MR. G.E., aged eighty-three, retired business man after a very active life. Family physician finds him in good physical condition for his age except for residual bladder infection from hypertrophied prostate. April 12, 1932, combined cataract extraction, left, pocket-flap corneal section. On completing capsulectomy a small amount of liquid vitreous presented and lens was removed on loupe, a nuclear type of senile cataract. Vision before operation was 20/200. Patient left the hospital the ninth day after operation with his eye slightly red, some cortical substance clouding the pupil.
The eye convalesced rather slowly under the use of dionin and atropin. June 1, new vessels were noted along the pupillary border from 10 to 6 oclock July 15, attempted the pupil slightly contracted. Although one-quarter grain of morphine hypodermic had been given and the usual cocainization, the patient complained of severe pain during the needling process and interfered greatly with the procedure. July 18, colon bacillus vaccine and urotropin were given over a period of about ten days by the family physician because of a moderate bladder infection. August 16, eye white; tension minus; globe shrunken at upper limbus; iris drawn back; pupil occluded; transillumination clear; and vision nil (?).
Having recently heard Dr. Linder of Vienna on the subject of vitreous changes in relation to detached retina, I am inclined, to feel that the shrinking of vitreous produced a detachment of the retina although at this patients age, doubtless, much of the posterior part of the vitreous body was quite liquefied. November 8, consultation with Dr. Riemer gave the following opinion: left eye-faulty light projection, hypotension, drawn-up pupil, and shallow anterior chamber. He thought there was, doubtless, a separation of the retina and advised against further operative procedure.
The patient died on May 25, 1934, slightly over two years after the operation. The death certificate showed general septicemia with prostatic obstruction but an autopsy, showed miliary tuberculosis of spleen, liver and, perhaps, brain, the latter tissue not being examined microscopically.
At his age of eighty-three he still was quite alert and active and was loath to retire from his business and institutional connections. He was a man highly thought of in the community and his opinion was much sought after. His physical condition might be considered quite good for his age and the family physician could never and more than residual bladder infection from prostatic obstruction. The autopsy findings of miliary tuberculosis, I believe, give us a clue to the failure in securing a good eye.
Doubtless, the operative trauma was sufficient to produce a pathologic process in an otherwise quite eye. On the other hand, process in an otherwise quiet eye. On the other hand, according to Linder, a prolapse of vitreous oftentimes will result in a contraction of the vitreous fibers pulling upon the upper quadrant of the iris and, perhaps, pulling the retina loose from behind.
Mr. W.G., aged seventy; May 19, 1931, cataract extraction, left, corneal section completed with a conjunctival bridge. During the operation, there was considerable commotion on the floor above. It was found later to be members of the x-ray department moving heavy packages. It shook the ceiling of the operating room and brought up the question of extraneous infection. Mr. G. was an elevator operator in the hospital for a number of years and always had a very poor physique.
Physical examination was made one month previously (at the time of preliminary iridectomy) and revealed no particular faults. Blood count at that time showed while cells, 6,200; neutrophiles, 64 per cent; and hemoglobin, 80 per cent.
At the first dressing on the third day after operation, the cornea was hazy, anterior chamber cloudy, and eye red. Blood count showed white cells, 8,600; neutrophiles, 82 per cent; and red cells 3,950,000. Urotropin, grs. 10 each three hours, and viosteral, gtts. 15, t.i.d., were prescribed. From this point on we were aware that we had a patient with very poor resistance and the eye became more noticeable infected. He left the hospital on the twenty-sixth day with the eye fairly quiet, shrunken, and without vision. He was re- admitted to the hospital August 15, 1931 (because home conditions were not satisfactory for care) with a diagnosis of iritis of the right eye.
Blood count showed white cells, 4,50; neutrophiles, 62 per cent; hemoglobin, 65 per cent; and cells, 3,190,000. October 20, the shrunken, operated left eye was removed because it was thought the condition of the right eye might represent a sympathetic infection. The laboratory reported much infiltration and caseation necrosis in the ciliary body and retina; many foreign-body giant cells; and made diagnosis of tuberculosis. X-ray at that time showed increased density at both apices, with calcified glands in the left hilus, consistent with old pulmonary tuberculosis.
He left the hospital on November 30, having had a series of tuberculin treatments. His remaining right eye showed the typical mutton-fat, postcorneal deposits and could clinically be diagnosed as a tubercular iritis. Subsequently, this patient has been observed in the out-patient department with a tendency for this eye to flare up occasionally. He has been in a tubercular institution and his health is improved very much.
