owing to absence of subjective complaints, to lack of portance to that of cataract itself. Not only were a large cooperation on the part of patients in physical examina- number of monographs devoted wholly to this subject, tions, and to the difficulty of obtaining from such pa- but every work on general surgical topics set aside one or tients specimens of sputum for examination. more chapters for the discussion of artificial pupil. It seems to me, however, that the number of path- This is in great contrast to the limited space which mod- ologic records on which the above statistics are based is ern works on ophthalmology grudgingly yield to this still sufficiently large, and that in view of the remarkable important subject. showing of the figures the existence of a distinctly ft is difficult for us to appreciate the conditions which heightened immunity against tuberculosis in cases of brought about so large a percentage of cases of pupil- general paresis is hardly to be questioned. lary occlusion. Crude surgical procedures, poor opera- To what is this immunity due? tive technic and the utter lack of asepsis often resulted It has been shown by experimental inoculations that in iridocyclitis or iridochorioiditis. The couching of the paretics are immune against syphilitic infection.2 This lens, the free discission of both hard and soft cataracts, immunity is attributed to previous syphilitic infection, the frequent introduction of the knife-needle through which is now generally regarded as the one essent'al the dangerous ciliary zone, and the bungling efforts at factor in the etiology of general paresis. The question extraction all increased the tendency to inflammatory that naturally suggests itself is: May not the immunity reaction, while inadequate therapeutics and lack of against tuberculosis be due to the same cause? Syphi- antiphlogistic measures frequently permitted the de- litic infection, as is well known, gives rise in the human posit of plastic exúdate in the pupillary area, thus re- organism to an inflammatory reaction which is almost sulting in membranous occlusion of the pupil. identical in its nature with that which results from OPERATIONS FOR ARTIFICIAL PUPIL tuberculous infection. This fact, it seems to me, adds probability to the above assumption. For the sake of historical completeness, and in order In this connection also other questions of practical to better emphasize the special domain of iridotomy, 1 interest suggest themselves: If syphilis does confer will mention briefly the various methods that have been immunity against tuberculosis, at what clinical stale employed in making an artificial pupil. These are : of syphilis does this immunity develop? How would (1) Division of the thickened iris-membrane by an the course of a case of tuberculosis be affected by a su- incision made either through the sclerotica or through peradded syphilitic infection. the cornea. This is true iridotomy. I found among all the pathologic records which (2) Excision of a portion of the iris through a pre- I examined five cases of insanity due to syphilitic brain viously made corneal opening. This is now known as disease. All of the patients were entirely free from iridectomy. tuberculous lesions. I found also records of eight cases (3) Separation of the iris from its ciliary attachment. of cerebral hemorrhage with histories of syphilis; in This was generally known as iridodialysis, but sometimes two of these a few small scars were found at the apices called iridorrhexis. of both lungs probably healed tuberculous lesions', (4) Simple incision of the pupillary and of — margin, the rest showed no evidences of tuberculosis. The num- the free iris tissue. This has been designated sphincter- ber of these cases is too small, of course, to justify any otomy by some, and coretomy or iritomy by others. conclusion, and further investigation, both clinical and Either one of the latter terms is to be preferred, because anatomic, would be required to answer the above ques- it is more clearly descriptive. tions. (5) Detachment of the synechiae at the pupillary margin, either anterior or posterior, thus allowing the to retract. This was known as HISTORY OF IRIDOTOMY pupil corelysis. (6) Strangulation of the prolapsed iris in the corneal KNIFE-NEEDLE VS. SCISSORS\p=m-\DESCRIPTION OF AUTHOR'S incision was called iridencleisis. The prolapse was some- V-SHAPED METHOD times tied with a ligature. S. LEWIS ZIEGLER, A.M., M.D., Sc.D. (7) Trephining of the iris-membrane, by passing a Attending Surgeon, Wills Eye Hospital; Ophthalmic Surgeon. St. small trephine or punch through a corneal incision. Joseph's Hospital (8) Section and removal of a portion of the sclerotica PHILADELPHIA and chorioid by knife or trephine, with replacement of To Cheselden has been conceded the honor of being the conjunctiva over this opening, the conjunctiva thus the father and originator of iridotomy. Nearly two acting as a substitute for the cornea in transmitting centuries have elapsed since he first published the report light. This was called sclerectomy. of his procedure in the Philosophical Transactions for (9) Transplantation of the cornea for total leucoma. 1728. Ever since that time, his signal success has been This was usually preceded by partial or complete tre- acknowledged by all except those who either failed to phining of this membrane. equal his dexterity, or who were prejudiced by their In addition to these nine distinct methods certain ambition to originate a new method. combinations of these have been described and success- A careful review of the medical literature of the cen- fully practiced : and a tury half following Cheselden's announcement (10) Division and excision have frequently been per- can not fail to impress the reader with the great interest formed together. attached the an to operations for formation of artificial (11) Separation and excision have likewise had some pupil, which subject was considered second only in im- vogue. and have 2. Krafft-Ebing: Die Aetiologie der progressiven Paralyse, (12) Separation strangulation occasionally Arbeiten, 1897, ii, 12. been practiced. Read in the Section on Ophthalmology of the American Medical Detachment of the and excision have Association, at the Fifty-ninth Annual Session, held at Chicago, (13) synechia3 June, 1908. also been performed.

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 HISTORICAL REVIEW OF IRIDOTOMY For more than a century the method of Cheselden seems to have been the storm of In this brief review of iridotomy1 we shall confine center controversy. Some our attention to the methods that have been advanced doubted his veracity, others essayed his operation but while a few a success. for the formation of an artificial pupil in cases of mem- failed, had moderate degree of branous occlusion of the removal of the Many attributed to him statements which do not appear pupil following in in lens, either by couching, extraction Or discission, the iris- his published report. He says clearly that each of his cases membrane in these cases being chiefly composed of in- couching had previously been performed, flamed iris tissue glued clown by retro-iridian exúdate and yet some have insisted that the lens was present, and to the thickened lens capsule. must have been wounded. He also states that his inci- The early history of iridotomy shows that the advo- sion was made from behind forward, and yet his fol- cates of this operation were divided into two schools, lowers, Sharpe4 and Adams,5 both describe the incision (1) those recommending the use of the knife-needle as being made from before backward. As Sharpe was for incising the iris-membrane, and (2) those adopt- his pupil, and presumably had seen him operate, Guth- ing the method of introducing scissors through a rie6 suggests the possibility of his having made his in- previously made corneal section and freely excising cision both ways, the teehnic being practically the same. the iris-membrane, or excising a portion of the same. Morand,7 in his "Eulogy of Cheselden," claims to have We will first consider the school which advocated personally seen him operate "on an eye in which the iris incision by the knife-needle. was closed by an accident," and gives a more detailed I. KNIFE-NEEDLE METHOD description which closely Cheselden,2 a renowned follows the original method. surgeon, and oculist to Her He states that Cheselden Majesty, Queen Caroline of presented him with one of England, first announced, his knife-needles as a sou- in 1728, his success in mak- venir of the occasion. Al- ing an artificial pupil by though Morand does not means of his knife-needle. record the exact date of his He made his puncture back visit to London, he does of the corneoscleral junc- state that it occurred dur- tion on the temporal side, ing the year 1729. Hu- passing the knife across the guier,8 in his exhaustive posterior chamber, and thesis on artificial pupil, making a counter-puncture also places the date of this in the iris-membrane near visit in the year 1729. This the nasal margin. He then fact is important, as some cut through the iris from writers have declared that behind forward as he with- Morand neither made the drew the knife, the incision visit to London nor saw being carried through two- Cheselden operate, but only thirds of its extent. The quoted the original account pupillary opening thus given in the Philosophical made was a long oval slit, Transactions. The publica- horizontally placed. He has tion of Morand's high en- reported two successful comiums in 1757 attracted cases3 (Pigs. 1 and 2), oc- renewed interest to the sub- curring in patients who ject of Cheselden's opera- had previously undergone tion among men of scien- couching of the lens. His tific and medical attain- instrument, strange to say, ments. was practically of the same Portrait of William Cheselden, 1688-1752. Painted by Richardson. Sharpe,4 in 1739, per- general shape as the Hays formed this operation in knife-needle, but was larger, and judging from the de- the same manner as Cheselden, except that after he had scription more clumsily constructed, as there was dan- entered the knife-needle through the sclerotic he passed ger of leakage of the aqueous and sometimes of the it through the iris and across the anterior chamber, vitreous when it was used. Its form resembled a com- and then incised the iris-membrane from before back- bination of a bistoury and a sickleshaped knife, having ward. Although he was Cheselden's pupil, and dedi- on to he a sharp edge on one side, a rounded back, and an acute cated his small volume surgery him, prob- point. We possess two good illustrations of this, knife- ably did his master more harm than good, as all the needle, one by Cheselden himself (Pig. 3), and the objections to Cheselden's method seemed to be based other by his pupil, Sharpe4 (Fig. 4). on the deprecatory remarks of Sharpe. He says, "I once performed it with tolerable success, and a few 1. Wagner, Karl Wilhelm Ulrich: Inaugural Thesis, G\l=o"\ttingen, 1818. He invented the which he 5. Adams, Sir William: Practical Observations on Ectropium, designation iridotomia, formed and et from the and Artificial Pupil Cataract, London, 1812, p. 37 seq. original Greek, [unk], [unk] (the iris) [unk] (cut). 6. Guthrie, G. J.: Operative Surgery of the Eye, London, 1830, 2. Cheselden, William: Philosophical Transactions, London, p. 428. 1728. xxxv, p. 451. 7. Histoire et M\l=e'\moires de l'Acad\l=e'\mie Royale de Chirurgie, 3. Ibid, abridged, vii, pl. v, Figures 2. 3 and 5. Paris, 1757, iii, p. 115. 4. Sharpe, Samuel: A Treatise on the Operations of Surgery, 8. Huguier, Pierre Charles : Des Op\l=e'\rationsde Pupille Artifici- London, 1739, p. 169. elle, Paris, 1841.

