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The Planned Extracapsular Cataract Operation
VOL. 64, NO. 3
DETACHMENT OF CORNEAL ENDOTHELIUM
the Cornea, Internat. Ophth. Clin. Boston, Little, Brown, 2:757, 1962. 2. Wolter, J. R. and Willey, E. N. : Lamellar split ting of Descemet's membrane. Am. J. Ophth. 61:331,1966. 3. Wolter, J. R. and Fechner, P. U. : Glass mem branes on the anterior iris surface. Am. J. Ophth. 53 :235, 1962. 4. Hogan, M. J. and Zimmerman, L. E. : Ophthalmic Pathology: An Atlas and Textbook. Philadelphia, Saunders, 1962, p. 282. 5. Samuels, B. and Fuchs, A. : Clinical Pathol ogy of the Eye. New York, Hoeber, 1952, p. 69. 6. Mayou, M. S. : The pathology of keratitis punctata. Tr. Ophth. Sox. U. K. 44:81, 1924. 7. Nagano, O. : Untersuchungen zur Pathologie
453
des Hornhautendothels. Arch. f. Augenh. 76:26, 1914. 8. Cogan, D. G. : Applied anatomy and physiol ogy of the cornea. Tr. Am. Acad. Ophth. 55 :329, 1951. 9. Chi, H. H., Teng, C. C. and Katzin, H. M. : Histopathology of corneal endothelium : A study of 176 pathologic discs removed at keratoplasty. Amer. J. Ophth. 53 :215, 1962. 10. Busacca, A. : Biomikroskopie und Histopathologie des Auges, Vol. I. Zürich, Schweizer Druck- und Verlagshaus, 1945, p. 377. 11. Duke-Elder, S.: System of Ophthalmology, Vol. VIII Diseases of the Outer Eye, Part II St. Louis, Mosby, 1965, pp. 715, 723.
THE PLANNED EXTRACAPSULAR CATARACT OPERATION ANDREW F. DE ROETTH,
M.D.
Spokane, Washington There is no doubt that in the majority of senile cataract operations, the intracapsular method gives better results with fewer com plications than the extracapsular method. The only advantage of the extracapsular op eration is that the capsulozonular barrier is not disturbed. There is no consensus when this method is indicated, or how to carry it out. This publication will discuss briefly these two aspects—indications and techniques—of the extracapsular methods. The role of the vitreous is well documented in the etiology of retinal detachment; its most drastic con sequence occurs when vitreous is lost during cataract operation. Following uncomplicated intracapsular removal of the senile cataract the hyaloid membrane is not infrequently defective or missing. This was the case in 13.5% in my series.1 It allows the vitre ous to fill a variable portion of the anterior chamber, and even to touch the cornea. This condition can be called intraocular vitreous prolapse to differentiate it from vitreous hernia, the vitreous bulge with intact hy aloid face. In vitreous prolapse, if other predisposing conditions of the retina or choroid are present, a mild jarring or pull ing action of the vitreous may be sufficient to cause retinal detachment.
In the last 15 years, 22 uncomplicated cat aract operations were done on the second eye of patients whose first eye had suffered retinal detachment; 15 detachments were primary and seven had followed cataract op eration. Of the 22, one patient did not re turn for a follow-up and a second had a de tached retina at the time of the operation of his second eye. In 14, the cataract was re moved intracapsularly, that is, with loss of capsulozonular barrier. Of these, four de veloped retinal detachment. Six cataracts were removed by the planned extracapsular method, and none was followed by retinal detachment. On fairly rare occasions, corneal edema and/or keratopathy may develop when formed vitreous, due to loss of the capsulo zonular barrier, touches or adheres to the cornea. Based on these considerations, the follow ing indications for planned extracapsular cataract operation are suggested : 1. Spontaneous or postoperative retinal detachment in the opposite eye. 2. In persons less than 20 years of age. 3. Loss of vitreous with marked vitreous blur following cataract extraction of the op posite eye. 4. Loss of the other eye due to unknown
454
AMERICAN JOURNAL OF OPHTHALMOLOGY
cause, (for example, detached retina or ker atopathy, especially if due to adherent vitre ous). 5. Vitreous hernia touching or adherent to the cornea, causing corneal edema follow ing cataract extraction of the opposite eye. 6. Epithelial dystrophy and/or bullous keratopathy of the opposite eye following intracapsular cataract extraction. In short, the extracapsular method is rec ommended only when preservation of the capsulozonular barrier is deemed advisable. TECHNIQUE OF EXTRACAPSULAR
CATARACT
OPERATION
