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

Home , Iridodialysis

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 (intracapsular 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 intracapsular method. Under the influence and instruction of Dr. F. H. Verhoeff most of these cataractous lenses are removed 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 inserted into the cornea at approximately 11 o'clock at right angles to the limbus; a similar suture is inserted at approximately 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 double-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 sliding 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 performed 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 performed 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 impression 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 hyaloid 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 corneoscleral 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 corneoscleral 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 iridodialysis 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 instance bleeding into the vitreous occurred at the time of operation, although no vitreous was lost. In another instance 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. 1.-Appearance of iris openings. A, B, C, D-Group I: Large iridodialysis. E, F, G, H-Group II: Small iridodialysis. v-

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Fig. 2.-Appearance of iris openings. A, B, C, D, E-Group III: No visible iridodialysis openings. F-Group IV: No iridodialysis openiing; large pupil. G-Group VI: Drawn-up pupil. H-Ten days after extraction; sutures in place. BEETHAM: Cataract Extraction with Iridodialysis 109 and the trauma to the ciliary body caused by pressure during the lens extraction probably explain the amount of post- operative irritation encountered. It is the general impression that post-operative irritation occurs with greater frequency in this type of extraction than in some of the less complicated procedures. In at least four cases adhesions to a thickened hyaloid membrane developed, but in no case did this develop to such an extent as to cause impairment of visual acuity. One patient developed a troublesome iridocyclitis following rupture of the capsule, scooping of the lens, vitreous loss, and the formation of a dense inflammatory pupillary membrane. No keratitic precipitates were observed in any other case. In every instance, with the exception of this case, glasses were prescribed within three months after extraction, and in the great majority of cases within two months. The Appearance of the Iris Openings (Chart 3) (Figs. 1 and 2).-One of the main reasons for removing the cataract through an iridodialysis opening is to give good cosmetic results. It is my belief that a round or slightly oval pupil with any degree of iridodialysis is more desirable from a cosmetic standpoint than is the usual iridectomy or iridotomy. The results obtained have been divided into six groups. In Group I, consisting of nine eyes, the iridodialysis opening is somewhat large; the pupil is small and oval horizontally. Fortunately, the upper lid usually covers the iridodialysis opening, and then one sees only a small pupil exposed through the palpebral fissure. In Group II, consisting of 42 eyes, only a small iridodialysis opening is visible. The pupil is comparatively small, and is either fairly round or oval horizontally. In Group III there are 49 eyes in which no obvious iridodialysis opening can be seen. The pupil in this group tends to be comparatively small and fairly round or oval. In Group IV, consisting of ten eyes, no iridodialysis opening is visible, but the pupil is fairly large, quite round, and reacts poorly, if at all, to light. In Group V, consisting of seven eyes, the records are inadequate. Group VI includes five 110 BEETHAM: Cataract Extraction with Iridodialysis eyes, two with drawn-up pupils and three with peculiarly shaped pupils, the result of excision of post-operative iris prolapse. The drawn-up pupil in one case was due to loss of vitreous through the original pupillary opening, and in the other to failure to reposit the iris for fear of causing vitreous loss. CHART 3.-APPEARANCE OF IRIS OPENINGS-122 EYES. GROUP I GROUP 11 GROUP III

IRIDODIALYSIS LARGE IRIDODIALYSIS SMALL IRIDODIALYSIS NOT VISIBLE PUPIL SMALL, OVAL PUPIL SMALL, ROUND PUPIL SMALL, ROUND OR OVAL OR OVAL