Here was a patient, therefore, with very poor physical condition, although nothing pathologic could be charged against him, and it was not the supposed dust from the ceiling the operating room which produced the infection but an endogenous tuberculosis incited by operative trauma.
Mrs. M. OC, aged sixty-four; April 12, 1932, combined cataract extraction, left, pocket-flap corneal section, with no complications. Blood count showed white cells, 5,650; and hemoglobin, 70 per cent. On the ninth day the eye became red and some pain hospital on the tenth day ad was seen April 25 by the family physician who found her very nervous, with headaches, etc. This physician had gone over her carefully before entrance to the hospital and given her a clear bill of health.
The eye continued to be red. May 31 keratitic precipitates were seen with striped keratitic. August 25, a series of colon bacillus vaccine given because of clinical symptoms of gallbladder disease, with little effect upon the eye. April 18, 1933, after more redness and pain in the eye and after the diagnosis of a chronic gallbladder by the family physician, she was re-hospitalized for study and a needling. Three blood counts gave white cells ranging from 4,500 to 6,900; neutrophiles from 35 to 70 per cent; lymphocytes from 19 to 38 per cent; hemoglobin, 80 per cent; and red cells consistently 4,600,000.
Blood chemistry showed N.P.N., 36; sugar, 111 mgs. per c.c.; blood Wassermann and Kahn, negative. Graham test, negative. Examination of cervix revealed structures practically normal. X-ray of edentulous alveolar processes showed then negative. Nasal sinuses practically clear. The left eye was needles, securing a good opening, although the upper part of the cornea was hazy with some vascularization. She left the hospital on the fifth day. No conjunction could be drawn from our investigation other than that there was low resistance partly due to an unbalanced diet.
September 25, 1933, in a local hospital with an acute gallbladder, patient having passed some stones. January 8, 1934, taken to the hospital as an emergency case. Upon operation, found rupture of gallbladder. August 3, 1934, gallbladder still draining. Eye quite and looks better than since the beginning of trouble following first operation. The patient has been lost from observation and further data are not obtainable.
It seems reasonable to conclude that the marked gallbladder infection was the cause of the poor result to the operation upon this eye. It illustrates how difficult it is sometimes to find the source of focal infections.
Mr. L.S., aged sixty-five, retired small merchant. January 16, 1934, preliminary iridectomy. A senile immature cataract, right. February 14, 1934, cataract extraction, right, with capsulotomy. The patient left the hospital on the ninth day with some lens cortex in the pupillary in a drawn-up iris. These three operative procedures were done by a confrere.
I first saw the patient in June, 1934, with a low-grade iridocyclitis, some pain, a drawn-up this wholly occluding the pupil with organized exudate in the upper third. He was reported-by his son who is a physician-to be in good physical condition and he entered the hospital on June 11 for 4an iridotomy which was done the following day very satisfactorily by cutting across the iris fibers and securing a 4 mm. nearly round pupil. Within a few days tension arose in the eye and it was necessary to use pilocarpine. Blood count showed white cells, 9,200; and neutrophiles, 68 per cent. Patient left the hospital on the eighth day and did not report for observation until July 6, at which time the eye was nearly white.
No fundic reflex could be seen through the recent iridotomy. Tension was 40 by McLean; transillumination almost black, probably haemorrhage. Under treatment with dionin, atropin, syrup of hydriodic acid, etc., and after a study of the patients general condition, the eye has gradually improved. September 28, 1934, blood count showed red cells, 4,800,000; white cells, 14,200; and neutrophiles, 64 per cent. There was a subacute, non specific prostatitis. May 7, 1935, the eye is now white, tension normal, transillumination clear. If another blood count and examination of prostate demonstrates conditions satisfactory, we will feel satisfied in making another iridotomy, expecting a much better result.
This case may be classified as one of the vague focal infections interfering with and delaying a postoperative convalescence.
All four of these cases were apparently adequately investigated before entering for intra-ocular surgery. Therefore, there was no way of anticipating the complications which developed postoperatively. The writer wonders whether an intracapsular operation in an or all of these patients might have made any difference in the results which followed. Of the total number of patients coming to cataract operations, there doubtless are a great many who are probably inadequately investigated, particularly from the point of view of general physical conditions, and there must be a certain larger or smaller number of such results as are herein reported.
The large majority of cataract operations are done an patients whose general physical conditions is not good for one or more of several reasons and it is surprising oftentimes how good a surgical result is obtained in the presence of unfavorable circumstances. My answer to an inquiring patient about an anticipated result ion any given cataract operation depends upon the following factors; a healthy eye in an otherwise fairly healthy body, a capable surgeon with experience, and an operation in a hospital accustomed to caring for cataract cases which ought to carry with it very high percentage of good results.