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The Nonoperative Treatment of Senile Cataract
T H E NONOPERATIVE TREAT MENT OF SENILE CATARACT. A. S. GREEN, M. D., AND L. D. GREEN, M. D. SAN FRANCISCO, CAL. This paper considers the etiology and forms of partial senile cataract, describes the method of treatment for it, and gives in statistics results obtained.
Senile cataract is a condition which concerns a very large proportion of the human race. While apparently more common among certain peoples than others, none are exempt. It may almost be regarded as an accompaniment of old age just as is gray hair. One observer has found that opacification of the crystalline lens of greater or lesser degree is present in over 90 per cent of all people, past the age of sixty-five. Among white races it occurs frequently as early as forty. When opacification has begun, its rate of progress is very uncertain. A cataract may become mature in two or three months or it may remain immature for thirty-five years or more. Failing sight of old age, not correctible by glasses, is very often due to this condition. Fortunately this opacification usually takes place at the periphery of the lens, beyond the pupillary area, and thus does not generally interfere with vision. However, the pupillary region is involved with sufficient frequency to reduce the acuteness of vision in many elderly people. ETIOLOGY.—Aside from the cataracts occurring in general diseases as in diabetes, or those following the ingestion of poisons as naphthalin, ergot, etc., and that which is frequent among certain vocations as in glass blowing, we know very little of its etiology. Neither do we know much about its prophylaxis. The question that interests us is: Can the progress of opacification of the crystalline lens be checked or prevented? The attitude of ophthalmologists generally has been that the condition must go on to maturity and the cataract then be removed surgically. While it is absolutely unnecessary to allow a patient to await the blindness that comes with a mature cataract before resorting to operative intervention, it is also a mistake to operate be-
fore the development has reached such a stage as to interfere with business or pleasure. Roughly that stage is reached when vision has fallen to 50 per cent. When it has been reduced to less than 50 per cent there is no need to temporize further, and the cataract should be removed surgically. It is, however, before a loss of 50 per cent has occurred that nonoperative measures should be used to avoid subjecting the patient to an indefinite period of worry and impaired efficiency. Many remedies have been suggested for the arrest or absorption of cataracts. But it has remained for Col. Henry Smith of AmrLtsar, India, to put the nonoperative treatment on a more definite basis. By that method in over 80 per cent of our cases, the opacification has been checked oT the vision improved. But to obtain these results the treatment must be begun before vision has fallen to half of normal, and carried out in detail. The earlier the treatment is instituted the better the result. The permanency of the treatment is, however, uncertain. With some patients the improvement lasts only a few months, with others the improvement has remained after a period of over four years, the time when we first commenced this treatment. But if this particular treatment does not improve the vision it can do no harm as there is practically no danger from this procedure. W e have not had a single deleterious result. Should an operation for cataract be necessary later it is probably an advantage to have had this treatment previously because of the apparent general improvement in eyes following this treatment. The greatest objection that may be raised is the severe pain often produced which may last for several hours. T Y P E OF CATARACT AND HISTOLOGIC
CHANGES.—The type of cataract which
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best responds to this treatment is the simple, uncomplicated senile with radial or diffuse opacification. Dense nuclear or subcapsular cataracts will not be affected materially by this treatment. The pupil should be first dilated in order to exclude retinal changes, especially the senile macular degenerations. These will often account for failure to obtain improvement in vision for which the treatment would otherwise be blamed. Ophthalmoscopic examination of the lens after treatment will show little apparent change in spite of the improvement in vision as only the finest opacities seem to be affected rather than the larger ones. METHOD OF PROCEDURE.—The patient