GROUP IV GROUP V GROUP VI

I0 5

IRIDODIALYSIS NOT VISIBLE NOT PUPIL MUTILATED PUPIL LARGE, FAIRLY ROUND RECORDED DRAWN UP - a IRIS PROLAPSE -3 It is certainly true that in practically every instance the final iridodialysis opening is smaller than it was immediately following operation. There is a definite though slight ten- dency for the pupil to be drawn up, due either to fibrosis and contracture of the superior portion of the iris or to the formation of anterior synechiae. I believe now that at operation a special effort should be made to reposit the iris sufficiently so that a definite iridodialysis opening results. Although the pupils are intact and fairly round, they do not react so well as might be expected. The amount of reaction varies greatly, and is distinctly less than the amount present before opera- BEETHAM: Cataract Extraction with Iridodialysis 111 tion, and probably less than that observed after simple extraction. This lack of elasticity of the pupil is probably due to fibrosis of the upper portion of the iris. Functional Result.-A visual acuity of 6/6 is usual after cataract extraction, whether done with iridotomy, iridectomy, or iridodialysis. It is not easy, therefore, to evaluate the advantage of an intact, fairly round pupil. In this group there are four patients on whom at some previous time intracapsular cataract extraction with iridectomy had been performed on one eye. In each instance the patient maintained that the eye with the iridodialysis was the better functioning eye, although visual acuity was recorded as the same for each eye. It is obvious that such eyes are more tolerant of bright light than are those on which complete iridectomy has been performed. Incidentally, the astigmatism, measured after operation, varied from 1 to 5 diopters, with an average of 2.75 diopters for the entire group. Glaucoma (Chart 4).-Chronic simple glaucoma was diag- nosed in 15 eyes before cataract extraction. In each instance typical glaucoma nerve-fiber bundle defects were demonstrated in the visual field. CHART 4.-GLAucOMA. Diagnosis made before lens extraction ...... 15 eyes (Glaucoma field changes in each.) Diagnosis (?) made after lens extraction ...... 3 eyes (No glaucoma field changes.) Case 1: Tension, 36 mm. three months after extraction, maintained below 30 mm. the past twenty-four months with 1 per cent. pilocarpine once daily. Case 2: Tension, 25 mm. six months after extraction; 31 mm. twenty-six months after extraction; maintained at 23 mm. the past six months with 1 per cent. pilocarpine twice daily. Case 3: Failure of anterior chamber to reform for one month after extraction; extensive anterior synechiae formation; tension, 40 mm.; cyclodialysis; tension, 22 mm. for past ten months. Lens extraction was the first surgical procedure to be performed on ten eyes. In all ten the intra-ocular pressure was influenced favorably. The pressure was either less after 112 BEETHAM: Cataract Extraction with Iridodialysis cataract extraction when no miotics were used, less after extraction using the same miotic therapy as before operation, or less after extraction with reduced miotic therapy than before operation. Glaucomatous field changes have not pro- gressed in any eye during the period of observation, which, unfortunately, has been no longer than thirty-eight months in any case, with an average observation period of approximately twelve months for the group. A large iridodialysis opening was produced in one eye, a small opening in six eyes, and no visible iridodialysis opening in three eyes. Corneoscleral trephining was performed upon five eyes at least six months before cataract surgery was undertaken. In each of the five eyes a cystic draining cicatrix was present before cataract operation, but was visible in only one eye after operation. The cataracts were removed through corneal incisions just anterior to the trephine blebs. An iridodialysis was produced on each side of the previously made peripheral trephine iridectomy, and the lens was extracted through the opening thus made. The intra-ocular pressure has remained satisfactory in three eyes. In two eyes the pressure was moderate for over one year, then gradually in- creased to readings of 37 mm. and 55 mm. respectively. Fur- ther glaucoma surgical measures were necessary in order to obtain satisfactory intra-ocular pressure readings in these cases. Elevation of the intra-ocular pressure has been recorded in three instances in which it was believed that no elevation was present before the cataract extraction. In the first instance the pressure rose to 36 mm. Hg (Schi6tz) three months after operation. Pilocarpine once daily was prescribed, and at no time hag a pressure above 30 mm. been recorded during the subsequent twenty-four months of observation. The lens was extracted intracapsularly without vitreous loss. The pupil is small and round, and no iridodialysis is visible. In the second instance an intra-ocular pressure as high as 31 mm. Hg (Schi6tz) was recorded approximately thirty-six months BEETHAM: Cataract Extraction with Iridodialysis 113 after intracapsular extraction without vitreous loss. Twelve months earlier the pressure was recorded as 25 mm.; miotics reduced it to 23 mm. No cupping of the optic disc exists, and there are no glaucomatous field changes. The pupil is comparatively round and of moderate size; no visible iridodialysis exists; a small anterior synechia