite clear-cut. In the two eyes that suffered vitreous loss, and also late visual loss, the relation between the macular disease and the vitreous was not so clear. Whereas the effect of vitreous loss on vi­ sion was indirect, the effect upon the shape of the pupil was direct. Only two of the 18 finished with round, central pupils ; the others all showed more or less distortion, such as oval, pear-shaped, updrawn or Ushaped pupils.30 The vitreous loss seemed to be related to age and this, in turn, to the strength of the zonule. This group of 18 averaged only 57 years of age, whereas the entire series aver­ aged 66.4 years. Seven of the 18 were 50 years or younger, three being in their thirties. Only four were over 70 years of age. Vitre­

INCARCERATION OF IRIS AND IRIS PROLAPSE

RETINAL DETACHMENT, POSTOPERATIVE

Seven patients developed retinal detach­ ment from one month to three years post­ operatively. Four came within eight months and were all successfully treated surgically, by diathermy barrage (no scierai shorten­ ing) . The resulting vision was 20/20, 20/40, 20/50 and 20/200. One did not develop for three years and was operated upon elsewhere "with good results." The sixth came one year postoperatively as a result of a hole in the

960

A. C. H I L D I N G TABLE 7 I R I S INCARCERATION AND PROLAPSE: TREATMENT AND RESULTS

(1934-1954) Case

Sutures

Irid.

Repaired

Extent

Vision

Final Pupil

Remarks

Incarceration just at 12 o'clock

No

20/50

U-shaped between 2 iridotomies

Grade I

Successfully 7th da.

H.M.

U-shaped

Developed postoperative psychosis. Out of bed after 2nd da. postop. D e ­ veloped high astigmatism; died within yr.

Scissors iridoto m y & iris reduced

20/20

Updrawn between 2 iridotomies

One of these iridotomies failed to pene­ trate the iris. Prolapse occurred here

Grade 1

Cauterized & reduced

20/15

U-shaped between 2 iridotomies

Occurred on 20th da.

0

Incarceration at 1 o'clock

No

C.F.

Pear-shaped

Degenerative changesat disc and macula

4

0

Incarceration with tendency of wound to gape

Iridotomy & another suture placed

20/15

U-shaped

Migraine with vomiting and weeping on 5th da. Incarceration between su­ tures. After repair, iris above folded be­ hind vitreous

1-189

4

0

Incarceration a t 12 o'clock with tendency to gape

Iridotomy with reduction of iris

20/20

Oval

1-197

5

0

Grade I

Iridotomy and reduction

20/200

Oval

Frightened 3rd postop. night; sat up suddenly. Macular disease with central scotoma

Grade II prolapse

After 2 wk. Re­ duced & 1 sclerocorneal suture placed

20/30

Updrawn (iridencleisis)

Low-grade preop. glaucoma. Iridencleisis done—only conjunctiva sutured

20/30

U-shaped

Iris folded behind vitreous giving ap­ pearance of full iridectomy

1-7

2

1-22

0 Both cut

1-108

2

1-95

2

3

1-145

4

1-167

3

2 Slits

2 Grade I. A 3rd Occurred 2nd failed da. to pen­ etrate

2-35

Conj. only

2-60

4

0

Incarceration 1st da.

Iridotomy & iris reduced

2-130

4

1

Incarceration

No

20/30

Pear-shaped

Pear-shaped pupil

2-154

4

1

Grade II prolapse

After 21 da. cau­ tery. Vitreous amputated

20/20

Updrawn

H a d prominent "frog eyes." Wound tended to gape

2-245

4

1

Incarceration?