should be in a bed in a hospital. Near the bed, within easy reach, should be an electric stove with a basin of hot boric solution for compresses. The eye is anesthetized with three drops of 4 per cent cocain solution instilled at intervals of five minutes. Twenty mm. of 1-4000 cyanide of mercury solution is drawn into a freshly sterilized glass syringe with a small needle. To this 2 mm. of sterile 4 per cent cocain is added. The needle is then inserted under the conjunctiva just below the external rectus and about 1 cm. from the limbus in an area free from blood vessels, and the solution slowly injected. A large bleb of conjunctiva is raised. The hot compresses are applied at once and maintained as long as the patient has pain. It is about the only thing that gives relief. A hypodermic of morphin may be necessary. The eye is compressed three times daily for three or four days afterwards. The treatment as described above is that as given by Col. Smith. In addition to this the writers have found it of great value to institute auxilliary treatment that is carried out by the patient at home, over a period of from four to six months. One week after the injection the patient is given a 1 per cent solution of K. I. which is to be used as an eye bath in an eye cup for five min-
utes every morning, and evjsry other night. On the alternate night the patient puts one drop of 2 per cent dionin in the eye. The strength of the dionin is increased 2 per cent each month until an 8 per cent solution is used. This method of using dionin and K. I. has been highly lauded by other writers, and used in connection with the Smith treatment we have found it very satisfactory. The injection is given only once. Whether repeating the injection would be beneficial we are not prepared to say as we have not tried it. The results given below were those obtained in private practice, and included 72 eyes. Cases Per cent Improved 42 58.5 Arrested 18 25 Cataract progressed . . . 12 16.5 The degree of improvement in vision ranged from 11 per cent to 150 per cent. In twenty-five cases or 36 per cent of those injected, there was an improvement in vision of 11 to 40 per cent. In sixteen cases or 22 per cent of those injected there was an improvement in vision of 50 per cent or better. The period of observation ranged from a few weeks to four and one-half years. The vision a day or two after injection is usually lower than just prior to injection, but improves very rapidly thereafter and reaches its maximum about one week after. The conjunctiva becomes greatly swollen so that it may protrude between the lids for a few days. The redness persists for three or four weeks. After this the eyes feel "stronger" and the patient reads and sews with much more comfort than before. CONCLUSION. From our experience and the observation of others who have given the treatment a thoro trial, this method has been a decided help in conserving vision at a time of life when even a few months or years of sight is worthy of consideration.
Senile cataract is a condition which concerns a very large proportion of the human race. While apparently more common among certain peoples than others, none are exempt. It may almost be regarded as an accompaniment of old age just as is gray hair. One observer has found that opacification of the crystalline lens of greater or lesser degree is present in over 90 per cent of all people, past the age of sixty-five. Among white races it occurs frequently as early as forty. When opacification has begun, its rate of progress is very uncertain. A cataract may become mature in two or three months or it may remain immature for thirty-five years or more. Failing sight of old age, not correctible by glasses, is very often due to this condition. Fortunately this opacification usually takes place at the periphery of the lens, beyond the pupillary area, and thus does not generally interfere with vision. However, the pupillary region is involved with sufficient frequency to reduce the acuteness of vision in many elderly people. ETIOLOGY.—Aside from the cataracts occurring in general diseases as in diabetes, or those following the ingestion of poisons as naphthalin, ergot, etc., and that which is frequent among certain vocations as in glass blowing, we know very little of its etiology. Neither do we know much about its prophylaxis. The question that interests us is: Can the progress of opacification of the crystalline lens be checked or prevented? The attitude of ophthalmologists generally has been that the condition must go on to maturity and the cataract then be removed surgically. While it is absolutely unnecessary to allow a patient to await the blindness that comes with a mature cataract before resorting to operative intervention, it is also a mistake to operate be-
