Cataracta Secondaria, or after cataract, as it sometimes called, is the term applied to changes occurring in the capsule of the lens that remains after the extraction of the cataract. Secondary cataract may be either simple or complicated. In the majority of cases, after the extraction of the lens, the lacerated anterior capsule is thrown into folds and adheres to the posterior capsule, within these folds is shut up a small amount of lens substance which becomes opaque or there may be simply a proliferation or increased thickening of the capsule. This simple form may be either thick and opaque or thin and almost transparent. It may appear within a few days after the operation, or not for months, and is more apt to come on rapidly when peripheral opening of the capsule has been made. The complicated form of secondary opacity is a more serious affair, for these cases there may be thickening and contraction, the iris, which is adherent to the capsule, is drawn up toward the wound and may wholly obliterate the pupil. Cyclitis, detachment of the retina and other changes may ensue, the vitreous becomes fluid and the eye passes into atrophy, and some-times even sympathetic ophthalmia may result from the irritation.
Secondary cataract should never be operated upon until all signs of irritation of the eye have ceased. We believe that, as a rule, four weeks after the extraction is the earliest date that the operation for secondary cataract should be made, and that it would be better to wait as many months, or even a year in many cases. Generally, however, these patients are desirous of securing the use of the eyes again as soon as possible, so that usually the operation is made in from six week to three months after the extraction. We have seen a very thick, opaque secondary opacity gradually absorb so that after several months it became very thin and almost transparent. The operation for secondary cataract is discission, described on page 444.
Cataracta Capsularis is the name sometimes used when there is an opacity of the capsule. It may be seen either congenitally or as secondary to some other inflammation of the eye; and there is generally a proliferation and thickening of the epithelium of the capsule. This form of cataract is more often placed under the heading of polar cataract, either anterior or posterior.
DIAGNOSIS.-The simple diagnosis as to the presence or not of either a partial or complete cataract has been sufficiently shown under the symptoms already detailed. The importance, however, of a thorough examination of the cataract itself, together with a diagnosis as to whether complicated or not by other diseased conditions of the eye, is of the utmost value in forming an opinion as to the advisability of an operation and the prognosis as to the ultimate vision after an extraction. The size and density of the lens should be determined, the action of the pupil, whether adhered to the capsule, sluggish or freely movable, and the tension of the eye must be considered. The perception of light is the most important diagnostic point to determine both the acuity and the field of vision. In a mature, uncomplicated cataract the patient should be able to recognize the light of a candle in a dark room from thirty to forty feet away. The patient should also be able to recognize the direction from which the light comes, and the test should be made by holding the light in all parts of the field of vision. Any inability to recognize the light in the different directions would at once cause a suspicion of some intra-ocular lesion, which, of course, renders the prognosis less favorable. The examination as to the light perception may be made by the ophthalmoscopic mirror held from three to five feet away and using a weak illumination. A decided limitation in the field might indicate detachment of the retina, atrophy of the choroid, or other lesions of the nerve, retina or vitreous. The tension of the eye should be noted, as cataract may occur with glaucoma, when it would be increased, or with an inflammation of the ciliary body or choroid, when we would have a diminished tension with possibly a discoloration of the iris and tenderness of the ciliary region. Fluidity of the vitreous would be indicated by tremulousness of the iris and lens. This might also occur from a relaxation or loosening of the suspensory ligament. The lens itself, if shriveled or flattened, or if a chalky-white or calcareous appearance, would indicate some serious intra-ocular changes.
Operative procedures are not necessarily contra-indicated by the existence of any of these conditions, still it is important to recognize the complication in order that the probable results may be correctly appreciated by both the surgeon and the patient. The diagnosis as to whether the cataract is mature or not is also of importance, as in immature cataract, where there is not complete opacity of the cortex of the lens, more or less of its cortical substance may remain after escape of the nucleus and cause trouble. The usual test is by the oblique illumination, which, when the cataract is immature, shows a shadow upon the lens on the side from which the light comes. This is the shadow of the iris and is due to the fact that the opaque lens is posterior to the plane of the pupil and that there is a clear space between the iris and the opacity. When the cataract is ripe the opacity is level with the margin of the pupil and there is no shadow formed. In hypermature cataract the shadow is present, but a careful examination may show the yellow nucleus of the lens sunken out of the axis of the eye and its rim may be seen in the pupil and may change its position as the head is inclined from one side to the other. We must avoid mistaking the black rim at the pupillary border of the iris, due to a projection of its posterior pigment layer, for the shadow. In certain cases of so-called amber lenses the nucleus of the lens, instead of appearing of the usual grayish-white color, assumes an amber-like translucency, and in these cases there may be a slight iris shadow together with a certain reddish reflex from the fundus with the ophthalmoscope, while the cataract is really matured as much as it ever will be. No red reflex from the fundus is to be seen with the ophthalmoscope in any other variety of cataract when matured. The appearance of the surface of the lens gives some information, for when the striae appear very fine the lens is hard, while, if broad and white, the cortex is more or less soft.
PROGNOSIS.-In the immature senile cataracts, particularly where the opacity is in the form of peripheral striae, I believe, if they are taken in the earlier stages, that the tendency to progress to complete opacity can be checked by homeopathic treatment in the majority of cases. In my report of “Homoeopathic Treatment of Incipient Senile Cataract, with Tabulated Results of One Hundred Cases” this claim of the value of homoeopathic remedies to check the progress of incipient cataract was borne out by the fact that one-half of all the cases under observation for two years or over showed no failure in the vision and no increase of the opacity, and that in about one-third more there had been but a very slight loss of vision. Further that in those cases where the vision was better than 15/50 at the commencement of the treatment, there was no increase of the cataract in 60 per cent. of the cases; but that in those cases where the vision was not better than 15/50 the growth of the cataract seemed checked in but 45 per cent. of the cases treated. Therefore, I believe we are warranted in holding out to patients with incipient senile cataract a probability of preserving their sight unimpaired, instead of dooming them to a long period of gradually increasing blindness, with the prospects of an operation at the end. Rare instances of the spontaneous disappearance of cataract by absorption have been reported. The usual course, however, of cataract, when once started, is a steadily increasing opacity of the lens until complete blindness has ensued. For matured cataracts nothing but operative procedures are to be considered, and, when uncomplicated, the results are usually good. Unfavorable conditions in these are when the patient is very greatly debilitated, in very fat subject, or when there is a bad cough. Other conditions which would militate against the prompt healing of the wound are of course unfavorable and should be relieved, if possible, before the operations is undertaken. The most formidable of these are catarrh of the lachrymal sac, chronic conjunctivitis and pterygium, all of which should be corrected, if possible. Careful prophylaxis is always an essential feature in the prognosis and should be followed out thoroughly. The results of cataract operations are usually good. Statistics have been complied which will show the average per cent. of failure of numerous operators, taken collectively, to be only from 5 to 10 per cent.; but, for individual operators of an extended experience, the per cent. has been much lower.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.