No

20/30

Central

N o t quite sure of incarceration. M a y have been adhesion only

2-256

3

2

Incarceration

Yes—cautery & 1 suture

20/50

Slightly updrawn

T h e central suture was of mattress type and was too tight, depressing the cornea

Incarceration — 8 Prolapse, Gr. 1—4 Pro­ lapse, Gr. I I — 2

Repaired—10

TOTAL

Full

Myopic degeneration of retina. Vitre­ ous seen but none lost

20/15-2 20/20-3 20/30-4 20/50-2 20/200-1 <20/200-2

macula. This eye was myopic ( — 6.0D) and was one that had lost vitreous, and was the one which had been struck against the corner of the bed table on the 10th postoperative day, splitting the wound open. No attempt was made to repair the detachment. The seventh patient returned after 13 months with a blind eye and a story from the local physician that there had been a "corneal ulcer" with perforation. Repair was not attempted. In these few cases, the surgical results of repair of postoperative retinal detachment were good. Visual results, with one excep­

tion, were also good. Had the series been larger, the simple operation used would probably have been found inadequate in many instances. It cannot be stated with certainty that only seven eyes in the 555 developed retinal de­ tachment, because follow-up information was not available on all of the patients. INTRAOCULAR

INFECTIONS

PANOPHTHALMITIS

This disastrous complication occurred in only one eye. Extensive suppuration devel-

EXPERIMENTAL APPROACH TO CATARACT SURGERY oped and the eye was lost. The source of the infection was not apparent unless it was a rather extensive pyorrhea. A slip in aseptic technique is always a possibility. ENDOPHTHALMITIS

A less severe intraocular infection was diagnosed in a second eye. This patient dis­ appeared after 17 days, but, when last seen, the anterior chamber was still somewhat cloudy, there was exudate in the pupil, but infection was controlled.32'33 PULMONARY EMBOLISM

This serious complication occurred in three patients. The first was in a 74-year-old man, who developed an embolism on the second postoperative day, which he survived, only to experience a fatal one on the sixth post­ operative day. An 81-year-old woman sur­ vived an episode of phlebitis followed by an embolus on the 10th postoperative day. In an 84-year-old man, the diagnosis of pulmonary embolus was somewhat doubtful but an epi­ sode on the ninth postoperative day could well have been that. He also survived. POSTOPERATIVE PSYCHOSIS

Postoperative psychosis is not uncommon and can be serious, although it usually is not. 34 · 35 Thirteen patients in this series de­ veloped such mental aberrations. In seven, they amounted to only a slight confusion for one or two days ; all patients recovered nicely. An eighth died of pulmonary embo­ lism on the sixth postoperative day (see above). The mental condition was more or less serious in the remaining five patients. The details appear in Table 8. A certain number of patients in the cata­ ract age group apparently live habitually pre­ cariously near to mental instability and any operation, like other stressful events, may upset them mentally. COMMENTS

Complications resulting from the opera­ tion, in this series of cataract extractions, were relatively few and most were minor.

961

The most serious were glaucoma and clinical iritis. Thirty-nine (seven percent) of the eyes showed glaucoma when the patient pre­ sented himself for cataract treatment. These, of course, did not constitute operative com­ plications, but they made the operative pro­ cedures more complicated and results were not as good as in the series as a whole. Only a little more than a third received normal vision. Glaucoma anaphylactica is a distinct en­ tity and was diagnosed in three eyes. It was relieved in all three by cataract extraction. Seventeen eyes (three percent) developed glaucoma postoperatively. Most of these were successfully handled and the visual result was better than in those with preoperative glaucoma, 10 of the 17 attaining to normal vision. Prolonged collapse of the anterior chamber is a fruitful cause of postoperative glaucoma and is to be feared. No case of glaucoma developed as the re­ sult of a shallow anterior chamber, even when this was extreme. One wonders at first how this can be, since narrow-angle glaucoma is a disease entity. The explanation could lie in a different mode of development of post­ operative glaucoma. When the anterior cham­ ber is collapsed, either from leak or lack of aqueous production (or both), the iris lies in contact with the cornea and extensive synechias may form before the surfaces can be separated again by returning aqueous vol­ ume. The corresponding filtration angle may then be blocked, and the tension will mount. When the chamber is merely very shallow, rather than empty, the anterior face of the iris and the cornea are not in actual contact and adhesions probably do not form. As soon as the leak stops or aqueous production is resumed, the surfaces separate and outflow begins as aphakic depth is established. Clinical iritis occurred in 31 eyes (5.6 per­ cent) . The visual result in these eyes may not be seriously compromised if the iritis is of low grade (13 of the 17 having grade I attained to a vision of 20/30 or better). But, if it is at all severe or prolonged, it is very damaging. One third of the 31 attained

