The final step in the removal of the lens, and for this purpose it is my preference to remove the speculum, hold-ing the upper lid with the index finger of the feet hand while the assistant draws down the lower lid; (See Fig. 88), but most authorities recommend leaving the speculum in situ. Pressure is then made with a scoop upon the lower border of the cornea, directing the force backward, not upward, until the upper edge of the lens, having been titled forward, engages in the wound; the direction of the force should now be slightly upward as well as backward, following the lens as it passes out. The cortical substance is usually more easily removed directly following the nucleus than after waiting for the anterior chamber to fill, and the effort should be made to remove as much of the cortical substance as possible by gentle manipulation of the cornea with the scoop gradually coaxing it out. A too prolonged attempt in this direction, however, must not be made, as it tends to increase the danger of inflammatory reaction, and a clear pupil can be obtained later by discission.
After removal of the lens great care should be taken to thoroughly cleanse the wound from any cortical substance, shred of capsule, or prolapse of the iris. This is done with a hard rubber spud or spoon, dropping a solution of boracic acid upon the eye at the same time. The conjunctival sac is then thoroughly cleansed by irrigating with a solution of boracic acid, all shreds or blood-clots removed, and the dressing is then applied. Many forms of dressing have been used by different operators from the simple application of strips of isinglass plaster to very elaborate bandages. My plan has been to apply to the closed eyes a piece of antiseptic gauze. The hollow at the inner canthus is then filled up with borated absorbent cotton, and over this another light layer of the cotton; the whole is then held in place by two strips of one-half inch adhesive plaster. These plasters are to run from the check to the brow, one over the inner the other the outer can-thus, care being taken that there be no pressure made upon the eyeball. This dressing when carefully applied makes no pressure upon the eye, and, while light and comfortable, supports the eye by keeping the lids closed and at the rest. It is far more comfortable than the bandage and is easily raised for examination and dressing of the eye.
AFTER-TREATMENT.-The patient is placed in bed in a slightly darkened room and directed to lie as quietly as possible, turning from the back to the unoperated side as he desires. We believe it best that the patient be not allowed to sit up to eat, or as a rule, permitted to get up to urinate; but that rest in the prone position be followed for the first two or three days, unless the patient be-comes very nervous and restless, when more liberty may be allowed. After this time he may be permitted to sit up and gradually allowed to do more each day. The dressing should not be removed of the first twenty-four or hours, if it has not be-come disarranged, or the patient has not complained of pain or discomfort of the eye. It is my custom to open the eye twenty – four hours after the operation, especially in the simple extraction, sufficiently to see if the anterior chamber is re- established and the iris in place. At the end of the second or third day, if there has been no trouble, the eye may be more thoroughly examined for the first time. The covering of the unoperated eye may be removed at the end of the third or fourth day. Normally the patient will have some smarting and often pain in the eye for the first four or five hours after the operation. The application of the ice-bag to the side of the head, or raising the dressing enough to draw down the lower lid and let out a tear, will usually relieve the pain. It is the routine practice of the majority of operators to instill a drop of atropine every day after the first forty-eight hours; this seems hardly necessary unless there are indications of iris present. The covering of the eye, as a rule, can be removed about the sixth day and the eye protected for a few days longer with a light shield or smoked glasses. The eye is gradually accustomed to more and more light and the patient allowed to go out from the tenth to the fourteenth day.
Accidents during the operation are apt to be met with. One in which the iris falls before the knife during the incision has already been referred to. Another unfortunate accident is, when the incision is too small to permit of the escape of the lens, as too great pressure at this time to expel the lens may cause rupture of the zonula and prolapse of the vitreous may ensue. When this occurs, the incision should be enlarged with the blunt- pointed scissors. Dislocation of the lens, either partial or complete, has occurred from too great pressure with the cystotome. If it is pushed back into the vitreous it should be removed with the scoop or wire loop.
Escape of the vitreous may occur either before or after the extraction of the lens. If it occurs before the lens has become engaged in the external wound, further pressure on the cornea must be at once abandoned, as it will cause additional loss of vitreous without resulting in the escape of the lens. The lens will then have to be removed with the scoop or wire loop, which is gently in-serted well behind the lens, care being taken not to cause greater dislocation, and, by gentle forward to prevent its slipping off, is gradually drawn out. When the loss of vitreous has occurred after the escape of the lens, the eye should be at once closed, a bandage applied, the patient put to bed with an ice-bag to the eye and Aconite given. Loss of vitreous, while a frequent and undesirable accident, is not necessarily serious, as good visual results are often obtained even after a large loss. Kerschbaumer Archiv. Ophthal., vol. xx., 3, 1891. reports the loss of vitreous thirteen times out of two hundred cases operated upon, and in no instance did loss of the eye occur.
In some cases the division of the capsule is not of sufficient ex-tent to allow of the shelling out of the lens, and when this occurs the cystotome must be again inserted and a large laceration made.
The absence of an anterior chamber is often noticed at the first dressings, but it should occasion no alarm if the wound is clear, as it often not resorted for a number of days.
Of the evil results that may occur after the operation severe pain is usually the forerunner, and may set in within a few hours or several days after a perfectly smooth operation and may indicate an intra-ocular haemorrhage, suppuration of the wound or iritis.
Intra-ocular Haemorrhage is the most serious accident that occurs at the time of an extraction, and as a rule, results in panophthalmitis and loss of the eye. It is fortunately of extremely rare occurrence, as shown by the fact that, in the extended experience of Dr. Knapp, but one case had been seen by him up to November, 1890, which he reports in the Archives of Ophthalmology, January, 1891. In this case the eye was saved by carefully removing the blood, washing the conjunctival sac with a mild antiseptic, sterilizing the outside of the lids and applying an anti-septic dressing, which should be changed once or twice daily, according to the discomfort and discharge. If panophthalmitis supervenes, the eye should be enucleated at once.
Suppuration of the Cornea, since the general practice of anti sepsis in ophthalmic surgery, has, fortunately, become of quite infrequent occurrence. It results from some infection of the wound, either introduced at the time of the operation or within the first few days following, from some lachrymal or conjunctival discharge, and in some cases occurs in the very old or debilitated patients from want of sufficient nutrition in the cornea. It occurs usually within the first three, days, though may occur as late as two weeks after the operation. The onset of suppuration is usually ushered in with severe pain, and upon examining the eye, we find the lids swollen and puffy, the conjunctiva chemosed, the cornea hazy and sloughing at the margins of the wound. The suppurative process may be checked and the wound healed with out any damaging results, in slough of the cornea with leucoma, or extend into a general panophthalmitis. The treatment is practically the same as described under ulcerations of the cornea.
Iritis following cataract extraction generally makes its appearance about the eighth day, sometimes earlier or later, and should receive the usual treatment for this condition.
To prevent as well as to arrest the progress of any form of inflammation in its initial stage occurring soon after cataract extraction, no local remedy is equal to the use of ice. Internal medication is also of decided value in the treatment of the various complications which arise after cataract extraction. For the neuralgic pains, which often occur within the first twenty- four hours, relief can often be obtained from five-drops doses of the tincture of Allium cepa, as first recommended by Dr. Liebold. Morphine in rare cases may be of service to relieve this pain. In any inflammation of the eye following cataract extraction, Rhus tox. is a most valuable remedy, and is given as soon as the patient begins to complain of pain, accompanied by lachrymation and puffiness of the lids. After pus has formed. Hepar, Silicea, or Calcarea hypophos., either alone or in alternation with Rhus, are of value. In some cases a low form of chronic conjunctivitis follows for a while after the operation, and one of the best things for this condition is to keep the patient out in the open air.
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.