There are two well-known methods and a third one has been published more recently. 1. The cystotome is used to make a rent in the capsule. Following this, the capsule is no longer taut, and it seems difficult if not impossible to cut out a certain shape of the capsule with the cystotome without injuring the posterior capsule or breaking the zonular fibers. Duke Elder2 states, "The lens capsule is highly elastic, tending to roll out when cut leaving a gaping wound." Yet, the recently perfected suction operation of the soft cata ract relies on this fact. It has seen its widest use in congenital cataract because of certain advantages over other techniques in such cases. But the suction operation still leaves the anterior capsule in the eye. Partially to obviate this in his operation of congenital cataract, McLean3 cuts a triangular piece from the anterior capsule with the Ziegler knife ; this piece and the lens material are removed by suction. 2. The back-toothed capsule forceps of Schweigger and its several modifications are fine instruments. A substantial portion of the anterior capsule can be removed with such instruments. But, inadvertently, one may grasp only a small fold. Or the lens may be dislocated before the capsule rup tures, or the capsule may fail to break and intracapsular removal results. Finally, Kirby 4 notes, "if the grasp with the forceps does
SEPTEMBER, 1967
not take out a clean piece of the capsule, but appears to tear it up toward the superior zonule, care must be exercised not to tear too far and create a hole in the zonule above." Should this happen, the capsulozonular bar rier is not preserved. 3. The third instrument, a modified erisophake for planned extracapsular extraction was devised by Veirs. 5 Suction is supposed to tear the capsule in the area of the erisophake cup. One cannot help but wonder whether the zonular fibers would break be fore the anterior capsule is ruptured, or whether the posterior capsule would break before the force of suction broke the ante rior capsule. The ideal instrument with which to per form an extracapsular extraction must (a) remove a large piece of the anterior capsule to prevent formation of a secondary mem brane; (b) make possible removal of the nucleus and as much cortex as possible ; (c) preserve the capsulozonular barrier; (d) avoid dislocation of the lens. These consid erations lead to selection of the technique of capsulectomy. After the usual corneoscleral wound, the placing of sutures and basal iridectomy, a two-mm opening is made in the capsule about three mm above the anterior pole of the lens. The pupil has to be at least five-mm wide even after these manipula tions. The central lip of the capsule wound is held with smooth forceps while a circular piece of capsule is excised with semicircular scissors. The scissors has narrow blades, with a radius of curvature of 2.5 mm. Only a narrow, thin blade can be advanced be tween the capsule and nucleus in the thin plane of the anterior cortex. The capsule is cut from above inferiorly, on both sides of the capsule forceps, thus removing a circu lar piece of capsule five mm in diameter. The extraction of the nucleus and the at tempted removal of the cortex with irriga tion follows as in any extracapsular opera tion. The gap caused by removal of a large piece of capsule facilitates this maneuver. In immature cataract the clear portion of the
VOL. 64, NO. 3
PLANNED EXTRACAPSULAR EXTRACTION
cortex corresponding to the pupillary area and attached to the capsule is automatically removed by capsulectomy. SUMMARY
Extracapsular extraction is indicated when preservation of the capsulozonular barrier is advisable. The different techniques of the extracapsular operation are discussed and the virtues of capsulectomy, utilizing special scissors, are described. 508 Old National Bank Building (99201)
455
REFERENCES
1. de Roetth, A. : The vitreous face following intracapsular extraction. Am. J. Ophth. 45:59, 19S8. 2. Duke-Elder S. : System of Ophthalmology. Vol. II. Anatomy of the Visual System. St. Louis, Mosby, 1961, p. 314. 3. McLean, J. M. : Congenital cataract. High lights of Ophthalmology. 8:279, 1965. 4. Kirby, D. B. : Surgery of Cataract. Philadel phia, Lippincott, 1950. 5. Veirs, E. R. : A new erisophake tip for ex tracapsular extraction of cataract. Tr. Am. Acad. Ophth. Otolaryng. 66:264. 1962.
ACTIVE T E M P O R A L A R T E R I T I S A S A C O N T R A I N D I C A T I O N TO ELECTIVE SURGERY W I T H GENERAL A N E S T H E S I A BERNARD
L.
MCGOWAN,
LIEUT.
(MC)
U.S.N.R.