A. C. H I L D I N G TABLE 8 POSTOPERATIVE PSYCHOSIS

(1934-1954) Age (yr.)

Dura­ tion (da.)

1-5

69

2

Yes

Occurred 4 t h - 6 t h da. Allowed to sit up and open eye. Became all right

20/20-2

1-22

65

1

Yes

Occurred 2nd da. Sat up and became better

(?)—very poor

1-84

84

1

Yes

Irrational on 4th da. and depressed on 10th. Recovered

20/40-2

1-175

66

lndef.

No

Became psychotic and did not recover—sent to mental institution. Had shown previous signs of instability. Could not understand English. Poked finger into eye and ruined it. Had to be restrained

H.M. (?)

2-52

85

Indef.

No

Mentally confused 3rd da., bandage removed and not replaced ; clear 4th day. 9th day con­ fused again. After 3 mo. mental deterioration

Poor—central reti­ nal degeneration

2-96

74

2

Yes

Died on 6th da. from pulmonary embolism

2-102

78

2

Yes

Confused 2nd and 3rd da.

20/30

2-97

69

1

Yes

Slight confusion 1 da. only

< 20/200—chr. glau­ coma

2-99

83

1

Yes

1 night only

20/40

2-110

50

?

Yes (?)

This patient was mentally retarded and opera­ (?) tion was done under general anesthesia. Ir­ rational for a time

2-215

68

Several wks.

2-300

45

Indef.

(?)

Anxiety state—was still present after 4 yr.

20/15

2-314

79

1

Yes

Very mild

M.O.—chronic glau­ coma

Case

Remarks

Recovery-

Yes-after History of previous postoperative psychosis several following abdominal operation wks.

to only 20/100 vision or less and half of these (six) became entirely blind. Rupture of the capsule with its accom­ panying loss of cortex seemed to be a factor in many. Two thirds occurred among the capsulotomies (intentional or otherwise) and only one third in the five-times-larger group of intracapsular extractions. A long history of previous recurring iritis was present in some. Postoperative hyphema was no problem in this series of 555. This complication can be avoided if the conjunctiva is not molested. If a conjunctival flap is used, it can still prob­

Vision

—

20/30

ably be eliminated largely by using not less than four corneoscleral sutures. Conjunctival sutures will not answer. They are useless to close the incision. They only hold the flap down and should not be expected to do more. It is not certain that any instance of epi­ thelial downgrowth occurred in this series. No eye was enucleated on account of it. One was so diagnosed, but probably wrongly, since the visible lesion appeared in only three weeks, was shaped like an icicle and remained unchanged for a long period after that. It was suspected (in retrospect) in two others, but, in one, trouble did not appear

