INTRACAPSULAR CATARACT EXTRACTION WITH THE ERISIPHAKE.

WILLIAM ZENTMAYER, M.D.

P H I L A D E L P H I A , PA.

This paper gives a brief description of the operation practised and the results obtained by Prof. Barraquer during his visit to Philadelphia. It also gives a critical estimate of the value of this operation for ophthalmic surgeons in general. Read before the Section on Ophthalmology of the College of Physicians of Philadelphia, Oct. 19, 1922. (See p. 232.)

Last fall I had the honor, by request. of presenting before this Section an analysis (criticism) of the intracapsular operation as performed by Lieut. Col. Smith at Wills Hospital. Tonight, at the request of the Chairman of the Sec­tion, I shall do the same by the opera­tion of intracapsular cataract extraction as performed by Prof. Ignacio Barra­quer with the erisiphake.

As the instrument and method of procedure are of comparatively recent introduction, it will not be out of place to briefly describe each. According to the description published by its maker, the apparatus consists of two essential features: the erisiphake proper or cup­ping canula, and the pneumatic machine for producing the vibratory vacuum. The erisiphake consists of a white metal holder to which is adjusted a platinum cup. It is furnished with a set of valves operated by a button, by means of which communication with the vacuum pro­ducer can be established or inter­rupted at will for the purpose of alter­ing the pressure. It is claimed that not only is the lens seized by the cup, but that the fibers of the zonule are ruptured by means of vibrations transmitted to the lens when the air within the cup be­comes rarefied. The vacuum is pro­duced by a socalled pneumatic vibratory vacuum machine, which is operated by an electric motor.

Preparation of the patient: For two hours before the operation, at intervals of ten minutes, a few drops of solution of—

Euphthalmin chlorid 0.25 grm. (gr. iv.). Cocain hydrochlorid 0.25 grm. (gr. iv.). Adrenalin Sol. (1-1000) 3 cc. (m. xlv.) Sod. chlorid Sol. (6-1000) 3 cc. (m. xlv.) are instilled into the eye. In selected cases a 1% solution of novocain is injected along the fibers of

the facial nerve to secure temporary paralysis of the orbicularis muscle.

T H E OPERATION.

The assistant, to the right of the surgeon, raises the upper eyelid by means of a Desmarres elevator and raises the eyebrow with the little finger. With the other hand he holds the lower lid, while the surgeon fixes the globe with a Landolt forceps below the cornea. The incision includes 2/5 of the circum­ference of the cornea, and follows the limbus thfuout. A small conjunctival flap may be made. While the flap is being made, the eyeball must not be de­formed or displaced. In patients who threaten to be troublesome, a corneal su­ture is introduced. An iridectomy, pref­erably an incomplete basal one, may be made; but by preference none is made.

During extraction, the lower lid is drawn away from the globe and pressed against the cheek bone. The surgeon lifts forward the upper eyelid by means of a Desmarres elevator held in his left hand. The patient is directed to look downward. The cup of the erisiphake is now introduced in­to the anterior chamber from the tem­poral side of the wound in case of the right eye, and the nasal side in case of the left eye, as far as the center of the pupil, or still lower, behind the iris, sliding over the capsule without pres­sure upon the lens. The vacuum is now formed by pressing the button with the thumb. The rarefaction is said to take place by jerks, thus creat­ing sufficient vibration to rupture the zonule, this being aided by the diminu­tion in the diameter of the lens, result­ing from the partial protrusion of its mass into the cup. The degree of vacuum necessary to bring about this result varies from 50 to 70 cm. Hg.

202

CATARACT EXTRACTION WITH BRISIPHAKE 203

In case of a combined operation, the lens is removed by pulling forward the upper rim in such a manner that the lower side of the lens follows the curve of the patella fossa, keeping in contact with it and being guided to the side of the flap opposite to that at which the instrument was intro­duced, the rear surface being kept in contact with the scleral lip. When no iridectomy, or only a peripheral but­ton hole iridectomy is made, the lens is first lifted straight up 1 mm. The louver margin of the lens which touches the posterior surface of the iris now becomes uppermost, the posterior surface of the lens being in contact with the posterior surface of the cornea. The extraction is completed as in the combined operation. If an iridectomy has been made, the edges of the iris are replaced. In the other method 0.5 % eserin ointment is in­troduced into the conjunctival sac. The lids are gently closed, the palpe-bral fissure is covered with bichlorid ointment, 1-3000, a single layer of gauze, 4 x 5 cm., is moulded into the

eyelids and moistened with salt solu­tion, the hollows of the orbits are filled up to the level of the eyebrows by small flecks of cotton. The whole is then covered with gauze, shaped like eyeglasses and fastened with adhesive plaster. The dressing must not extend beyond the limits of the orbits.

The number of operations here presented is too small from which to draw conclusions. The visual results are not equal to those obtained by an operator of far less experience and dexterity operating by the extracap-sular method. The absence, in this series, of complications so frequent in the expression method of intracapsular extraction, is probably due more to the skill of the operator than to the safety of the method.

The utility of an operative procedure must be estimated, not by the technic and results of its most skillful inter­preter, but by those likely to be at­tained by the surgeon of average abil­ity. Any method of operating that re­quires a skill and experience not to be

Service of

2. Griscom2 . . . .

4. Holloway1 . . .

5. Holloway . . . .

6. Holloway . . . .

7. Radcliffe

"8. Radeliffe= . . .

