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.