EXPERIMENTAL APPROACH TO CATARACT SURGERY for five years and, in the other, the eye im­ proved and vision remained fair. It is commonly held that downgrowth is due to the proximity of epithelium to an in­ adequately closed incision. I think the matter is not that simple. In view of the fact that downgrowth would seem possible in a large proportion of surgery in which the eye is penetrated, and occurs so rarely, one cannot help wondering if there is not some other factor—or factors—more important than in­ adequate closure.38 If corneal incisions invite downgrowth, why does it not occur regularly in corneal grafts? I have seen no report of any such. Considering McDonald's work on the importance of early elements in healing," and Patz' experimental production of epi­ thelial invasion through the puncture of a needle carrying methylcholanthrene into the vitreous chamber,18 it seems to me that other possibilities should be investigated. Among these would be relative susceptibility to malignancy (a follow-up study), prothrombin activity, use of anticoagulant drugs or steroids and delay of healing by injudicious irrigation at the time of operation. A limbus-based conjunctival flap has both advantages and disadvantages. Beyers, 50 years ago, stated that, "Professor Kuhnt has so elaborated the principle (of the conjuncti­ val flap) that, with the work of Prof. Schoeler, really very little remains to be said on the subject."38 Dr. Schoeler published his article in 1877 and Kuhnt wrote in 1884 and 1898. The flap later fell into disuse but is currently widely used again. The evidence seems to indicate that it does reduce—but does not eliminate—the rare complication of epithelial downgrowth. Whether or not it re­ duces leak is not so clear. Leak and filtration under the flap occur not infrequently. On the other hand, hyphema occurs very commonly with flaps (almost regularly, according to some writers) and almost never without. This complication may be serious. Catgut sutures, that should be used for closure under the flap, are irritating, slow to absorb and they may slough out of the sciera and

963

cornea and may slough through the flap, thus creating a fistula that may be just as devas­ tating as downgrowth. It has been found experimentally that cor­ neal epithelium does not dip down into the track of a catgut suture as it does into that of a silk suture. 36 ' 39 · 43 Some surgeons have, therefore, discarded silk in favor of catgut. Like so many other things, this issue is "not all black and white, but gray." Why doesn't epithelium follow along the catgut? Appar­ ently because of the inflammatory reaction and necrosis caused by the catgut (a soluble tissue from another species of animal). Cor­ neal epithelium does not readily survive in­ flammation and necrosis in the underlying stroma. It is this necrosis that causes slough­ ing and fistulization. It is exactly on account of this necrosis (which prevents epithelial growth) that Estrada and others favor silk over catgut. Silk, which is more inert, does not cause such a severe tissue reaction. Working under a flap, it is difficult to make a knife incision. One uses the scissors and the incision is bound to have irregularities in it that favor leak and damage to the iris and endothelium is greater. The last chapter on the use of conjunctival flaps has not been written.14-44 Fear of epithelial transplants from de­ tached cells or groups of cells, dislodged dur­ ing operative manipulations, seems largely groundless. Loose cells are probably always present all through the operation and they must gain access to the anterior chamber but they do not grow. I scraped off most of the epithelium from the corneas of 14 cats' eyes and injected the scrapings into the anterior chamber. There was no growth in any.4r' Both clinical and experimental observations lead one to the conclusion that epithelium will not grow in or into the anterior cham­ ber unless it brings its own blood supply with it, or can engraft itself upon the blood supply of the iris. Postoperative macular disease, due to vit­ reous loss of anterior adhesions, seems to be a definite entity that occurs occasionally.

964

A. C. HILDING

Study of pre- and postoperative vitreous dynamics25·2r> seems to indicate that it is due to abnormal stress upon the vitreous attach­ ment at the macula. The anteroposterior di­ ameter of the vitreous is increased after lens extraction and the normal slack of the anteroposterior vitreous fibrils is nullified more or less. Thereafter, movements of vit­ reous during normal rotation of the eye would be felt first and most strongly in the attachments of these anteroposterior fibrils. Actual horse-tail adhesions to the incision would aggravate this stress. Four eyes in the series showed macular disease that could have been on this basis. Postoperative hypotony, where there was no evidence of leak, occurred frequently and was presumed to be due to operative trauma to the aqueous-producing mechanism.10'46 These eyes behave like eyes that have suf­ fered severe blows. Such eyes uniformly recover but it is not beyond the realm of pos­ sibility that an occasional eye might be damaged beyond recovery. Postoperative choroidal separation occurred very fre­ quently among those eyes examined for it. When hypotony is marked, the blebs are especially large. No treatment was used in any case in this series. As normal tension re­ turned, the blebs receded and disappeared. In my opinion, the condition requires no treatment and should be let alone. Postoperatively the hyaloid commonly herniates through the pupil into the anterior chamber but this should be no cause for alarm, if one recalls the mechanics of vitre­ ous structure and movements. Aqueous passes freely through the hyaloid and by colloidal action enters the vitreous, normally keeping the latter mildly inflated, so that the hyaloid is everywhere in contact with the confines of the vitreous chamber. The lens supports it anteriorly and shapes a concavity in the hyaloid. When the lens is removed, so is the anterior support, and the concavity everts and protrudes through the pupil, and there is slight tension upon the everted hya­ loid.