Chelsea, Massachusetts
The problem of sudden monocular blind ness during anesthesia is relatively un common. In the reported cases, the cause has been attributed to occlusion of the cen tral retinal artery due to inadvertent pres sure on the eye during the procedure, some times with associated hypotension.1"3 The possibility of infarction of the retrobulbar portion of the optic nerve by mechanical distortion of the nerve and increased in traorbital pressure during retinal detach ment surgery has also been reported.4 Al though thrombosis of the central retinal ar tery in patients with pre-existing arterial disease has undoubtedly been noted follow ing general anesthesia,5 no specific instance of this complication could be found in the literature. Blindness occurring during gen eral anesthesia has not previously been noted in temporal arteritis. The increasing fre quency with which temporal arteritis is rec ognized adds significance to the questions raised in this report. From the Department of Ophthalmology, Massa chusetts Eye and Ear Infirmary, Boston.
CASE
REPORT
This 76-year-old white man of Greek extrac tion was admitted to the Massachusetts Eye and Ear Infirmary with the symptoms and signs of carcinoma of the larynx. An ophthalmologic con sultation was requested because he had recently lost all vision in the left eye. Ocular history. At the age of 59 years, the pa tient had had a cataract extraction, R.E, and four years later a cataract extraction, L.E. Vi sion of 20/20 was obtained, O.U. He then had no visual symptoms until two weeks prior to ad mission when he noted blurring of vision in the left eye. This was accompanied by "white, green and blue spots" in front of the left eye and pro gressed to total blindness. He specifically denied discomfort in the eyes, headaches, scalp pain or tenderness, pain on chewing, malaise and fever. He admitted to weight loss of approximately five pounds during the preceding two weeks. Ocular examination. Corrected vision, R.E., 20/30; L.E., no light perception. Bilateral aphakia with large full iridectomies was noted. No pu pillary reactions could be obtained. Fundus exam ination of the right eye was normal, but the left eye showed mild blurring of the disc margins with some hyperemia of the nervehead. The arterioles were attenuated. Hemorrhage was present in the nerve-fiber layer immediately supranasal to the disc. Central and peripheral fields, R.E., were entirely normal. Both carotid pulsations were full and equal. No scalp tenderness could be elicited. The temporal arteries were neither prominent nor
DETACHMENT OF CORNEAL ENDOTHELIUM
the Cornea, Internat. Ophth. Clin. Boston, Little, Brown, 2:757, 1962. 2. Wolter, J. R. and Willey, E. N. : Lamellar split ting of Descemet's membrane. Am. J. Ophth. 61:331,1966. 3. Wolter, J. R. and Fechner, P. U. : Glass mem branes on the anterior iris surface. Am. J. Ophth. 53 :235, 1962. 4. Hogan, M. J. and Zimmerman, L. E. : Ophthalmic Pathology: An Atlas and Textbook. Philadelphia, Saunders, 1962, p. 282. 5. Samuels, B. and Fuchs, A. : Clinical Pathol ogy of the Eye. New York, Hoeber, 1952, p. 69. 6. Mayou, M. S. : The pathology of keratitis punctata. Tr. Ophth. Sox. U. K. 44:81, 1924. 7. Nagano, O. : Untersuchungen zur Pathologie
453
des Hornhautendothels. Arch. f. Augenh. 76:26, 1914. 8. Cogan, D. G. : Applied anatomy and physiol ogy of the cornea. Tr. Am. Acad. Ophth. 55 :329, 1951. 9. Chi, H. H., Teng, C. C. and Katzin, H. M. : Histopathology of corneal endothelium : A study of 176 pathologic discs removed at keratoplasty. Amer. J. Ophth. 53 :215, 1962. 10. Busacca, A. : Biomikroskopie und Histopathologie des Auges, Vol. I. Zürich, Schweizer Druck- und Verlagshaus, 1945, p. 377. 11. Duke-Elder, S.: System of Ophthalmology, Vol. VIII Diseases of the Outer Eye, Part II St. Louis, Mosby, 1965, pp. 715, 723.
THE PLANNED EXTRACAPSULAR CATARACT OPERATION ANDREW F. DE ROETTH,
M.D.
