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Some Compucations of Lens Extraction

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Some Compucations of Lens Extraction 412 S.-A. MEDIESE TYDSKRIF 10 April 1971 adequate immobility. We use intravenous Diamox, or information is that the cornea remains clear. urovert if necessary. Overlying sutures are no longer used, and if they are, The disc cannot be cleanly trephined out in such a soft then only during the operation in larger grafts in order to eye and a good deal of use is made of the scissors or razor­ hold the graft in position to prevent excessive bulging of knife. Adherent iris must be abscissed freely, and if there the iris diaphragm. After all the edge-ta-edge sutures have is a cataractous lens, it is removed by cryophake. been tied, the overlying sutures are removed. Both here and in aphakic cases vitreous anterior to the The autograft, of course, is the most gratifying of all iris must be swept away or lifted on a sponge so as to grafts. Wherever possible, the blind eye should receive the clear the angle as far as possible. Four large peripheral disc from the other eye unless it is very degenerate or iridectomies are performed when the iris is intact. calcified or too thin, because it will take much more Here it is useful to remember that the hole gapes and readily than a homograft and the patient is no worse off a graft somewhat larger than the hole may be an advan­ cosmetically. The only disadvantage is a puzzling appear­ tage, as I have already mentioned. As many sutures as ance after the operation, owing to an apparent trans­ possible must be inserted-ideally 24 in such a large graft. position of the eyes!' It is my custom always to introduce air behind the Case 11. A Coloured man aged 50 years was sent to us cornea in a full-thickness graft, unless I can see the from the platteland, with a blind right eye with a clear anterior chamber forming. This is done by a preplaced cornea and a left eye with very poor vision and a scarred oblique puncture just in front of the limbus using a Rycroft cornea from long-standing ulceration. needle. This will separate the iris and vitreous from the A cross-over autograft was performed and the result posterior corneal surface and open the angle. has been highly satisfactory. He can now see to get around In very large grafts this may not be possible and here and help himself. The poor cornea has been placed on his it is better to introduce the air by a cyclodialysis route, blind eye, which is no worse off than before. entering some 4 mm behind the limbus and, of course, entering the anterior chamber at the angle. CONCLUSION Case 10. A White male aged 65 years was sent to us The conditions discussed and the cases presented serve to from a distant part with gross bilateral corneal degenera­ illustrate the wide variety of types of corneal disease one tion and bullous keratopathy which developed, as he stated, encounters in a large general hospital which serves a large after operations for cataract followed by needling. Both area of the country. In each case an assessment has to corneae were white and irregular for most of their extent, be made of the peculiar needs of the patient and a decision except for a narrow paralimbal strip. reached as to the best procedure for re-establishing useful The right vision was hand movements onlv the left had vision, whether by a preliminary graft or a final functional no perception of light. In the right eye an' 'S'I-mm full­ optical graft. thickness graft was placed in an S-mm trephine cavity. I am sure that many other hospitals in the country Intravenous urovert was used. Vitreous protruded through present equally challenging opportunities for those who a large gap in the posterior capsule, of which some re­ wish to promote the restoration of visual function by mained. This was abscissed, leaving a clear vitreous-iris providing a healthy transparent cornea. diaphragm. Four weeks later the graft was clear and corrected REFERENCES vision 6/36. Slit-lamp examination showed some vitreous I. Swarup. B. and Cowan, E. C. (1968): Brit. l. Ophtha!., 52. 273. 2. Louw, J. G., Le Roux, P. L. M. and Rhategan, E. F. (1967): Ibid., in front of the iris, but it had some sort of 'face' and 51, 716. 3. Gundersen. T. (1961): Arch. Ophtha!.. 