The shape of this protrusion varies as the pupil changes size. When the pupil is wide, it forms a small portion of a large sphere and, when the pupil is small, it may form more than half of a small sphere. The pupil­ lary margin may slide freely upon the pro­ truding hyaloid and leave a zone of pigment marking its excursions. On the other hand, the iris frequently becomes adherent and the hyaloid must then move with the iris. Under these conditions, when the pupil contracts, the hyaloid may balloon into the anterior chamber and, when it dilates, the hyaloid may be put on the stretch like a tight mem­ brane. The hyaloid may, and not infrequently does, eventually give way. This adherence of the iris to the· hya­ loid commonly follows cataract extraction. Whether this is related to the normal attach­ ment between the lens capsule and hyaloid (Eggers' line) is not clear.25·27-28·47 Such adhesions do not result in increased tension unless a layer of fibroblasts forms upon the hyaloid surface and across the pupil. It re­ quires no treatment unless a fibrous layer forms. The everted hyaloid may stretch and mushroom into the anterior chamber. In one eye in this series, it practically filled the anterior chamber. It did not, however, seem to make actual contact with the corneal endothelium. Vision was 20/20. Unless the hyaloid lies against the endothelium and causes clouding, this mushrooming into the anterior chamber is harmless and requires no treatment. There was no instance of contact with endothelium in these 555 eyes, although bulging of the hyaloid into the anterior chamber was almost universal when the latter was intact. Often the hyaloid ruptures and vitreous fibrils protrude into the anterior chamber and lie in contact with the cornea. This condi­ tion also seems harmless, even when the vit­ reous structure lies directly against the cor­ nea. Clouding of the latter does not result. This fact may point the way to treatment

EXPERIMENTAL APPROACH TO CATARACT SURGERY

965

of clouding from contact of the intact hya­ loid—simply rupture the hyaloid.