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 months after, the very orifice I had made contracted and sors in order to prevent reclosure of the incision, no brought on blindness again." He mentions the danger direct confirmation of this statement can be found in of wounding the lens, the lack of success in paralytic iris his writings. with affection of the retina, the danger of iridodialysis Beer,12 in 1792, first published his method, which he from traction of the knife, and the possibility of failure designated as "an improvement on Cheselden's meth- because the incision would not enlarge sufficiently. od." Although the teclmic is somewhat different, the Thirty years later (1769) he published the ninth edi- procedure is practically the same as that originated by tion of his book without recording a single additional Heuermann in 1756. Beer selected certain cases in case, but added the thought that, since extraction of which a prolapsed iris had followed the lower incision the crystalline lens showed the cornea was not so vul- for cataract, causing adherent leucoma with a tensely nerable as had been believed, he would "imagine" that drawn iris-membrane. He plunged his double-edged a larger knife might be introduced perpendicularly lance-knife (Fig. 5) through the cornea and stretched through the cornea and iris and a similar incision out iris, from above downward made. In his first eight editions he pictures Ches- and a little obliquely (Fig. elden's iris-knife (Fig. 4, vide p. 538), but in his ninth 6), so as to incise the center edition he substitutes a broad lance-knife with two edges of the tense iris fibers cross- which closely resembled the one Wenzel (vide Fig. 17) wise, at right angles to the line of traction; cutting hori- zontally when the traction was vertical, and vertically when this was horizontal. In his monograph on artificill pu- pil,13 1805, he substitutes for the lance-knife his new broad iris-knife, which is Fig. 1.—Original case of Fig. 2.—Second case of irid practically same as that shown iridotomy. Iris incised above otomy. Iris incised below the later (Cheselden). (Cheselden). by Walton (vide Fig. 12), as, indeed, Walton's procedure had just introduced (1767), and which Sharpe suggests (vide was almost Fig. 6. Beer's iridotomy 13) — also be for of the cataract." Fig. with broad iris-knife (after "can used the extraction identical with that of Beer. Mackenzie). a the He evidently did not have very clear idea of sub- For other conditions he usu- ject, and only ¡succeeded in casting doubt and discredit ally employed Wenzel's until chance he on the method of his own operation by Cheselden, which, judging by encountered a puzzling case which led him to perform he had tried but once. statement, the operation we now know as iridectomy (1797) and Heuermann,9 in 1756, had already antedated these which thereafter became his favorite procedure for arti- thoughts of Sharpe by practising a similar method. He ficial pupil. passed a double edged lance-knife through the cornea Adams,14 in 1812, revived the of Cheselden the and then made a operation instead of through sciera, sweeping with certain modifications. While his was incision the iris-membrane without puncture through enlarging made in the same location, his technic was different. He the corneal wound. He was the first to probably punc- entered the sciera with a small iris-scalpel5 of his own ture the cornea with the iris-knife. special design (Fig. 7), which, like Sharpe, he passed Janin,10 about 1766, performed Cheselden's operation through the iris-membrane into the anterior chamber, several times with but little success to reclosurc owing carrying it across to the nasal side (Fig. 8). From en-

,Fig. 8.—Adams' iris scalpel in situ, Fig. 9. Iridotomy snowing location of scierai puncture by A d a m—s' method (after Lawrence). (after Lawrence). Fig. 3.—Original knife-needle in situ, behind the iris (Cheselden). trance to exit he always kept the edge of the knife turned back toward the iris, so as to cut from before of the wound He by plastic exúdate. adopted Sharpe's backward. He was thus able by the most delicate pres- but later on the incision from a modification, changed sure of his instrument, to make a long horizontal inci- horizontal to a vertical one with better results. He, how- sion, without causing iridodialysis (Fig. 9). If the first ever, afterward abandoned this procedure and became incision appeared to be too short, he did not withdraw the originator of the other school, composed of those the knife entirely, but again carried it forward and who to use the scissors. preferred partially withdrew it, always cutting in the same plane. in made a free corneal incision with a Guérin,11 1769, To quote his own words, "by the efforts to cataract and then introduced a small iris- repeating large knife, divide the iris care in so to make as slight with which he made a crucial (taking doing knife, incision from before a of as the instrument, in- backward in the center of the iris-membrane. degree pressure possible upon Although stead of withdrawing it out of the eye at once, as recom- Guthrie6 states that Guérin afterwards re- distinctly mended by Cheselden), a division of that membrane moved the four angles of the cross with a pair of seis- 12. Beer, Georg Joseph : Lehre der Augenkrankheiten, Wien, 9. Heuermann, Georg: Abhandlung der Vornemsten Chirurgi- 1792, ii, p. 12. schen Operationen, Copenhagen and Leipzig, 1756, ii, p. 493. 13. Beer, Georg Joseph : Ansicht der K\l=u"\nstlichenPupillen-Bild- 10. Janin, Jean: M\l=e'\moireset Observations sur l'Oeil, Lyon, 1772, ung, Wien, 1805, p. 105. p. 101. 14. Adams, Sir William : A Treatise on Artificial Pupil, London, 11. Gu\l=e'\rin,M.: Maladies des Yeux, Lyon. 1769, p. 235. 1819, p. 34, et seq.