is present. In the third instance, aflat anterior chamber persisted for one month after operation. An extensive anterior synechia formed, and the intra-ocular pressure rose to 40 mm. Hg (Schi6tz). Further surgery was necessary in order to control the in- creased pressure; it has remained at 22 mm. during the past year. The pupil is fairly large and somewhat irregular in outline; there is no visible iridodialysis; an obvious anterior synechia of moderate size is present. Anterior synechia of some degree is probably present in every eye operated upon by this method. An obvious peripheral anterior synechia is present in 14 eyes, not including the four with post-operative iris prolapse. Gonioscopy dis- closes the presence of anterior synechiae in each of six eyes so examined-eyes without obvious anterior synechiae under ordinary inspection. The synechiae are chiefly from 9.30 to 11.00 o'clock and from 1.00 to 2.30 o'clock. It is my belief that the iris never reattaches itself to its original location, but seems to adhere to the site of incision. In the group with visible iridodialysis there is probably an anterior synechia adherent to the incision both temporally and nasally. In the group without visible iridodialysis there is most likely an anterior adhesion to almost the entire length of the incision. The canal of Schlemm is posterior to the synechiae and pre- sumably is not occluded. The significance of peripheral anterior synechia in this group is, therefore, far different from that of the anterior synechia that would result from simple extraction where the iris base has not been disturbed and where anterior synechia would necessarily mean occlusion of Schlemm's canal. Many tonometric readings have been made, and the only elevated readings are those that have 114 BEETHAM: Cataract Extraction with Iridodialysis been described. I do not believe, therefore, that this type of anterior synechia necessarily predisposes to the development of glaucoma. In fact, it is reasonable to suspect that moving of the base of the iris to a position in front of Schlemm's canal may be desirable and may lessen the possibility of post- operative glaucoma. Separated Retina.-Separation of the retina occurred in two eyes. In the first eye, a spontaneous separation of the upper one-half of the retina occurred six months after intracapsular cataract extraction without vitreous loss. Opera- tion to replace the retinal separation was refused. In the second case, a separation of the upper one-third of the retina occurred nine months after intracapsular cataract extraction without vitreous loss, and two months after a severe blow on the head. This patient had a myopia of moderate degree before cataracts developed. Diathermy coagulation with Walker points was carried out, with good success; a visual acuity of 6/6 and a fairly full field were obtained. It was believed that in each of these eyes there was a non-visible disinsertion at the ora serrata. In neither instance was a hole or tear observed. Other Complications.- The other complications can be enumerated briefly; thus: purulent endophthalmitis, 1 case; epithelialization of the anterior chamber, 1 case; separated choroid, 7 cases. CHART 5.-OTHER COMPLICATIONS. Cases Separated retina ...... 2 Separated choroid ...... 7 Vitreous hemorrhage ...... 2 Iridocyclitis .1...... Purulent endophthalmitis ...... 1 Epithelialization of anterior chamber ...... 1 CONCLUSION A report of 122 cases of cataract extraction through an iridodialysis opening is made. I believe that the operation is both feasible and reasonable, and that the results are grati- fying. In my opinion the operation is still in an experimental KIRBY: Procedures in Intracapsular Cataract Extraction 115 stage, but the results so far obtained have been so encouraging that I will continue its use. The cosmetic and functional results are usually good. The operative and post- operative complications do not differ greatly from those obtained by other methods of cataract extraction. In eyes in which both cataract and glaucoma were present, the glaucoma has been favorably affected by the removal of the cataract through the iridodialysis opening. It is hoped that a larger series of cases will show that the frequency of post- operative glaucoma is reduced.

PROCEDURES IN INTRACAPSULAR CATARACT EXTRACTION: A NEW METHOD*

DANIEL B. KIRBY, M.D. New York, N. Y. The success of various surgeons with the intracapsular extraction of cataract in producing excellent and lasting visual results has definitely established this procedure as a safe and desirable one. It is the purpose of the writer to record here brief analyses of the principles of the techniques of intracapsular cataract extraction as performed by other surgeons, to describe his own experience, to discuss variations in technique, and those of a method that he originated, and finally to point out how these may be coordinated and applied to the various types of zonules and cataracts. The particu- lar indications and contraindications will not be discussed, but it may be stated here that under certain conditions intracapsular extraction is the operation of choice. It should also be stated definitely that, just as surely, the extracapsular operation is the- method that will give the best results under other conditions. * From the Department of Ophthalmology of the College of Medicine, New York University, and Bellevue Hospital.