must be made between sutures and not under them, and at or slightly central to the line of incision and not under the shelf. SUMMARY AND CONCLUSIONS 5. The shape of the vitreous body, the A series of laboratory studies on various dynamics of its movements, and the stress phases of cataract surgery is reviewed and upon its various attachments are markedly an analysis of 555 cataract extractions, in altered by lens removal. Serious damage is which the experimental findings were in­ possible even though the hyaloid remains in­ corporated in the operative procedures, is tact. presented.48·49 These extractions were done 6. Eversion of the navicular fossa and in the 20 years prior to 1954. No conjuncti- protrusion through the pupil is to be ex­ val flap was used in this series, although it pected and is generally harmless. has been used in some since 1954. 7. Downgrowth of epithelium is rare and It was concluded that: probably depends upon other factors than 1. The eye pays a price for each surgical only proximity of an epithelial margin and step or maneuver to which it is subjected. malocclusion of the wound. These elderly people can be upset by elabor­ 8. Irrigations of the anterior chamber are ate preoperative preparations. Therefore, not harmless and should be used sparingly. both the operative procedures and the prepa­ 9. Postoperative hypotony, without leak, is rations should be reduced in number and common for some weeks and is probably due simplified as much as possible. Speed in to trauma to the ciliary body and resultant operation is not as important as gentleness reduction of aqueous production. and limitation of the number of steps. 10. Visual results were good. About 90 2. Of two types of incision and closure percent attained to 20/30 or better, unless that were used: ( 1 ) a knife incision with two there was other disease present that com­ preplaced Verhoeff sutures and three periph­ promised the vision. eral iridectomies, (2) a limbal groove, four 11. Postoperative high grade astigmatism preplaced McLean sutures, and completion was practically eliminated by corneoscleral of the incision with scissors, the knife inci­ sutures. The average was 1.65D. sion is smoother and less traumatizing but 12. Most complications encountered were more difficult. The practical results of the relatively minor. Gaping of the wound, high two methods were essentially the same. Per­ grade astigmatism, iris prolapse and post­ haps anterior synechias were more frequent operative hyphema were virtually eliminated. with the scissors incision. Lens extraction Vitreous loss occurred in three percent but was generally accomplished intracapsularly was minor with few exceptions. with an Arruga forceps. 13. Clinical iritis and postoperative glau­ 3. Five points of protection are required coma remained the two most serious compli­ for reasonably safe closure of the wound. cations. The former was usually associated These can be a combination of corneoscleral with a history of recurrent iritis or rupture sutures or tiny peripheral iridectomies. At of the capsule. Most of the latter followed least one should be an iridectomy. Conjuncti- prolonged absence of the anterior chamber. val sutures should not be expected to hold Research Laboratory, the margins of the incision together. St. Luke's Hospital (11). 4. Peripheral iridectomies, to be effective, REFERENCES

1. Kandori, F., and Kurimoto, S.: An inferior approach to the cataract extraction following filtering operations for glaucoma. Yonago acta med., 3:107-111, 1958. (Abstr, Surv. Ophth., 4:85-86 [April] 1959.)

