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(Extracapsular Extraction). at the Massachusetts Eye and Ear Infirmary Fully 80 Per Cent

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(Extracapsular Extraction). at the Massachusetts Eye and Ear Infirmary Fully 80 Per Cent 104 BEETHAM: Cataract Extraction with Iridodialysis has definite fibers that originate in the periosteum of the outer canthus, some coming from above, and some from below. Conse- quently one incision alone through the orbicularis will not sever those fibers completely. If you will refer to the anatomic illustra- tions in Sabotti-McMurrich, you will see that these fibers are so arranged that it would be impossible to prevent the contraction of the orbicularis from affecting the upper lid and the lower lid simultaneously with one incision. CATARACT EXTRACTION WITH IRIDODIALYSIS WILLIAM P. BEETHAM, M.D. Boston, Mass. Complete removal of the opaque crystalline lens (intra- capsular extraction) has much in its favor compared with the old, time-honored procedure of capsulotomy and expression of nucleus and cortex (extracapsular extraction). At the Massachusetts Eye and Ear Infirmary fully 80 per cent. of uncomplicated senile cataracts are removed by the intra- capsular method. Under the influence and instruction of Dr. F. H. Verhoeff most of these cataractous lenses are re- moved by the method described by him in 1927.* With smooth, especially designed forceps, the lens capsule is grasped at its superior portion just anterior to the equator, and removal of the lens by a sliding movement is accom- plished by a combination of traction with the forceps above and pressure with a small muscle hook or lens expresser exerted near the limbus below. An iridectomy or an iridotomy is done to facilitate the grasping of the capsule and the removal of the cataract. Obviously, it would be preferable to preserve the sphincter intact if this could be done without sacrificing the advantages to be gained by iridectomy. I have attempted to do this by * Verhoeff, F. H.: "A New Operation for Removing Cataracts With Their Capsules," Trans. Amer. Ophth. Soc., 1927, xxv, p. 54. BEETHAM: Cataract Extraction with Iridodialysis 105 producing an iridodialysis above and removing the cataract through the opening thus obtained. The results obtained by this method have, from the onset, been so encouraging that I have continued to employ it as a routine procedure. A description of the method follows: DESCRIPTION OF OPERATION After the usual surgical preparation, which includes a retro- bulbar injection of novocain, an injection of novocain into the lids at the outer canthus, and the placing of a bridle suture around the superior rectus muscle, the conjunctiva is dissected upward from the limbus from approximately 9.30 to 2.30 o'clock. Corneoscleral sutures are used, such as those described by Verhoeff* in 1927. A No. 1 silk suture is in- serted into the cornea at approximately 11 o'clock at right angles to the limbus; a similar suture is inserted at approxi- mately 1 o'clock. Each of these sutures makes a track about 2 mm. in length, and penetrates to about one-third of the thickness of the cornea and sclera. The corneal section is performed, the knife cutting through these sutures. The cut sutures mark the tracks that are to be rethreaded with dou- ble-arm silk sutures, and they are removed after the double- arm sutures have been inserted; these sutures are then passed through the previously dissected conjunctival flap. After both sutures have been properly placed and the loops of thread have been pulled aside, the iris is grasped at 12 o'clock with smooth capsule forceps and pushed downward toward 6 o'clock, thus tearing the iris loose at its base. This is done by means of at least two or three bites of the forceps, so that eventually an iridodialysis is produced, which occupies about 80 or 90 degrees. Through the opening thus formed it is now easy to grasp the crystalline lens, and by a combination of traction and pressure the cataract is removed by the slid- ing method through the iridodialysis opening. The iris is * Verhoeff, F. H.: "A Corneo-sclero-conjunctival Suture in Operations for Cataract," Trans. Amer. Ophth. Soc., 1927, xxv, p. 48. 106 BEETHAM: Cataract Extraction with Iridodialysis carefully reposited, and an effort is made to see that it is free from the wound, especially near the sutures. The sutures are then tied. Eserin is instilled, and a double eye bandage is applied. On the second day the dressing is changed, and atropin is instilled. After seven to ten days' hospitalization the patient is discharged, and instructed to return two weeks after operation for removal of the sutures. I have employed iridodialysis in 122 cataract operations. The patients were all private cases, and followed consecu- tively, exclusive of these cases: 1. Those in which an iridectomy was inadvertently per- formed while making the corneal section. 2. Those in which an iridectomy was performed as a mat- ter of choice, owing to the presence of posterior synechiae. 