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 may, in almost all cases be effected, of a requisite size to During the following seventeen years no notable ad- establish a permanent artificial pupil" (Figs. 10 and vance was made, the scissors method still retaining its 11). hold on the profession, until in 1869. von Graefe, after Here were three elements of success, a sharp knife, a long reflection, became convinced of the dangers of that gentle sawing movement, and the most delicate pressure • method, and- communicated to one of his pupils, M. o+' the instrument. His method was a decided advance, Meyer, his method of simple iridotomy performed with and he reported success in nearly one hundred cases. the knife-needle. Meyer18 quotes his views as follows : Others, less skilful, however, failed of success, and the "For such cases von Graefe has suggested another method of severe criticisms of operation, the principle and execution of which are contained in Scarpa,15 though evidently unjust note written for that illustrious savant in and cast a shadow of the following us by tinged by personal animosity,16 18G9: doubt on the method. "When, in consequence of a cataract the lens is From time on a form operation, that for nearly half century this absent, and when there is highly developed retro-iiitic exuda- of iridotomy was practically abandoned, the pendulum tion, with disorganization of the iris tissue, flattening of the swinging toward the use of scissors, which Maunoir had cornea and the other sequela? of a destructive iridocyclitis, I popularized and Scarpa had indorsed. Walton,17 how- substitute simple iridotomy for iridectomy, which is the opera- ever, about 1852, proposed a method closely resembling tion hitherto performed, generally without success. The opera- that of Heuermann and almost identical with that of tion consists in inserting a double-edged knife, resembling in Beer His iris-knife (Fig. was shape a very sharp pointed lance-knife, through the cornea and (vide Fig. 6). 12) newly formed tissues till it pierces the vitreous body, and im- mediately withdrawing it; and, while withdrawing it, enlarg- ing the wound in the membranes without increasing the size of the corneal wound. Experience shows that such plastic membranes attached to the atrophied iris and to the capsule of the lens have a tendency to contract sufficient to maintain, to a certain extent, the opening which has been made. "If, in the ordinary method of iridectomy, combined with laceration or extraction of the false membranes, we find that of 11.—The Fig. 10.—Occlusion pupil Fig. resulting pu- the artificial pupil usually becomes closed, we must attribute (Adams). pil after iridotomy (Adams). this to an excessive vulnerability, which immediately sets up proliferation in those tissues which have been touched, and which are endowed, in consequence of their structure, with an

Fig. 14.—Occlusion of pupil Fig. 15.—New pupil after in- (Walton). cision with iris-knife (Walton).

irritability altogether peculiar. We know that even the transi- tory reduction of the intraocular pressure, which follows the evacuation of the aqueous humor, is sufficient to give rise to hemorrhage in the anterior chamber, which interferes with the perfect success of the intended operation; but most of our fail- ures in the ordinary methods are due to the irritation caused by the forceps and the traction on the surrounding structures. in make Fig. 13.—Iris-knife position to Simple is free from such it is, so to (Walton, after Beer). iridotomy inconveniences; central pupil speak, a sub-corneal act, and enjoys the immunity which be- longs to subcutaneous operations. the same as the broad iris-knife of Beer. practically "I have also reduced the corneal wound to a minimum, by incised the cornea near the and He limbus, passed using small falciform knives. These are passed through the the knife across the anterior chamber to the middle of false membranes, which are then cut from behind forward." the iris-membrane which he punctured with a sweeping Von Graefe thus two vertical incision If the tissue still retained proposed methods, (1) by cutting (Fig. 13). from before backward with a double-edged lance-knife, its elasticity there appeared a long pupillary aperture, to the method of and and vertical 14 and This incision, according Heuermann, (2) by elliptical (Figs. 15). cutting from behind forward with a sickle-shaped knife, however, like all those made through a single set of the after the original suggestion of Cheselden. Later in the was successful when there was sufficient iris fibers, only same as he on his last bed of he became in the iris tissue to draw the slit year, lay illness, resiliency remaining so absorbed in the study of this subject that he sent a open, and thus keep the edges from uniting. While telegram to the Heidelberg Congress19 (September, this method never became very popular, there were some in which he advocated the method the sickle- who later it a narrow 1869), by practiced by substituting very shaped knife-needle as the best procedure. His last mes- Graefe knife for the iris-knife of Heuermann, Beer and to his that this latter still has consid- sage colleagues showed, therefore, through Walton. In fact, procedure mature conviction he favored the use of the erable both for and strongly vogue, iridotomy capsulotomy. knife-needle, and the making of a sub-corneal incision in 15. Scarpa, Antonio: Trattato Della Principali Malattie Degli the iris-membrane without evacuating the aqueous hu- Occhi, Ed. quinta, Pavia, 1816, translated by James Briggs, Lon- don, 1818, p. 373. 18. Meyer, Edouard: Trait\l=e'\Pratique des Maladies des Yeux, 16. Edin. Med. and Surg. Jour., No. 58. Paris, 1880, translated by Freeland Fergus, Philadelphia, 1887, p. 17. Walton, H. Haynes: The Surgical Diseases of the Eye, Lon- 396. don, 1861, p. 604. 19. Klinische Monatsbl\l=a"\tterf\l=u"\rAugenheilkunde, 1869, p. 431.

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 mor. His untimely death, however, prevented him from the first known description of iridotomy by the scissors further perfecting this procedure and presenting it to method it is probable that Janin was the originator of the profession. this procedure. Galezowski,20 in 1875, published a somewhat similar Wenzel,22 in 1786, employed a different method. With method in which he used his falciform knife, aiguille-a- a lance-shaped cataract knife he entered the cornea, serpette (Fig. 16), which he introduced through the dipped through the iris-membrane, returned to the an- cornea and iris-membrane, making either a horizontal terior chamber, and continuing to cut made a counter- or a vertical incision, with a "go-and-come" (sawing) puncture on the opposite side of the cornea, following movement, after the suggestion of Adams. If this which he completed his cataract incision. This gave a single cut was not sufficient, he made a linear incision of semilunar flap of iris tissue which could easily be ex- the cornea with a Graefe knife, drew out the iris and cut cised by scissors passed through the large corneal open- it off with scissors. By a process of evolution, however, ing (Fig. 17). he perfected the former procedure and eliminated the Maunoir,23 in 1802, took up the method of Janin, scissors. This latter method was published in the with the object of improving it. He made an incision third edition of his book in 1888. He punctured near the corneal margin, through which he introduced the cornea and iris-membrane with the sickle-shaped a pair of long, thin, angular scissors of his own design knife, making first a horizontal incision by the saw- (Fig. 18), one blade of which was sharp-pointed like a ing movement of Adams, and finishing with a second lancet, and the other button-pointed like a probe. The cut m the vertical iris-membrane was then punctured by the sharp blade direction, thus form- ing a T-shaped inci- sion. In actual prac- tice, however, he frequently prolonged this second cut, thus a crucial in- Fig. 17.—Wenzel's cataract knife and making Fig. 19.—V-shaped iridotomy Fig. 20.—Parallelogram pupil method of incision (after MacKenzie). cision after the man- with scissors (Maunoir). f Maunoir). ner of Guérin.11 The writer,21 in 1888, was led to devise an operation at about the natural location of the pupil, and an inci- with a modified Hays knife-needle, in which through a sion executed toward the ciliary margin of the iris. corneal puncture he made a converging incision in the Finding that this single incision did not always suc- iris-membrane which resembled an inverted V. The re- ceed,24 he subsequently improved this method by making sulting pupil opened up and formed either a triangular a second incision from the pupillary area toward the or an oval-shaped pupil depending on the degree of stiff- iris margin, in the line of the radiating iris fibers, thus ness or resiliency of the iris-membrane. This method milking a divergent V (Fig. 19). This triangular flap will be described in detail later on. was then allowed to shrink back, or if too stiff, was drawn out and excised. The resultant pupil assumed II. SCISSORS METHOD the shape either of a triangle, a parallelogram (Fig. We will now return to the consideration of the second 20), or a crescent (Fig. 21). He always made his in- school in which scissors were introduced through a previ- cision parallel with the radiating fibers of the iris and across the circular fibers. Scarpa,15 in 1818, having abandoned his own method of iridodialysis as wholly unsatisfactory, adopted Mau- noir's procedure with enthusiasm, chiefly because he had