966

A. C. HILDING

2. Hughes, W. L.: Report on a combination operation for cataract with glaucoma. Am. J. Ophth., 48: 1-14 (July) 1959. 3. Leydhecker, W. : Glaucoma and cataract extraction. Acta XVII Cone. Ophth., 1954, pp. 233-239. 4. Syed, R. Ali: Hypermature cataract: its complications and treatment. Medicus, 16:1-15, 1958. 5. Lehman, S., and Pearman, R. W.: Lens-induced glaucomas. Tr. Can. Ophth. Soc., 9:69-77, 1957. 6. Kronfeld, P. C : Delayed restoration of anterior chamber. Am. J. Ophth., 38:453-465 (Oct.) 1954. 7. Weisel, J., and Swan, K. C : Mydriatic treatment of shallow chamber after cataract extraction. AMA Arch. Ophth., 58:126-129 (July) 1957. 8. Verdaguer, J.: Corneal sutures and late emptying of the anterior chamber. Arch. chil. de. oftal., 12: 75-81, 1955. 9. Miller, J. E., Keskey, G. R., and Becker, B.: Cataract extraction and aqueous outflow. AMA Arch. Ophth, 58:401-406 (Sept.) 1957. 10. Hilding, A. C : Reduced ocular tension after cataract surgery. AMA Arch. Ophth, 53:686-693 (May) 1955. 11. Vail, D.: Diamox to prevent hyphema after cataract extraction: A negative report. Tr. Am. Ophth. Soc, 54:165-181,1956. 12. de Saint Martin, R.: What are the usual causes of postoperative hyphema in cataract extractions? Ophthalmologies 132:345-364 (Dec.) 1956. 13. Scheie, H. G.: Incision and closure in cataract extraction. AMA Arch. Ophth, 61:431-452 (Mar.) 1959. 14. Arruga, H. : Sutures and iridectomies in cataract operations. Sec. Ophth. Acad. M. Se, Barcelona, 1953. 15. Hilding, A. C : Removal of sclerocorneal sutures. AMA Arch. Ophth, 24:371-372 (Aug.) 1940. 16. Long, J. C, and Tyner, G. S.: Three cases of epithelial invasion of the anterior chamber treated surgically. AMA Arch. Ophth, 58:396-400 (Sept.) 1957. 17. Bingen, F.: Postsurgical epithelial invasion into the anterior chamber. Bull. Soc. beige d'opht, 117: 614-619, 1957. 18. Patz, A , Wulff, L , and Rogers, S.: Experimental production of epithelial invasion of anterior chamber. Am. J. Ophth, 47:815-827 (June) 1959. 19. Maumenee, A. E , and Shannon, C. R. : Epithelial invasion of the anterior chamber. Tr. Pacific Coast Oto-Ophth. Soc, 36:107-135, 1955. 20. Regan, E. F.: Epithelial invasion of anterior chamber. AMA Arch. Ophth, 60:907-927 (Nov.) 1958. 21. Chatterley, J. G.: Epithelial invasion of the anterior chamber. Thesis written as a partial require­ ment for the basic course in ophthalmology at Wayne University, Detroit, Michigan, May, 1954. 22. Gallardo, E , and Weidenheim, C. W.: Epithelial membrane in anterior chamber after cataract surgery: Case report and comments on X-ray treatment. Am. J. Ophth, 39:868-870 (June) 1955. 23. Calhoun, F. P , Jr.: The clinical recognition and treatment of epithelization of the anterior cham­ ber following cataract extraction. Tr. Am. Ophth. Soc, 47:498-553, 1949. 24. Desvignes, P , and Behart: Ocular hypertonus after operation for cataract. Arch, d'opht, 20:373388 (June) 1960. 25. Hilding, A. C : Normal vitreous, its attachments and dynamics during ocular movement. AMA Arch. Ophth, 52:497-514 (Oct.) 1954. 26. : Alterations in the form, movement, and structure of the vitreous body in aphakic eyes. AMA Arch. Ophth., 52:699-709 (Nov.) 1954. 27. Wieger, G. : Ueber den Canalis Petiti und ein Ligamentum Hyaloideocapsulare, Strassburg, 1883. Quoted by Duke-Elder, W. S.: Textbook of Ophthalmology. St. Louis, Mosby, 1933, v. 1, pp. 111-112. 28. Reese, A. B , and Wadsworth, J. A. C. : Adhesion of lens capsule to hyaloid membrane and its rela­ tion to intracapsular cataract extraction. Am. J. Ophth, 46:495-498 (Oct.) 1958. 29. Irvine, S. R.: A newly defined vitreous syndrome following cataract surgery: Interpreted accord­ ing to recent concepts of the vitreous. Am. J. Ophth, 36:599-619 (May) 1953. 30. Boyd, B. F.: Latest developments in ophthalmology. The use of acetylchohne chloride in cataract surgery. Highlights of Ophthalmology (U.S. Ed.), 3:292, 1959. 31. Agarwal, L. P , and Malik, S. R. K. : Postoperative iris prolapse, its cause and management. Ophthalmologica, 138:133-137, 1959. 32. Neveu, M, and Elliot, A. J.: Prophylaxis and treatment of endophthalmitis. Am. J. Ophth, 48: 368-373 (Sept.) 1959. 33. Gordon, D. M.: Antimicrobial therapy in ophthalmology. Surv. Ophth, 3:107-121 (Apr.) 1958. 34. Weisman, A. D , and Hackett, T. P.: Prevention of delirium following eye surgery. New Eng. J. Med, 258:1284-1289, 1958. 35. Harley, R. D , and Mishler, J. E. : Cataract surgery: Use of ataractic and antiemetic drugs. Am. J. Ophth, 47:177-184, 1959. 36. Hilding, A. C.: Corneal epithelium and penetrating corneal defects in cats: with special reference to epithelial downgrowth. Am. J. Ophth, 48:787-802 (Dec.) 1959.

