Forty-two per cent. remained unchanged; 13 per cent. were improved; 26 per cent. were slightly worse; and 19 per cent. were decidedly worse. There is a striking similarity between the results presented by the two surgeons. This goes to show how hard it is to determine just what is nature and what is drug effect. Dr. Risley believes that vision can be improved or maintained in many cases by correcting errors in the refraction and giving attention to the general health. He emphatically states that increased visual power is not due to “the absorption of any opacities already formed in the lens, but to improved conditions of the vitreous, choroid or retina.”.
Admitting that there are cases helped by the Homoeopathic remedy and correcting of the refraction, still there is large class of immature cataracts in which both of these means are out of the question. Sufficient vision remains to go about, but not to engage in the ordinary avocations of life. These are the patients which enlist our sympathy and tax our skill. Waiting for maturation of the cataract may mean broken-down health, or poverty, or both. What can be done? Two active courses can be pursued:.
First.-Remove the immature lens as it is.
Second.-Artificially mature it and then remove it.
For myself, I prefer the first plan as involving less risk. This can be accomplished by two methods, each with a variety of modification. The one feature which distinctly distinguishes one from the other is whether or not injections are made into the anterior chamber. Dr. Tweedy dose not use injections, but performs an iridectomy and makes a peripheral opening in the capsule with the Grafe knife. He claims that such a capsulotomy keeps the particles of lens substance, which cannot be removed, from coming in contact with the iris. Some surgeons, however, remove a piece of the anterior capsule, and others make a point of doing a preliminary iridectomy.
The method of making intra- ocular injections is rapidly gaining ground. McKeown, De Wecker, Panus, Knapp, Lippincott, and many others, are employing it to a considerable extent. A variety of instruments has been devised for this purpose and a number of different solutions tried. McKeown has used simply distilled water in 70 per cent. and Panus’s solution in 30 per cent. of his cases. De Wecker injects a weak solution, and Knapp a one-half per cent. boracic acid solution, and Knapp a one-half per cent. of sodium chloride.
The bichloride of mercury is not now used because of the discovered danger to the cornea. I have employed injections ten times. If the lens is very immature, as it was n six cases, I do an iridectomy; otherwise not. I make a free laceration of the anterior capsule and inject a warm I per cent. sterile boracic acid solution. I have not had a single had result.
In two cases V = 20/20. A sharp attack of iritis followed in one case, but was controlled, and useful vision resulted. I employ a one-half ounce hypodermic syringe with a sterling silver tip, and never use the same tip on more than one case. A point made by Knapp is not to be overlooked; that is, to introduce the nozzle within the corneal section, so that the liquid will run from within out. This is disregarded by some, but it seems to me that there is an element of danger in washing septic matter into the wound.
The second plan, that of artificially ripening the lens, has many followers: Foerster, McHardy, Noyes, and others. There are six different ways of accomplishing it:.
First.-Simple division of the anterior capsule.
Second.-Division of anterior capsule and iridectomy.
Third.-Division of anterior capsule and external massage.
Fourth.-Simple paracentesis and external massage.
Fifth.-Iridectomy and external massage (Foerster’s operation.).
Sixth.-Iridectomy and internal massage.
As the mere mention of these methods so clearly indicates the work to be done, a fuller description seems unnecessary.
In operating upon mature or nearly mature cataracts, the first thing to be decided upon is, shall an iridectomy be performed? The profession are still divided on this point. Simple extraction, however, now has the lead, and certainly is the ideal operation. With a section well in the corneal tissue, prolapse of the iris-the chief danger-is not a common complication. In extractions, with an iridectomy, prolapse of the iris into the angles of the wound is nearly as frequent. Preliminary iridectomy still has its advocates, and it would be hard to furnish better visual results than they are able to present.
No one method of operating will be adapted to all cases. We should never sacrifice the best visual results for the sake of cosmetic appearance. Simple extraction followed by secondary capsulotomy combines cosmetic effects of cataracts associated with myopia or slightly increased tension, in which iridectomy gives the better results.
There is one feature of simple extraction which has been of interest to me. Formerly I always used Eserine, a one-half or one per cent. solution immediately after the delivery of the lens. I have of late largely discarded it. Prolapse of the iris rarely occurs, less iritis follows, and fewer adhesions between the iris and capsule remain. When I employ Eserine now, I apply only a one-fourth per per cent. solution.
This causes less irritation. I should be pleased to know the experience of the members present regarding their treatment of a prolapsed iris. Some claim to have been able by gentle manipulation to replace it within the anterior chamber: others abscise it at once; and Dr. Knapp allows it to remain ten days or longer before abscising, unless it occurs during the first twenty-four hours after the extraction.
Regarding the after-treatment and dressing little need be said here. Nearly every oculist seems to have a method peculiarly his own. The tendency is markedly toward more freedom for the patient and more simple dressings for the eye. Some have gone to the very extreme and practically abandoned the idea of any after-treatment.
During the past few years a number of interesting modifications of cataract extraction have appeared, and in conclusion I will briefly bring to your attention some of them.
Dr. F. Parke Lewis divides the posterior capsule immediately after the delivery of the lens. He claims that by so doing, secondary cataracts are less frequent. Dr. Carter adopts the same procedure, claiming that it prevents the development of glaucoma. Both Drs. Tyner and Brockman prefer a preliminary peripheral capsulotomy with a Bowman’s stop-needle. Dr. Brockman reports four thousand cases thus operated upon. Galezowski and others open the capsule with the knife after making the first corneal puncture. Suarez De Mendoza introduces a suture into the lips of the section; and J.S. Prout keeps the lids closed by means of a suture. These measures, however, have not received any general adoption.
Finally, careful must be given to the division of secondary cataracts. a capsulotomy should be performed as soon as practicable. If delayed too long, the capsule becomes tough and hard to cut. In the prescribing of glasses, Javal’s ophthalmometer has been of great service to me. If, more perfectly than any other instrument, shows the changes in the corneal curvature. This facilitates the work of finding the proper astigmatic glass which will give the highest visual result.
Secondary capsulotomy, when necessary, and the prescribing of glasses, are the final steps in the operation for giving sight a cataract patient. They are the finishing touches upon a piece of work that has been skilfully and delicately wrought, and without which all that has preceded may be of no avail.
DISCUSSION.
B.B. VIETZ, M.D.: Cocaine.-Of course all appreciate its worth. The strength of the solution to use, and the dangers of the drug are points that interest us and about which any discussion can be raised. For the first two years after cocaine came into use, I used a four-grain solution only in all operation about the eye. Enucleation was painlessly performed in two cases, iridectomy many times, etc., and I am not yet entirely convinced but that the effect of a weak solution, everything considered, is as satisfactory as when a stronger one is used. If then, a four- grain solution produces anaesthesia so completely, surely a two per cent. solution is plenty strong enough for the oculist.
Dangers of Cocaine were not mentioned by the essayist. But the note of alarm is frequently sounded in our journals, one surgeon discarding it entirely in threat work. The dangers, I think, are over-estimated, for I have never seen any toxic effects whatever, and have used a 10 per cent. solution in operations about the nose and throat.
Antisepsis.-Dr. Bissell states that “cleanliness secured the maintained without the use of germicidal agents is the superior method.” I am fully in accord with this declaration. I take issue with the Doctor. however, upon the method he suggests for preparing our instruments. I do not believe it is necessary to take so much trouble and precaution. He puts them, he says, first into boiling water an alcohol; then transfers them to a sterilizer, where for an hour they are sterilized together with all solutions to be used. I confess to being very unscientific when it comes to the matter of antisepsis.