N^^ ^^^/ Fig. 18.—Maunoir's scissors. Fig. 21.—Crescent pupil (Maunoir). ously made corneal section and a free incision was made by a friendly correspondence24 personally encouraged in the iris-membrane, or a portion of the membrane ex- Maunoir with advice and suggestion during its develop- cised ment. He indorsed Maunoir's plan of a double incision Janin,10. in 17'68, having abandoned the procedure of when he stated his conviction that "experience has Cheselden, proposed a new method. He incised the proved that in order to obtain, with the most absolute cornea below as for cataract extraction, and raised the certainty, a permanent artificial pupil, it is necessary to with a while he a corneal lip spatula introduced pair of make two incisions in the iris so as to form a triangu- lower of which was curved scissors, the blade pointed. lar flap in the membrane, in the form of a letter V, the He plunged this sharp blade through the iris-membrane, apex being precisely in the center of the iris and the and with a single vertical cut made a crescentie pupii base near the great margin." Some have claimed that which gaped sufficiently for visual purposes. As this is Scarpa himself originated the V-shaped incision, but 20. Galezowski, Xavier: Maladies des Yeux, 2d. ed., Paris, 1875, 22. Wenzel, Baron de: Trait\l=e'\de la Cataracte, Paris, 1786, trans- p. 401, and 3rd. ed., Paris[ill] 1888, p. 384. lated by James Ware, London. 1805, ii, p. 256. of the author's written 21. A brief description method, by him, 23. Maunoir, Jean Pierre: M\l=e'\moiressur l'Organisation de l'Iris, was first published in de Schweinitz on Diseases of the Eye, Phila- et l'Op\l=e'\rationde la Pupille Artificielle, Paris, 1812. delphia, 2nd. ed., 1896, p. 607. 24. Medico-Chir[ill]Trans., London, 1816, vii, p. 301, and ix. p 382

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 he gives Maunoir full credit for its successful accom- DeWecker,28 in 1873, published his admirable mono- plishment, although he does suggest some additional graph on iridotomy, in which he proposed the operation indications for its practical application. which bears his name, and which has long stood as the His opposition to the knife-needle incision of Chesel- best recognized method of this procedure. He advo- den arose from the fact that the pupil either did not cated two different ways of performing this : 1, simple open, or if it did open would not remain permanent, iridotomy, and. 2, double iridotomy. chiefly because of the single iris incision. His antagon- 1. Simple Iridotomy.—This is practically the same ism to the more successful procedure of Adams was the operation as Critchett's sphincterotomy and Bowman's result of a caustic personal controversy18 with that skil- visual iridotomy, although differently executed. It has ful surgeon, who ably parried his charges.14 His great been supplanted in our day by iridectomy, and does not, . influence with the profession of that day, however, therefore, come within the purview of this discussion. served to check the sentiment in favor of Adams' pro- 2. Double Iridotomy.—He rightly claimed that this its cedure, and when the weight of his indorsement was cast was both antiphlogistic and optical in purpose. He in favor of Maunoir's operation the scales were de- employed two distinct methods, which he designated as cisively turned toward the side of the scissors method. (a) iritoectomie, and (b) iridodialysis. The instruments Mackenzie,25 in 1840, practiced Maunoir's operation he used were a small stop-keratome (Fig. 27) and a pair with considerable success, but in certain cases found it necessary to employ a slight modification of this pro- cedure. He reversed Maunoir's incision by making the same divergent V across the radiating fibers of the iris instead of parallel with them (Fig. 22), thus securing a triangular pupil (Fig. 23), which Lawrence20 thought might succeed in some cases where Maunoir's method would not be available.

Fig. 22. Mackenzie's inci- Fig. 23.—Resulting trian- sion in cornea— and iris-mem- gular pupil from Mackenzie's brane (Mackenzie). incision (Mackenzie). @) Fig 24.—Plan of F i g. 25. First Fig. 26. Rhom- Bowman's first iris incision, completed.— boidal pupil,— result- incision. Divergent Plan o f second, ing from Bowman's V. showing double V. iridotomy.

Bowman,27 in 1872, proposed a method which, though surgically difficult to execute, was quite ingenious, and may have been the initial suggestion that stimulated DeWecker to write his monograph in the following year. I will quote his description as follows: "We make a double opening.simultaneously on opposite sides of the cornea. It is more convenient, of course, to make these Fig. 27. Stop keratomes, 28. Forceps-scissors in a horizontal in a vertical direction. Fig. two than — openings — lines straight and angular (De (pinces-ciseaux) (DeWecker). I then run a pair of scissors in two diverging (Y) Wecker). from each incision, thus enclosing between the incisions a large square or rhomboidal portion of the iridial region of devised fine iris scissors You specially (pinces-ciseaux) including the pupil, and all the structures there. (Fig. 28), one blade being sharp and the other There no pointed then withdraw the portion thus cut out. is blunt. These scissors were a mechanical advance has great drag on the ciliary region; whatever is withdrawn over all previous instruments of this kind, and undoubt- been eut awav from its connections beforehand" (Figs. edly proved to be a most important element in the suc- 24, 25 and 20). cess of his procedure. This method is simply an elaboration of the one pro- (a) Iritoectomie.—He entered the stop-keratome posed by Maunoir, in which, instead of forming one di- through the cornea, made an exact 4 millimeter inci- vergent V, Bowman has made a duplicate incision on the sion, and then partly withdrew it while letting the opposite side, and by joining the bases of these two re- aqueous slowly escape. As soon as the iris-membrane sultant triangles has caused them to take the shape of a floated up against the knife, he pressed forward, making rhomboid, thus <>. a 2 millimeter incision in the iris. Slowly withdrawing the knife, he introduced the sharp point of the scissors 25. Mackenzie, William: Diseases of the Eye, 3rd. ed., London, the iris buttonhole and cut from edited Hewson, through obliquely 1840, p. 746, American edition, by Philadelphia, either of the incision toward the of a 1855, p. 815. extremity apex 26. Lawrence, Sir William: Diseases of the Eye, American edition, edited by Hays, Philadelphia, 1854, p. 478. 28. DeWecker, Louis : Annales d'Oculistique, Sept., 1873, p. 27. Transactions, Fourth Int. Ophth. Cong., London, 1872, p. 179. 123, et seq.