EXPERIMENTAL APPROACH TO CATARACT SURGERY

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37. McDonald, J. E. : Early components of corneal wound closure: experimental study. Arch. Ophth., 58:202-216 (Aug.) 1957. 38. Beyers, W. G. N.: Conjunctival flaps in ophthalmic surgery. Tr. Am. Ophth. Soc, 12:398-409, 1909-11. 39. Dunnington, J. H. : Ocular wound healing with particular reference to cataract incision. Tr. Ophth. Soc. U. Kingdom, 75:137-171, 19S5. 40. : Healing of incisions for cataract extraction: The sixth Sanford R. Gifford Memorial Lec­ ture. Am. J. Ophth., 34:36-45 (Jan.) 1951. 41. Dunnington, J. H., and Regan, E. F.: Absorbable sutures in cataract surgery. AMA Arch. Ophth., 50:545-556 (Nov.) 1953. 42. : The effect of sutures and of thrombin upon ocular wound healing. Am. J. Ophth., 35:167177 (Feb.) 1952. 43. : Some modern concepts of ocular wound healing. AMA Arch. Ophth., 59:315-323 (Mar.) 1958. 44. Estrada, W. Duque: Incisions and sutures in cataract surgery: An experimental study. Competetive thesis for the chair of ophthalmology at the Faculty of Medical Sciences, University of Rio de Janeiro, D.F., Brazil, 1955. 45. Hilding, A. C. : Comparative behavior of respiratory, conjunctival, and corneal epithelium, in the anterior chamber in cats and dogs. Am. J. Ophth., 50:276-290 (Aug.) 1960. 46. Veirs, E. R. : Hypotony following an intraocular surgical procedure. J. Internat. Coll. Surg., 27: 613-619, 1957. 47. Vail, D.: Doyne Memorial Lecture for the 42nd Oxford Ophthalmological Congress, Oxford, Eng­ land, July 1957. Cited in Surv. Ophth., 2:495 (Oct.) 1957. 48. Hilding, A. C. : The experimental approach to cataract surgery: Results in a series of 555 extrac­ tions done without conjunctival flap: I. Experimental and clinical work (Pre-operative preparation, operative techniques, postoperative care. Am. J. Ophth., 53:296-307 (Feb.) 1962. 49. : Part II. Postoperative results. Am. J. Ophth., 53:606-611, 1962.

AMBLYOPIA D U E T O TOBACCO, ALCOHOL A N D NUTRITIONAL DEFICIENCY* D I F F E R E N T I A L DIAGNOSIS W I T H SPECIAL REFERENCE TO T H E CHARACTER O F T H E VISUAL FIELD DEFECT DAVID O.

HARRINGTON,

M.D.

San Francisco, California There is a vast and enormously confused literature on the subject of toxic amblyopia due to tobacco, alcohol and nutritional de­ ficiency. Since tobacco amblyopia was first de­ scribed by Beer in 1792 down to the most recent articles by Silvette, Haag and Lar­ son,1 and Victor, Mancall and Dreyfus, 2 in 1960, hundreds of papers have been written and there is much disagreement among them as to the incidence of the condition, its eti­ ology, its pathology and its treatment. * From the Department of Ophthalmology, Uni­ versity of California School of Medicine. Pre­ sented before the Pacific Coast Oto-ophthalmologiçal Society at Palm Springs, California, May, 1961.

Much of this confusion stems from the use of the term "tobacco-alcohol amblyopia." Relatively few authors have differentiated between the amblyopia associated with the use of tobacco and that which was attributed to the use of alcohol. A notable exception was Traquair 3 · 4 who made a clear-cut dis­ tinction between tobacco amblyopia and al­ cohol amblyopia. As Silvette, et al.,1 have pointed out "the difficulty of ascertaining the true incidence of tobacco amblyopia among patients with eye disease is enhanced by the habit of many authors of reporting cases of 'tobacco-alco­ hol amblyopia' without distinguishing be­ tween the relative importance or unimpor-