Spokane, Washington There is no doubt that in the majority of senile cataract operations, the intracapsular method gives better results with fewer com plications than the extracapsular method. The only advantage of the extracapsular op eration is that the capsulozonular barrier is not disturbed. There is no consensus when this method is indicated, or how to carry it out. This publication will discuss briefly these two aspects—indications and techniques—of the extracapsular methods. The role of the vitreous is well documented in the etiology of retinal detachment; its most drastic con sequence occurs when vitreous is lost during cataract operation. Following uncomplicated intracapsular removal of the senile cataract the hyaloid membrane is not infrequently defective or missing. This was the case in 13.5% in my series.1 It allows the vitre ous to fill a variable portion of the anterior chamber, and even to touch the cornea. This condition can be called intraocular vitreous prolapse to differentiate it from vitreous hernia, the vitreous bulge with intact hy aloid face. In vitreous prolapse, if other predisposing conditions of the retina or choroid are present, a mild jarring or pull ing action of the vitreous may be sufficient to cause retinal detachment.
In the last 15 years, 22 uncomplicated cat aract operations were done on the second eye of patients whose first eye had suffered retinal detachment; 15 detachments were primary and seven had followed cataract op eration. Of the 22, one patient did not re turn for a follow-up and a second had a de tached retina at the time of the operation of his second eye. In 14, the cataract was re moved intracapsularly, that is, with loss of capsulozonular barrier. Of these, four de veloped retinal detachment. Six cataracts were removed by the planned extracapsular method, and none was followed by retinal detachment. On fairly rare occasions, corneal edema and/or keratopathy may develop when formed vitreous, due to loss of the capsulo zonular barrier, touches or adheres to the cornea. Based on these considerations, the follow ing indications for planned extracapsular cataract operation are suggested : 1. Spontaneous or postoperative retinal detachment in the opposite eye. 2. In persons less than 20 years of age. 3. Loss of vitreous with marked vitreous blur following cataract extraction of the op posite eye. 4. Loss of the other eye due to unknown
454
AMERICAN JOURNAL OF OPHTHALMOLOGY
cause, (for example, detached retina or ker atopathy, especially if due to adherent vitre ous). 5. Vitreous hernia touching or adherent to the cornea, causing corneal edema follow ing cataract extraction of the opposite eye. 6. Epithelial dystrophy and/or bullous keratopathy of the opposite eye following intracapsular cataract extraction. In short, the extracapsular method is rec ommended only when preservation of the capsulozonular barrier is deemed advisable. TECHNIQUE OF EXTRACAPSULAR
CATARACT
OPERATION
There are two well-known methods and a third one has been published more recently. 1. The cystotome is used to make a rent in the capsule. Following this, the capsule is no longer taut, and it seems difficult if not impossible to cut out a certain shape of the capsule with the cystotome without injuring the posterior capsule or breaking the zonular fibers. Duke Elder2 states, "The lens capsule is highly elastic, tending to roll out when cut leaving a gaping wound." Yet, the recently perfected suction operation of the soft cata ract relies on this fact. It has seen its widest use in congenital cataract because of certain advantages over other techniques in such cases. But the suction operation still leaves the anterior capsule in the eye. Partially to obviate this in his operation of congenital cataract, McLean3 cuts a triangular piece from the anterior capsule with the Ziegler knife ; this piece and the lens material are removed by suction. 2. The back-toothed capsule forceps of Schweigger and its several modifications are fine instruments. A substantial portion of the anterior capsule can be removed with such instruments. But, inadvertently, one may grasp only a small fold. Or the lens may be dislocated before the capsule rup tures, or the capsule may fail to break and intracapsular removal results. Finally, Kirby 4 notes, "if the grasp with the forceps does
SEPTEMBER, 1967