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 triangle, thus making a convergent V (Fig. 29). He RELATIVE ADVANTAGES 0E KNIFE-NEEDLE VS. SCI880E8 then the with the for- grasped resulting triangular flap In the at issue between these two ceps and removed it, leaving an open central reviewing questions pupil. schools of one can not the con- (b) Iridodialysis.—His second method was a coun- iridotomy, help noticing terpart of Maunoir's earlier operation, with the addi- stant oscillation from one method to the other as certain tion of He made the corneal and iris in- advances were made. The method by the knife-needle iridodialysis. seemed to the of cision with the stop-knife, as in the previous method. possess advantage easy accomplishment Slipping in his scissors he cut from the center of the and less postoperative disturbance, but with the disad- iris-membrane toward the and this vantage that often the pupillary opening was inadequate periphery, duplicated and reclosed exúdate. On the other incision at an oblique to the first, thus making a promptly by plastic angle the method the scissors was more difficult of divergent V (Fig. 30). This formed a triangular flap hand, by which he grasped with forceps and tore from its ciliary accomplishment, caused more traumatism to the eye, attachment by iridodialysis. was often complicated by great loss of fluid vitreous, and was followed severe reac- DeWecker's procedure was planned by a skilled opera- frequently by inflammatory tor, and required great dexterity in its execution. When tion, if, however, it proved successful, the resulting was and for visual however, the result was most brilliant. Nev- pupil permanent sufficiently large successful, The inclination of all seemed to be ertheless, it was impossible to eliminate the danger of purposes. operators hemorrhage and loss of fluid vitreous in iritoectomie, toward the use of the knife-needle, and it was only ne- while in there was the added of a cessity that forced them to adopt the more compli- iridodialysis danger of the with scissors. torn surface and traction on the ciliary body. His cated procedure open operation ciliary Von Graefe seemed to this when he referred strict injunction to have a trained assistant hold up the recognize speculum blades in order to avoid the loss of fluid to the knife-needle incision as "a sub-corneal act which vitreous, showed how much he feared this disastrous enjoys the immunity of subcutaneous operations." contretemps. The success of his method of incision is The chief advantages of iridotomy by the knife- well shown in the illustration of his two cases (Figs. 31 needle are the ease of incision, the lack of traction on and 32). the ciliary body, the freedom from postoperative inflam- I have already suggested the possibility of Bowman's matory reaction, the avoidance of opening an eyeball paper before the London Congress of 1872 having given origin to DeWecker's monograph in 1873. This seems ® ® Di- 20.—Iiitoectomie. Con. Fig. 30.—Iridodialysis. Fig. V Fig. 31.—Pupil by iritoecto- 32. pupil. V vergent (DeWecker). Fig. Stenopaic vergent (DeWecker). mie. Two incisions. Converg- Singlo iris incision— (DeWecker). ent V (DeWecker). quite reasonable when we consider that Bowman pro- two methods of one his double V posed iridotomy, oper- which may contain fluid the of the ation with a rhomboidal and vitreous, lessening pupil (previously quoted), to iris from lowered and the other a visual or cut- tendency hemorrhage tension, iridotomy sphincterotomy, by the avoidance of the nebulous scar the with a blunt corneal which often follows ting through pupillary margin a corneal incision in old knife. These two methods are exact of large inflammatory eyes. The prototypes revealed in the method DeWecker's proposals. Furthermore, DeWecker was disadvantages of the knife-needle at the London where he heard Bow- lay partly in the method and partly in the faulty instru- present Congress ments constructed in man's paper, and took part in its discussion. In fact, that day. Cheselden, Morand, thirteen years later DeWecker acknowledged29 that after Sharpe and Adams all made the mistake of entering the considering the objections to Bowman's method of iri- eye back of the corneoscleral junction, which,is so near dotomy "I addressed myself at that time to the search to the danger zone of the eye. Adams, however, made for an instrument which allows the avoidance of all trac- a two-fold improvement in adding to his operation a tion on the iris, and which can be handled through a sawing movement and in advocating the "most delicate narrow opening, while exerting its cutting action in a pressure of the instrument" in order to make a free in- plane parallel to the surface of the cornea, against which cision. Heuermann was the first to make iris apparently the diaphragm of the applies itself, after the escape the puncture through the cornea instead of through the of the aqueous humor. The forceps-scissors having been sciera. it was for me to cause to discovered, easy be revived the The advocates of the knife-needle method of and to make it take rank long labored procedure Janin, decisively under the of a in modern ocular disadvantage making single iris incision, surgery." while those who the scissors discovered DeWecker makes only a casual reference to Maunoir's employed early method, but credits Janin with the original suggestion that a double incision was necessary to success. Although of the method which he has thus elaborated. Neverthe- Janin was the originator of the scissors method. Maunoir was the to a less, it is quite evident that DeWecker's method was first deliberately try triangular flap, which simply a modification of the one outlined by Maunoir DeWecker later elaborated and made a permanent suc- seventy years before. Furthermore, he lays down the cess. The many disastrous results of the open opera- same rule that Maunoir first offered : "Always cut par- tion, however, compelled conservative surgeons, like von allel to the radiating fibers and perpendicularly to the Graefe, to revert to a study of Cheselden's method, and circular fibers of the iris." to seriously consider the great advantages which a suc- cessful the knife-needle method would con- 20. DeWecker et Landolt: Trait\l=e'\ Complet d'Ophtalmologie, iridotomy by Paris, 1886, ii, p. 393. fer on surgeon and patient alike.

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 THE CHOICE OF A KNIFE-NEEDLE Wills Hospital, and, although not well known to the at has been in constant use the 1. Cheselden's knife-needle 3 and was a profession large, by (Figs. 4) staff of that for more than half a I but a executed hospital century. splendidly designed instrument, poorly be for the de- one. The blade was too and the shank may pardoned briefly quoting original large (11 mm.) of the instrument as in so that both and vitreous scription published by Hays30 improperly rounded, aqueous 1855: were liable to escape through the scierai puncture. This may explain many failures, although the single "This instrument from the point to the head, near the handle leakage to is six-tenths of an its iris incision was undoubtedly the most serious fault of (a b, Fig. 36), inch, cutting edge the method. (a to c) is nearly four-tenths of an inch. The back is straight 2. The iris- scalpel of Adams (Fig. Fig. 4.—Cheselden's knife-needle (after Sharpe). 7 ) was poorly designed but splendidly executed, the long blade completely filling the wound and thus preventing the es- cape of any fluid. The cutting edge, however, was too long (15 to 20 mm.), and especially so for the exe- cution of the sawing movement ad- Fig. 36.—Hays' knife-needle, exact size and enlarged (Hays). vised by Adams. 3. The double-edged lance-knife 12 and (Figs. 5, 33) employed by 16.—Sickle-shaped knife, Aiguille-Jl-serpette (Galezowskl). Heuermann, Beer and von Graefe, Fig. was useful for the long sweeping in- cision in the iris-membrane which they advocated, but is not adapted for the method which will be de- Fig. 35.—Sichel's iridotome (after Meyer). scribed later. The same shaped knife (Fig. 33) with a smaller blade and a longer shank is also used for this purpose, but is like- Fig. 34.—Knapp's knife-needle. wise too broad, too oval pointed and too much bellied to cut well, while the upper edge is liable to scarify Descemet's membrane at the same time that the lower edge is ex- Fig. 7.—Adaras' iris-scalpel; large and small size. ecuting the incision in the iris tis- sue. . 4. The sickle-shaped knife (Fig. which von Graefe 16) recommends Fig. 37.—Ziegler's model of knife-needle. and Galezowski employs, is excel- lent for making the puncture, but for the go-and-eome movement, which Galezowski advises, is not nearly so good as the straight blade Fig. 33.—Double edged lance-knife (modern model). with a slight falciform point. It closely resembles the older falciform knife of Scarpa. 5. The knife-needle of Knapp (Fig. 34), which is so generally used for capsulotomy, is unfortunately not well Fig. 5.—Double edged lance-knife (Beer). adapted for iridotomy. The point is too oval, the cut- ting edge is too much bellied, and the blade is too short (5 mm.). It will not easily puncture a dense iris- membrane, and the long sawing incision can not be well executed, because the short blade either persists in Fig. 12.—Iris-knife (Walton, after Beer). slipping out of the iris incision or else allows the mem- Tue Various Knife-Needles and Ieis-Knives Mentioned brane to ride up on the shank, in either case interfering in the Text. (Grouped together for study and comparison.) with the completion of the operation. 6. Sichel's iridotóme (Fig. 35) closely resembles to near the point, where it is truncated so as to make the Knapp's knife-needle, and although specially designed point stronger, but at the same time leaving it very acute, for this purpose, has the same faults, an oval point and and the edge of this truncated portion of the back is made to cut. The remainder of the back is rounded off. a bellied edge. On the other hand, the blade is too long simply The (11 mm.) to be easily manipulated in the anterior cutting edge is perfectly straight and is made to cut up to the chamber. part where the instrument becomes round, c. This portion re- quires to be carefully constructed, so that as the instrument 7. The knife-needle as in Hays (Fig. 36), suggested enters the eye it shall fill up the incision, and thus prevent the same the early part of this paper, has the general shape escape of the aqueous humor." as Cheselden's instrument, although much smaller. It was devised by Dr. Isaac Hays, an early surgeon of the 30. Amer. Jour. of the Med. Sciences, July, 1855, p. 82.