■

10. Peter

Age

70

77

73

77

61

72

78

1 74 '

1 ?

65

Sex

M.

F.

F.

M.

M.

M.

M.

M.

F.

Eye

O.S.

O.D. 4

O.D.

O.D.

O.D.

O.D.

O.S.

O S .

O.D.

O.D.

Delivered

Intra­capsular Capsule ruptured

Intra­capsular

Intra­capsular

Intra­capsular

Intra­capsular

(Prel. Irid.) Capsule ruptured By spoon

not intracap. Intra­

capsular Intra­

capsular

Slight

Moderate

Slight

Irido-cyclitis

Iris Pro­lapse

No

No

No

No

No

No

No

No

No

No

Loss I of Vit- I reous I and V

Refraction

No -11 6/12

No No

No

No

No

No.

No

No .

No

Not recorded + 9.5 = + 4 ax. 180°

+ 11 6/15

+ 7 = + 1.75axl80° 6/9

+ 12= + 2 ax l80 ' 6/9

Not recorded 6/60

+ 10 = + 3 axl5" 6/15

10/10/22 +10 6/9 pt.

Not recorded 6/6 pt.

1. Striate Keratitis. First dressing, Aqueous filtered beneath conjunctiva. Probably Endophthalmitis Phaco-anaphylactica, as other eye had similar reaction following combined extraction. (Clark, C. S.)

2. and 3. Patient squeezed. Lens dislocated into vitreous capsule. Capsulotomy forty-six days Jater. Infec­tion: marked iridocyclitis; pupil occluded by membrane. Good L. P. ( I am indebted to C. S. Clark for the compilation of the above table, and to H. F. Hansell and L. C. Peter for leave to report their cases.)

SUMMARY. Vitreous Iris Severe reaction resulting in Failure to deliver

loss prolapse occlusion of the pupil in capsule None None Three One

One. (Severe reaction. , . . . , Pupil not occluded.) Vision—6/6 One. 6/9 Three, 6/12 One, 6/15 Two, 6/60 One, Not recorded One, Probable hand move­

ments One,

204 WILLIAM ZENTMAYER

reached by an average operator can­not be recommended. This is true of the method promulgated by Barra­quer, and also that by Smith. Granted that intracapsular extraction gives visual results so far superior to those obtained by extraction of the lens without its capsule, that there is justi­fication for assuming certain risks, methods which expose the eye to these risks and yet attain this desired result in only 70% (Barraquer) should not be approved. In unskillful hands the Smith operation would appear to be the safer, as loss of vitreous is the one serious danger, whereas, in the Barra­quer operation there is the added danger of serious injury to the iris or loss of the entire contents of the globe. In skilled hands the Barraquer method appears safer, as in comparing the ac­cidents and complications in these two

Notwithstanding accumulated knowl­edge of theory and method, good refrac­tion is by no means general. No proof of this statement will be asked by the older men, who are seeing much referred work. As at least 80% of our work is the measurement of ametropia, this statement stands as an indictment of our specialty. I think we may wisely consider some of the reasons for our failure to do better refraction and dis­cuss remedies.

First among reasons, I would place the lack of adequate opportunity for thoro training in this country. We have a few, very few high grade post­graduate schools where good work is being done; we have more very poor schools, where after a few weeks men are given a certificate so stating, and who seem to believe, that they are

short series, we find that Smith had 38 per cent of vitreous loss, Barraquer none; Smith had 38 per cent of iris prolapse, Barraquer none.

If an intracapsular operation is de­sirable, it would seem to the writer that a method which avoids undue pres­sure on the hyaloid, with its con­sequent danger of loss of vitreous and the danger resulting from the produc­tion of a vacuum within the eyeball, should be the method of choice. Such we have in the Stanculeanu forceps method, or in one of its modifications, particularly that of Knapp.

After all, the combined extraction, or extraction after preliminary iri-dectomy, give in the end, results which compare favorably with any of the other methods proposed, and surpass them in ease of acquiring a safe technic.

qualified to practice ophthalmology and oto-laryngology. Another reason is undoubtedly a lack of interest in the less spectacular part of our work, and an impatience with what is regarded by some as the drudgery of ophthal­mology.

Some men, either from lack of in­terest, lack of imagination or some­thing else, seem to have no conception of what a good refraction means. They never become interested in the refinements of the work, and as soon as possible relegate it to an assistant, who has no greater interest and per­haps less ability. I have some friends, a large part of whose refraction is done by lay assistants.

For thirty-five years, my best en­ergies and most of my working hours have been devoted to the study and

SOME PRACTICAL POINTS IN REFRACTION. CASSIUS D. WESTCOTT, M.D.

CHICAGO, ILL.

The best methods for the study and correction of ametropia, as judged by 35 years of practice, are here given. Essentials are plenty of time, careful determination of the static refraction with cycloplegia, repeated until the results on succeeding days agree. A post-cycloplegic test and measurement of accommodation. As a rule reexamination after two or three years is best. Read before the American Academy of Ophthalmology and Oto-Laryngology, September, 1922.