not take out a clean piece of the capsule, but appears to tear it up toward the superior zonule, care must be exercised not to tear too far and create a hole in the zonule above." Should this happen, the capsulozonular bar rier is not preserved. 3. The third instrument, a modified erisophake for planned extracapsular extraction was devised by Veirs. 5 Suction is supposed to tear the capsule in the area of the erisophake cup. One cannot help but wonder whether the zonular fibers would break be fore the anterior capsule is ruptured, or whether the posterior capsule would break before the force of suction broke the ante rior capsule. The ideal instrument with which to per form an extracapsular extraction must (a) remove a large piece of the anterior capsule to prevent formation of a secondary mem brane; (b) make possible removal of the nucleus and as much cortex as possible ; (c) preserve the capsulozonular barrier; (d) avoid dislocation of the lens. These consid erations lead to selection of the technique of capsulectomy. After the usual corneoscleral wound, the placing of sutures and basal iridectomy, a two-mm opening is made in the capsule about three mm above the anterior pole of the lens. The pupil has to be at least five-mm wide even after these manipula tions. The central lip of the capsule wound is held with smooth forceps while a circular piece of capsule is excised with semicircular scissors. The scissors has narrow blades, with a radius of curvature of 2.5 mm. Only a narrow, thin blade can be advanced be tween the capsule and nucleus in the thin plane of the anterior cortex. The capsule is cut from above inferiorly, on both sides of the capsule forceps, thus removing a circu lar piece of capsule five mm in diameter. The extraction of the nucleus and the at tempted removal of the cortex with irriga tion follows as in any extracapsular opera tion. The gap caused by removal of a large piece of capsule facilitates this maneuver. In immature cataract the clear portion of the
VOL. 64, NO. 3
PLANNED EXTRACAPSULAR EXTRACTION
cortex corresponding to the pupillary area and attached to the capsule is automatically removed by capsulectomy. SUMMARY
Extracapsular extraction is indicated when preservation of the capsulozonular barrier is advisable. The different techniques of the extracapsular operation are discussed and the virtues of capsulectomy, utilizing special scissors, are described. 508 Old National Bank Building (99201)
455
REFERENCES
1. de Roetth, A. : The vitreous face following intracapsular extraction. Am. J. Ophth. 45:59, 19S8. 2. Duke-Elder S. : System of Ophthalmology. Vol. II. Anatomy of the Visual System. St. Louis, Mosby, 1961, p. 314. 3. McLean, J. M. : Congenital cataract. High lights of Ophthalmology. 8:279, 1965. 4. Kirby, D. B. : Surgery of Cataract. Philadel phia, Lippincott, 1950. 5. Veirs, E. R. : A new erisophake tip for ex tracapsular extraction of cataract. Tr. Am. Acad. Ophth. Otolaryng. 66:264. 1962.
ACTIVE T E M P O R A L A R T E R I T I S A S A C O N T R A I N D I C A T I O N TO ELECTIVE SURGERY W I T H GENERAL A N E S T H E S I A BERNARD
L.
MCGOWAN,
LIEUT.
(MC)
U.S.N.R.
Chelsea, Massachusetts
The problem of sudden monocular blind ness during anesthesia is relatively un common. In the reported cases, the cause has been attributed to occlusion of the cen tral retinal artery due to inadvertent pres sure on the eye during the procedure, some times with associated hypotension.1"3 The possibility of infarction of the retrobulbar portion of the optic nerve by mechanical distortion of the nerve and increased in traorbital pressure during retinal detach ment surgery has also been reported.4 Al though thrombosis of the central retinal ar tery in patients with pre-existing arterial disease has undoubtedly been noted follow ing general anesthesia,5 no specific instance of this complication could be found in the literature. Blindness occurring during gen eral anesthesia has not previously been noted in temporal arteritis. The increasing fre quency with which temporal arteritis is rec ognized adds significance to the questions raised in this report. From the Department of Ophthalmology, Massa chusetts Eye and Ear Infirmary, Boston.
CASE
REPORT
This 76-year-old white man of Greek extrac tion was admitted to the Massachusetts Eye and Ear Infirmary with the symptoms and signs of carcinoma of the larynx. An ophthalmologic con sultation was requested because he had recently lost all vision in the left eye. Ocular history. At the age of 59 years, the pa tient had had a cataract extraction, R.E, and four years later a cataract extraction, L.E. Vi sion of 20/20 was obtained, O.U. He then had no visual symptoms until two weeks prior to ad mission when he noted blurring of vision in the left eye. This was accompanied by "white, green and blue spots" in front of the left eye and pro gressed to total blindness. He specifically denied discomfort in the eyes, headaches, scalp pain or tenderness, pain on chewing, malaise and fever. He admitted to weight loss of approximately five pounds during the preceding two weeks. Ocular examination. Corrected vision, R.E., 20/30; L.E., no light perception. Bilateral aphakia with large full iridectomies was noted. No pu pillary reactions could be obtained. Fundus exam ination of the right eye was normal, but the left eye showed mild blurring of the disc margins with some hyperemia of the nervehead. The arterioles were attenuated. Hemorrhage was present in the nerve-fiber layer immediately supranasal to the disc. Central and peripheral fields, R.E., were entirely normal. Both carotid pulsations were full and equal. No scalp tenderness could be elicited. The temporal arteries were neither prominent nor