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 8. The knife-needle, which I invariably use, is a modi- puncture a good fulcrum for the delicate leverage neces- fied pattern of that devised by Hays. The form of this sary in executing the iris incision. instrument lies midway between the falciform knife 6. The knife-needle should be so manipulated that no and the bistoury, and possesses the advantages of both. aqueous shall be lost, as this accident may prevent the It has a very delicate point which punctures easily, and completion of the operation, and may increase the ten- an excellent cutting edge of sufficient length (7 mm.). dency to iris hemorrhage by lowering the ocular tension. If the shank is properly rounded it can be used with a 7. Every incision should be made a thoroughly clean sawing motion, sliding backward and forward through cut, and all tearing of the tissues should be avoided. the corneal puncture without injuring the cornea, and 8. The most perfect artificial illumination should be without allowing the aqueous to escape. To accomplish secured, either by an electric photophore or a condensing this the more easily, the shank has been made 4 mm. lens, as both iridotomy and capsulotomy require con- longer than the original model. This instrument, there- stant and close inspection of the operative field. seems to meet all the of a perfect fore, requirements author's v-shaped iridotomy iris-knife, viz.. a falciform point which makes the best puncture, a straight edged blade which makes the best The method of V-shaped iridotomy, performed by me incision, and a cutting edge 7 mm. long, which is the best with my modified Hays knife-needle, may be described length for properly executing the sawing movement. My as follows : model31 of knife-needle (Fig. 37) resembles Cheselden's First Stage.—With the blade turned on the flat, the knife, as shown by Sharpe (Fig. 4), even more closely knife-needle is entered at the corneo-scleral junction, or than the original pattern of Hays does. through the upper part of the cornea (Fig. 38). and passed completely across the anterior chamber to within 3 millimeters32 of the apparent iris periphery. The knife is then turned edge downward, and carried 3 millimeters to the left of the vertical plane (Fig. 39). Second Stage.-—The point is now allowed to rest on the iris-membrane, and with a dart-like thrust the mem- brane is pierced. Then without making pressure on the tissue to be cut, the knife is drawn gently up and clown with a saw-like motion, until the incision has been car- ried through the iris tissue from the point of the mem-

Fig. 38.—Author's V-shaped iridotomy. Knife-needle entered Fig. 39.—Author's F i g. 40. First Fig. 41. Pupil through cornea. V shaped method. incision completed.— resulting from— V- Plan- of first incision. Flan of second in- shaped iridotomy. ESSENTIALS OF SUCCESS IN 11UDOTOMY BY THE KNIFE- cision. NEEDLE METHOD bran« puncture to just beneath the point of the corneal This movement is made in a line 1. A good knife-needle must be carefully selected. puncture. wholly with We have already concluded that the modified Hays the axis of the knife, the shank passing to and fro knife-needle is the best model for this The through the corneal puncture, and the loss of any purpose. avoided in the knife-needle must, of course, have a well sharpened aqueous being carefully manipulation. point and edge. Third Stage.—The pressure of the vitreous will now 2. The character of the incision in the iris-membrane cause the edges of the incision to immediately bulge into a oval which the knife- is of vital importance. It should be a double incision. open long (Fig.40) through Guérin, Maunoir, DeWecker and Galezowski recognized blade is raised upward, until above the iris-membrane, and then across the anterior chamber to a cor- this. Guérin made a crucial incision, Maunoir and De- swung Wecker adopted the triangular flap, while Galezowski responding point on the right of the vertical plane, advocated the T-shaped cut. Our choice is the V-shaped which, owing to the disturbance in the relation of the incision, which is the one that will cut parts made by the first cut, is now somewhat displaced undoubtedly only and the second must be made at least 1 milli- through all the iritic fibers in such a way as to give us puncture the greatest retraction of the membrane. meter farther over, i. e., 4 millimeters to the right of 3. Absolutely no pressure should be made in cutting the vertical plane (Fig. 40). Fourth the knife on with the knife-needle. This must be recognized as the Stage.—With point again resting the a second is made the same main secret of success, whether you are a dense, membrane, puncture by incising the incision carried forward felt-like iris-membrane, or a thin filmy If ibis quick thrust, and rapidly capsule. movement to meet the of the rule is observed all traction on the ciliary body will be by the sawing extremity avoided. first incision, at the apex of the triangle, thus making 4. The knife-needle should slide backward and for- a converging Y-shaped cut (Fig. 41). C-tre must be taken at this that the of the on ward through the corneal puncture with a gentle saw- point, pressure knife-edge ing movement. the tissue shall be most gentle, and that the second in- 5. The corneal puncture and membrane counter- cision shall terminate a trifle inside the extremity of the puncture should be far enough apart to make the corneal first, in order that the last fiber may be -.^vered and thus allow the apex of the flap to fall down behind the lower 31. This knife-needle has been carefully made for me by L\l=u"\er, Paris, and by Ferguson, Philadelphia. 32. Compare with millimeter scale beneath each diagram.

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 part of the iris-membrane. If the flap does not roll but without success. Admitted to Wills Hospital by the late back of its own accord it may be pushed downward with Dr. Goodman, through whose courtesy I operated. the of the knife. When the is completed Operation.—On Jan. 15, 1889, I made two long incisions, point operation almost crucial, and extending the apex of the V, re- the knife is turned on the flat and with- beyond again quickly sulting in a W-shaped pupil, on account of the stiff iris mem- drawn. brane (Fig. 42). With S. + 10 D. he saw 20/50. CAUSES OF FAILURE Case 2.—History.—J. S., aged 30 years. O. S. injured and The most fruitful sources of failure are, a enucleated. O. D. sympathetic inflammation, chorioidal cata- first, poorly ract three discissions and and sharpened knife-needle; second, a inci- ; one iridectomy, down in. badly planned Membranous occlusion of I first saw him in 1888 while to sever the of the pupil. sion; third, inability apex triangle; house at the Wills was skil- the loss of too surgeon Hospital, where iridotomy fourth, early aqueous; fifth, heavy pres- fully performed nine times by one of the surgeons, the methods sure or with the knife-edge, and sixth, rocking rotating being varied and ingenious, but without success, as the in- the knife backward instead of making the sawing move- cision was invariably closed by plastic exúdate. My interest ment. All of these can easily be avoided, if the surgeon in this series of operations first drew my attention to the will only exercise care and subject of iridotomy, and stimulated me to develop the method good judgment. I submitted and which In an occasional the iris-membrane be so have here I first tried in Case 1. case, may One stiff that the of the will not retract. If the year later this patient came to my clinic at St. Joseph's apex flap Hospital. Iris was discolored, capsule thickened and visible apex can not be down the of the knife pushed by tip through the coloboma, down and in; areas of scierai thinning, turn the blade on the the base of the flat, puncture flap with pigmented chorioid showing through. T—3. Light per- by a quick thrust, and with a sawing motion cut across ception good, projection only fair. its fibers so that it will fall back as though hinged ; or, Operation.—On June 17, 1889, I made a V-shaped iridotomy if positive that the vitreous is not fluid, introduce a kera- along the outlines of the former iridectomy. The membrane into a or . tome in the cornea below, draw out the triangular tongue, freely opened up triangular pear-shaped pupil (Fig. cut it off with the iris and dress back the base 43), which proved permanent, but was only useful for quanti- scissors, tative vision, about 5/200. No further test could be with a silver made spatula. because the disorganized vitreous was filled with It is that the or iris lose floating possible capsule, tissue, may masses. I have seen him within a year, going about and earn- its In event we must either reverse the anchorage. that ing his living. From an operative standpoint I have always procedure by entering the knife-needle below, and cut considered this early effort one of my most successful cases,