fore the development has reached such a stage as to interfere with business or pleasure. Roughly that stage is reached when vision has fallen to 50 per cent. When it has been reduced to less than 50 per cent there is no need to temporize further, and the cataract should be removed surgically. It is, however, before a loss of 50 per cent has occurred that nonoperative measures should be used to avoid subjecting the patient to an indefinite period of worry and impaired efficiency. Many remedies have been suggested for the arrest or absorption of cataracts. But it has remained for Col. Henry Smith of AmrLtsar, India, to put the nonoperative treatment on a more definite basis. By that method in over 80 per cent of our cases, the opacification has been checked oT the vision improved. But to obtain these results the treatment must be begun before vision has fallen to half of normal, and carried out in detail. The earlier the treatment is instituted the better the result. The permanency of the treatment is, however, uncertain. With some patients the improvement lasts only a few months, with others the improvement has remained after a period of over four years, the time when we first commenced this treatment. But if this particular treatment does not improve the vision it can do no harm as there is practically no danger from this procedure. W e have not had a single deleterious result. Should an operation for cataract be necessary later it is probably an advantage to have had this treatment previously because of the apparent general improvement in eyes following this treatment. The greatest objection that may be raised is the severe pain often produced which may last for several hours. T Y P E OF CATARACT AND HISTOLOGIC
CHANGES.—The type of cataract which
424
A. S. GREEN AND L. D. GREEN
best responds to this treatment is the simple, uncomplicated senile with radial or diffuse opacification. Dense nuclear or subcapsular cataracts will not be affected materially by this treatment. The pupil should be first dilated in order to exclude retinal changes, especially the senile macular degenerations. These will often account for failure to obtain improvement in vision for which the treatment would otherwise be blamed. Ophthalmoscopic examination of the lens after treatment will show little apparent change in spite of the improvement in vision as only the finest opacities seem to be affected rather than the larger ones. METHOD OF PROCEDURE.—The patient
should be in a bed in a hospital. Near the bed, within easy reach, should be an electric stove with a basin of hot boric solution for compresses. The eye is anesthetized with three drops of 4 per cent cocain solution instilled at intervals of five minutes. Twenty mm. of 1-4000 cyanide of mercury solution is drawn into a freshly sterilized glass syringe with a small needle. To this 2 mm. of sterile 4 per cent cocain is added. The needle is then inserted under the conjunctiva just below the external rectus and about 1 cm. from the limbus in an area free from blood vessels, and the solution slowly injected. A large bleb of conjunctiva is raised. The hot compresses are applied at once and maintained as long as the patient has pain. It is about the only thing that gives relief. A hypodermic of morphin may be necessary. The eye is compressed three times daily for three or four days afterwards. The treatment as described above is that as given by Col. Smith. In addition to this the writers have found it of great value to institute auxilliary treatment that is carried out by the patient at home, over a period of from four to six months. One week after the injection the patient is given a 1 per cent solution of K. I. which is to be used as an eye bath in an eye cup for five min-
utes every morning, and evjsry other night. On the alternate night the patient puts one drop of 2 per cent dionin in the eye. The strength of the dionin is increased 2 per cent each month until an 8 per cent solution is used. This method of using dionin and K. I. has been highly lauded by other writers, and used in connection with the Smith treatment we have found it very satisfactory. The injection is given only once. Whether repeating the injection would be beneficial we are not prepared to say as we have not tried it. The results given below were those obtained in private practice, and included 72 eyes. Cases Per cent Improved 42 58.5 Arrested 18 25 Cataract progressed . . . 12 16.5 The degree of improvement in vision ranged from 11 per cent to 150 per cent. In twenty-five cases or 36 per cent of those injected, there was an improvement in vision of 11 to 40 per cent. In sixteen cases or 22 per cent of those injected there was an improvement in vision of 50 per cent or better. The period of observation ranged from a few weeks to four and one-half years. The vision a day or two after injection is usually lower than just prior to injection, but improves very rapidly thereafter and reaches its maximum about one week after. The conjunctiva becomes greatly swollen so that it may protrude between the lids for a few days. The redness persists for three or four weeks. After this the eyes feel "stronger" and the patient reads and sews with much more comfort than before. CONCLUSION. From our experience and the observation of others who have given the treatment a thoro trial, this method has been a decided help in conserving vision at a time of life when even a few months or years of sight is worthy of consideration.