64, 260. there was aqueous between it and the cornea. Our latest 4. Louw, J. G. (1969): S. Afr. Med. l., 43, 1399. SOME COMPUCATIONS OF LENS EXTRACTION E. B. LAWTO , M.B., CH.B. (CAPE TOWN), D.O. (R-c.P. LOND., R.C.S. ENG.), Department of Ophthalmology, Unil'ersity of Cape Town and Croote Schuur Hospital SUMMARY ferred to the couching procedure, which was practised in The operation of lens extraction for CalaraCI has been Europe, until Jacques Daviel performed the first planned practised for many years. About 4% of cases develop lens extraction on S April 1745. In 1753 he published some major complication and a fell' of these are reviewed, accounts of 115 cases, of which 100 were successful; three namely vitreous loss and its sequelae and management, years later, there were only 50 failures in his series of macular oedema, fhe 'flal anterior chamber, postoperative 434 cases." glaucoma and postoperative infection. Compared with Daviel's failure rate of 11 %, we can The treatment of each complication is briefly oIIllined. expect a major complication in 4% of all cases." The possible complications of cataract surgery are innumerable. Surgical treatment of cataract dates back more than 3000 The literature on the subject is vast, though often repeti­ years. Records of the couching operation are found in tive. I have selected a few common or important com­ Hindu medical writings, long before the Christian era. plications as the theme of this article. The Roman writers, Galen and Celsus, speak of cataract The ultimate failure is enucleation of the eye. Blodi has surgery in the time of Herophilus, in 300 BC. They re- estimated that 1·3 o~ of eyes will be lost at some stage, • -= 10 April 1971 S.A. MEDICAL JOURNAL 413 following intracapsular extraction, and 2·0% after extra­ (b) '/nternar pressure. Choroidal haemorrhage, and capsular extraction" choroidal congestion, by competing with the vitreous for the space available within the scleral sac, may exert an VITREOUS COMPLICATIONS expulsive force from within the eye. Apart from not We have all, in the words of Prof. Derrick Vail 'seen opening abnormally hard eyes, little can be done to avoid vitreous presenting, beading, oozing, flowing and ca;cading the catastrophe of choroidal haemorrhage. However, one out of newly opened eyes'." The loss of fonned vitreous can minimize choroidal congestion, which is a reflection at operation, shattering for the surgeon, is also one of the of raised venous pressure in an open eye. most serious mishaps for the eye. In its wake come a (c) Vitreous pathology. One cannot avoid vitreous host of sequelae. pathology, but one can take steps to reduce the likelihood ~er e'ye~ . Six cent of which have lost vitreous at opera­ of vitreous loss in such cases. tIOn, wIll be lost WIthin one year. Of the remainder 18 % will have no useful vision a year after operation, and 23 % Prevention of Vitreous Loss after 2 years. Three years after surgery only 20% of There are certain warning signs of likely vitreous loss. such eyes will have a visual acuity of 6/18 or better.'· Failure to take these signs seriously may lead to unneces­ sary difficulty. In this regard we must beware of: Incidence of Vitreous Loss (i) the myopic eye and the prominent eye; The incidence of vitreous loss varies widely in reported (ii) the eye with previous iridocyclitis or glaucoma; reviews (Table I) from 17'3% down to 0·9%. A review of (iii) the cataracta brunescens; our cases at Groote Schuur Hospital for 1967 gave an (iv) the fellow eye of a previous 'vitreous loss eye'; and incidence of 14'1 %. Derrick Vail states that the incidence above all, should not exceed 3%" If one takes the reports from (v) the case of the subluxed or dislocated lens. Table I, published after 1950, the average incidence of BrieflY, the precautions one may take against likely vitreous loss is found to be 5·7%. vitreous loss are: (a) Minimize external pressure on the eye, by the use TABLE I. INCIDENCE OF VITREOUS lOSS IN CATARACT EXTRACTION* of lid sutures rather than a speculum for retraction; Author Year Percentage loss by the performance of a canthotomy and the avoi­ Daviel .. 1753 11·6 dance of a retrobulbar injection (this will necessitate De Wecker 1869 5·4 the use of general anaesthesia). Pagenstecher 1881 13-7 Jullundar Smith 1910 7-8 (b) Provide external support for the eye, by suturing a Vail (sm) India 1910 7 Flieringa ring to the episclera at 8 points. Vail (sm) Ohio 1910-1925 8·4 (c) Soften the eye pre-operatively by the intravenous Parker 1921 1I-3 injection of acetazolamide 500 mg and gentle, but Dunphy 1927 8'3 Elschnig 1926-1931 3-48 sustained digital pressure on the globe. Guillaumat et al. 1934 16·24 (d) Dehydrate, and so shrink the vitreous body, by the Guillaumat et al. 1939 5·29 use of an osmotic diuretic, given by intravenous Sinclair 1939 17· 3 infusion over a period of 30 minutes, starting It Kirby .. 1950 6·0 Little .. 7·1 hours pre-operatively (urea or mannitol at the rate Vail (im) 1925-1942 12·7 of 1·0 - 1·5 g/kg body-weight or isosorbide at the Vail (jnr) 1946-1961 3·7 rate of 2·0 g/kg).
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