Fig.42 (Case 1).—Iri- Fig. 43 (Case 2).—Iri- Fig. 44 (Case 3).—Iridotomy Fig. 45 (Case 3).—Iridotomy in a stiff iris-mem- in a soft dotomy dotomy eye-ball,. in a soft eyeball, with thin apex of iris flap after brane (author's original with dense iris-membrane. showing case). membrane and iris bombé. incision through adherent fibers. from above downward, or else pass a second knife-needle chiefly because of the great density of the iris-membrane and through the loosened edge of the membrane to fix it, and the lowered tension of the eyeball. then proceed with the usual method. Case 3.—History.—Mrs. A. D., aged 45 years. 0. D. iridect- the of omy for glaucoma seven years ago. 0. S. iridectomy two years Occasionally, apex the triangular flap will hold another because has been ago by surgeon, at which time there occurred slight fast, the last fiber of tissue not severed. incarceration of followed in If too to iris, by sympathetic ophthalmitis the leverage is short incise it from above, with- O. D. The severe iridochorioiditis resulted in cataract the and draw knife-needle and reintroduce it far enough some shrinkage of globe. The cataracts were extracted from from the apex to secure the proper leverage, and again both eyes in 1907, followed by dense opacity of cornea above, incise it gently, until it falls back. iris bombé, shallow anterior chamber, T—2. Here was a Traction on the accidental soft, distensible, iris tissue with shallow anterior chamber and ciliary processes, puncture of the of the or the of the membrane from greatly lowered tension eyeball, constituting one of the ciliary body, tearing most difficult conditions to on. its attachment all set or operate ciliary may up iridocyclitis ' glaucoma, and should therefore be avoided. As tense Operation.—On May 13, 1907, the eyes being quiet, and light perception and projection fair, was bands are liable to a similar condition V-shaped iridotomy capsular engender performed on both eyes. The leucomatous areas in the should be traction upper they incised. If any of these bands part of cornea necessitated making the pupil below. In O. D. should remain the we enter the in the edge of coloboma, may pupil opened up beautifully (Fig. 44), but in 0. S. a tag the knife behind them and gently saw through into the of iris hung fast (Fig. 45) and was again incised two months already cleared pupil, before withdrawing the knife. later. The artist has illustrated the remaining portion of this tag very well. As soon as the iris tissue was incised it re- ILLUSTRATIVE CASES tracted, making the pupils larger than the area of incision. test for a I will cite a few of the The glasses, nearly year later, March 15, 1908, briefly examples V-shaped oper- the result: ation, two that were my first efforts, and two that were yielded following recent cases. were all of the class that are often O. D. S + 13 D Z C + 4.75 D ax. 105° = 20/40. They 13 D abandoned as ; hence the visual result is far be- O. D. S + 2 C + 3 D ax 05°' es 20/40. hopeless Add low the operative success. O. D. S + 4 D = J. 10. Case 65 years. O. D. complete 1.—History.—F. M., aged O. S. S -f- 4 D es J. 10. membranous occlusion of pupil from iridocyclitis, following These were ordered tories. cataract extraction. The iris and capsule are tensely drawn up in biconvex She had worn glasses toward the ciliary border. Light perception and projection for a year, but claims vision is much better with the new ones. good. Several efforts have been made to incise the membrane, This seems like an excellent result when we consider that thes»

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 eyes had passed through glaucoma, iridochorioiditis and cata- AFTEB-TBEATMENT ract, followed by membranous occlusion of pupil, lowered ten- sion and fluid vitreous. The high hyperopia and astigmatism Postoperative inflammatory reaction is infrequent, show the phthisical condition of each globe. There is marked but if it should occur the usual antiphlogistic treatment cupping of both nerve heads and the fields are contracted. of atropin, calomel, ice-pads and leeching should be Case 4.—History.—Mrs. B. M., aged 64 years. O. S. struck actively instituted and continued until the eye is abso- by a stone in childhood, destroying vision. Dense leucoma The operation itself is an anti- chorioidal calcareous exclusion of lutely quiet. frequently above, cataract, deposit; measure, because it relieves iris-tension and pupil. T—1. fair. O. D. recurrent attacks of phlogistic Lpc. good. Lpj. traction on the The usual of inflammation for seven years, posterior syneehise and cataract. ciliary body. compress Counts fingers at 6 inches. Extraction with iridectomy, both gauze and cotton, covered with a Liebreich patch, may eyes, in 1907. Site of incision has become densely leucomatous. be applied to the eye for the first twenty-four hours and O. D. shows capsular area above, iris drawn up. O. S. com- rest in bed enjoined for that period. plete membranous occlusion of pupil. Operation.—Oct. 7, 1907, V-shaped incision was executed IN CONCLUSION entirely in the iris tissue of O. D., the pupil spreading out We have reviewed the of into an ovoid shape (Fig. 46), leaving area of and carefully history iridotomy capsule for two and noted how the small band of iris above. O. S. was operated on Jan, 13, nearly centuries, pendu- 1908, by the same method, the resulting pupil being alaiost lum has swung from knife-needle to scissors, and back round ( Fig. 47 ) owing to the resilient iris tissue. again. We have learned that Cheselden, the father of The test for glasses, March 10, 1908, gave the following re- iridotomy, originated the method of incision by the sult: knife-needle, which Heuermann and Adams O. 12 D c 1.25 D 135° modified, D. S + Z + ax. 20/50. later revived and We have seen how Janin — improved. O. S. S + 12 D Z C + L25 D ax. 135° = 20/70. Add abandoned this procedure and originated the scissors which Maunoir and caused O. D. S + 5 D = J. 6. method, greatly improved to hold for more than half a We have O. S. S + 5 D = J. 12. sway century. been the fact that the These were ordered in biconvex tories, which she now wears deeply impressed by mature, ju- von him to with great comfort. It is worth noting that O. S. still retained dicial mind of Graefe led abandon the scis- method and good visual acuity, although blinded by an injury nearly fifty sors and revert to the knife-needle ; finally years before. we have seen how, soon after his death, the great influ- ence of De Wecker had swerved the thought of the oph-

Fig. 46, (Case 4).—IHdo-cap- Fig. 47, (Case 4).—Iridotomy Fig. 48.—Author's F i g. 49. First Fig 50. Pupil V — — sulotomy, with band of iris, and with round central pupil in a shaped capsulot- incision completed. resulting from V- capsule in coloboma above. resilient iris-membrane. omy.- Plan of first Plan of second inci- shaped capsulotomy. incision. sion. CAPSULOTOMY BY THE V-SHAPED METHOD thalmic world back to the adoption of the scissor« The application of the V-shaped method to capsu- method in a greatly improved form. lotomy shows an even greater field of usefulness, as this Whether I have succeeded in sufficient facts method is the citing par excellence best way of incising a deli- and arguments to establish my thesis in favor of the cate cataract. be secondary capsular, This should done or not, I nevertheless submit to the under artificial knife-needle, pro- illumination. The pupil should be di- fession my V-shaped method of iridotomy and cap- as the incision lated, area of is necessarily smaller than with a confidence born of suc- in sulotomy twenty years' iridotomy, and unnecessary wounding of the iris cessful in its use, and with the that it be experience hope should avoided. The proposed capsular opening must may prove equally efficient in the hands of others who be so calculated as to fall within the area of the undi- will take pains to study and understand the method, and lated or an pupil, partly within the coloboma if iridect- who may have the patience to put it in practice. omy 1ms been previously performed. 1625 Walnut Street. The knife-needle is entered at the upper corneal mar- OF gin, passed across the anterior chamber to a point 2 mm. ABSTRACT DISCUSSION to the left of the vertical plane (Fig. 48), the capsule Dr. Geokge E. de Schweikitz, Philadelphia: Although Dr. punctured by a quick thrust, and the saw-like incision Ziegler only now publishes this detailed account of his opera- carried from below upward, as in iridotomy. The knife tion, he gave a description of it in 1896 in one of the editions is then raised up above the capsule and swung 3 mm. of my text-book. I mention this in order that Dr. Ziegler to the of the vertical the may have full credit for an early record of this ingenious right plane (Fig. 49), capsule with the lias been lim is and a incision carried operation. My experience operation again punctured, duplicate up - to the at the of the ited but entirely satisfactory. I have found it more satisfac- join first, apex convergingV (Fig..50.) and less than or call Where the is adherent to the under- tory dangerous iridotomy iridectomy. I pupillary margin especial attention to the necessity of a properly constructed or the is too it lying capsule, pupillary space small, may knife, as the ordinary knife-needle used in discission after be to start in a necessary the incision the iris tissue, cataract is not a satisfactory instrument for this operation. little below the pupil, and then cut upward until the I have not employed this operation in uncomplicated after knife emerges into the pupillary area, thus making an cataracts, as for them 1 still consider Knapp's knife-needle irido-eapsulotomy. The soft iris tissue is easily incised operation the best one. Ziegler's operation is more satisfac- if no pressure is made with the knife, and the sawing tory for complicated after-cataract and closed pupils follow- motion is maintained. ing iridocyclitis and thick membrane remaining after needling

Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/19/2015 of some congenital cataracts. I consider that the operation tissue. A very narrow Graefe knife with the cutting edge has a wide field of usefulness. forward is then made to divide the lateral bands at their Dk. C. H. Williams, Boston: I think that we shall some- junction with the iris tissue. The resulting pupil is usually times be disappointed in the amount of opening we finally circular. My belief is that, when possible, we should avoid obtain after operations on the iris for artificial pupil, especially additional operative traumatism to the iris tissue which has where there is a membrane of inflammatory deposit behind the shown itself so prone to react to injury. iris. I had a case which illustrates the need of a large Dr. Albert E. Bulson, Jr., Fort Wayne, Ind.: I have used division in order to obtain a serviceable pupil. A sea-captain two knives of Dr. Ziegler's pattern, according to his method, of 70 years came to me with a history of repeated attacks of in three different cases, with excellent results, but it is my iritis in each eye. There had also been some cyclitis in the opinion that the knives should always be of proper form and left, eye and in that eye there was not even perception of in perfect condition as to cutting edge and point or otherwise strong light. the operator will be disappointed in his results. The shank In the right eye an iridectomy had been done some in particular should be in proper shape and not taper if loss for closed and the had time previously pupil, patient of aqueous is to be avoided. A Ziegler knife with a sharp but more. A cataract good light perception nothing having cutting edge will permit of incision through a rather tough it decided to make an developed in this right eye, was finally membrane without traction. The knife is also an ideal one extraction, which was done without special difficulty. After for the ordinary operations for secondary cataract. the extraction the filled with a whitish pupil gradually deposit Dr. M. Wiener, St. Louis: I have used this excellent opera- and the iris was drawn to the corneal cicatrix, the upward tion for the last few years and found it better than vision being again reduced to perception of light. Four months any method I have used previously. One class of cases in which I after the extraction, the eye having become comparatively free found difficulty was those with very shallow anterior chamber from inflammation, a division of the iris and the membrane and lowered intraocular tension; and another in which we behind it was made by passing a Graefe knife through the have anterior synechia, the iris attached to the cornea irregu- upper part of the cornea directed toward the center of the so as to the iris and membrane. De larly. eyeball, penetrate I should like to ask Dr. what he does in these Wecker's scissors were then passed into the wound and a cut Ziegler conditions. If there be one where it is was made from above downward to within about 3 mm. of only spot attached, a motion it can be detached before the the lower part of the iris, which resulted in a cat's-eye pupil by sweeping V-shaped incision is made. I have found that I can a little through which the patient could see to play cards for about get along better the blade a little shorter than the one used one month. by having Dr. I had knives made with the blade about After this, the pupil became blocked by a whitish by Ziegler. some deposit beginning at the lower part and extending upward. two-thirds the length; in other respects the same. Five months later a second attempt to make an artificial pupil Dr. S. L. Ziegler, Philadelphia: The reference which Dr. de was made by passing the Graefe knife through the outer Schweinitz has so kindly made to his success with this opera- edge of the cornea and following this by three cuts with the tion in cases of membranous occlusion of the pupil leads me De Wecker scissors, one horizontal, one upward and inward, to believe that his adoption of this method for all of the last downward and inward. This resulted in a stellate- his cases of capsulotomy is only a question of time. The shaped pupil of good size. After a time the same process as V-shaped incision is undoubtedly the best one for Securing before began to fill up the pupil, but it only went so far as to a satisfactory opening in any type of membrane, whether fill up the stellate rays, leaving the center of the pupil free, thick or thin. The incision can, of course, be placed in any and the patient now has, with his correcting glasses, vision of part of the membrane and in any direction that you may 3/10 and can read ordinary newspaper print. wish to locate it. I do not believe there would be the slight- Dr. Edwaro Jackson, Denver: I have been familiar for est difficulty in securing good results in the cases Dr. Wil- years with Dr. Ziegler's work. When I was at the liams describes. I am sure that such drawn-up iris mem- Wills Eye Hospital fifteen j'ears ago, and before that I had branes will easily yield to this operation. The first ease I followed in the main the mechanical methods that he has fol- present in my paper illustrates this condition exactly. The lowed. No one who has not tried such an operation in diffi- second case was a similar one, the membrane being very dense cult cases, such as Dr. Williams has mentioned, can realize and the eyeball soft. In both cases the operations were success- the wide applicability of the method. I am sure that within ful, and the results have been permanent. Of course, you do h-ne the last ten years I have not used the de Wecker scissors in failure in these cases by the older methods. If the operation any case, and in some that looked quite as bad as the one is properly performed, however, there can lie no pressure und Dr. Williams has spoken of I have obtained a good pupil with no traction. In fact, I explicitly state in my paper that both comparative ease. In reference to gaping of the opening, to pressure and traction must be avoided, or failure will surely which Dr. Ziegler alludes in his paper, it is absolutely essen- One of the chief causes of failure in all methods of tial that the two incisions meeting at an angle shall come to- result. gether. If there is the least little shred of tissue left, it holds iridotomy has been the single incision, which is so liable to this tongue of iris and membrane in position, and you fail to close up. We must make a double incision. The V-shaped get a good pupil. If j'our knife is sharp enough, there is no cut has proved to be the most efficient in my hands. The need for any more than the minimum amount of pressure. The ultimate shape of the pupil formed by the V-shaped method tougher membrane will require the sharper knife and will re- depends almost entirely on the degree of stiffness or resili- quire longer sawing, but if you carefully observe the mechani- ency present in the iris membrane. cal conditions very tough membrane can be disposed of in this Anterior synechia; may be successfully freed with this form way. Leverage is of great importance. \'ou should at least of knife-needle. In the cases to which Dr. Wiener refors a have a leverage long enough to maintain its proper relation little shorter blade might be better, because of the cramped to the incision in the membrane. Its best relation is pretty position. For the long sawing incision of the ordinary case nearly perpendicular. By going into the limbus you get the of iridotomy, however, I consider this model of knife-needle longest leverage. just about perfect. Dr. Wiener also asks as to the degree Dr. Joun Green, Jr., St. Louis: Occlusion of the pupil of success in soft iris membrane. Case 3 is one of iris bombé consecutive to severe iridocyclitis after combined extraction in a soft eyeball, and well illustrates this condition. This usually presents a membrane occupying the site of the origi- membrane followed glaucoma and iridochorioiditis. I was nal eoloboma. If in such a case the margin of the upper lid, able to make an incision in it which opened the pupil even in distant fixation, does not encroach appreciably on the cor- wider than I cared to have it. This operation should not be nea the following procedure is applicable: A k,jr«tonie with condemned because the first trial results in a failure. On the the tip directed toward the center of the globe is made to contrary, the V-shaped method should be studied and prac- penetrate the membrane exactly at its junction with the iris ticed until the failures are practically nil.

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