3. Those in which discission or linear extraction was per- formed as the operation of choice. The Resident Staff at the Massachusetts Eye and Ear In- firmary has performed this operation at least 25 times, with results comparable to those reported in this paper, but their cases are not included in this report. DISCUSSION Type of Extraction (Chart 1).-In two cases, for special reasons, the extracapsular extraction was performed; in all the other cases intracapsular extraction was attempted. In 103 cases the lens was removed with the capsule intact. In 13 cases, just as the lens was being delivered, the capsule ruptured and was completely removed. In four cases the capsule ruptured and remained in the eye, along with cortical material. Thus, as regards removal of the capsule, attempted intracapsular extraction was unsuccessful in only four out of 120 cases. During the extraction one often had the impres- sion that the iridodialysis opening was not large enough to permit removal of the lens intact; it was found, however, that the lens would mold itself to some extent, and would slowly emerge through the stretched iridodialysis opening. BEETHAM: Cataract Extraction with Iridodialysis 107 CHART 1.-TYPE OF CATARACT EXTRACTION Attempted intracapsular extraction ................ 120 Successful (95.1 per cent.) .................. 116 Capsule intact ...................... 103 Capsule ruptured; completely removed. 13 Unsuccessful; capsule remaining in eye* ..... 4 Extracapsular extraction* ......... ............... 2 * One lens scooped. Vitreous Loss (Chart 2).-Although the vitreous and hya- loid membrane were often exposed, loss of vitreous occurred in relatively few cases. In two instances it was necessary to scoop the lens; in one of these a large amount of vitreous was lost, and in the other a small loss occurred. There were two other cases in which a small amount of vitreous was lost; in one it was through the pupillary opening, and in the other through the iridodialysis opening. Verhoeff has remarked that if vitreous was lost through an iridodialysis opening one would not expect to have the pupil drawn up. This proved to be the case in the only available instance, in which the resulting pupil was quite round and central in location. CHART 2.-VITREOUS Loss Loss during scooping of lens ...................... 2 Loss following lens delivery ....................... 2 Loss at time of operation (3.3 per cent.).4 Fluid vitreous ................................ 2 Post-operative iris prolapse ...................... 4 Reposited 1 Excised. ....... 3 Fluid vitreous was encountered on two occasions, partial collapse of the eye resulting as soon as the corneal section was completed. In these two cases intracapsular extraction through an iridodialysis opening was done without difficulty. Iris Prolapse.-It seems remarkable that post-operative iris prolapse should occur four times with the use of corneo- scleral sutures. The chief value of corneoscleral sutures lies in the tight closure of the incision effected at the end of the operation. Nevertheless, it would appear that in some cases 108 BEETHAM: Cataract Extraction with Iridodialysis the closure is still not sufficiently tight to prevent reopening of the wound and iris prolapse. In one eye, one of the corneo- scleral sutures tore loose, due to faulty insertion, causing a bulging of the wound and a prolapse of iris; this prolapse was reposited and another corneoscleral suture was inserted. In the other three cases the iris prolapse was evident at the first post-operative dressing. In each eye the prolapse was very small and occurred between the suture and the end of the cataract incision. In each instance the cataract had been removed intracapsularly without loss of vitreous, and the iris had been reposited in the usual manner. There was no reason to believe that iris prolapse might occur, except that, from a cataract operation standpoint, these patients were uncoop- erative. These prolapses were excised, and a good functional result was obtained in each case. Hemorrhage. -Hemorrhage during operation is variable. One or two drops of blood usually appear when the iridodi- alysis opening is made, but in many instances no bleeding occurs when the iris is torn from its base. On six occasions an excessive amount of bleeding was observed. In one in- stance bleeding into the vitreous occurred at the time of operation, although no vitreous was lost. In another in- stance marked intra-ocular hemorrhage followed excision of the iris prolapse. Recovery was slow, but was satisfactory in each case. Hemorrhage occurs with no greater frequency in this op. eration than in other types of cataract extraction. It is my belief that from 20 to 30 per cent. of patients exhibit a slight hemorrhage into the anterior chamber between the second and the fifth post-operative day. This type of bleeding has never resulted in permanent damage to the eye, but may delay convalescence. Post-Operative Inflammation.-As one would expect, post- operative inflammation varies markedly. The insertion of corneoscleral sutures, the tearing of the iris to produce the iridodialysis opening, the resulting release of iris pigment, Fig.
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