DISCISSION OF T H E L E N S A F T E R T H E T W E N T Y - F I F T H Y E A R .

RoDERic O'CONNOR, M . D .

OAKLAND, CALIFORNIA.

The general attitude on discission after the twenty-fifth year is stated, also the technic adopted. Curran iridqtomy has been tried with discission and seems worthy of more extended trial. The disadvantage of discission is the duration of the treatment. Its advan­tages are safety, simplicity, better cosmetic results and absence of astigmatism following. Thirteen cases are reported in tabular form. Read before the Colorado Congress of Ophthal­mology and Oto-Laryngology, August, 1924.

De Schweinitz, in his ninth edition, states that this operation is rarely done .after the fifteenth year, Fuchs states that it is indicated only in children and adolescents, while other authorities place the upper limit at the twenty-fifth year. However, Beard has suc­cessfully operated, by this method, after the forty-fifth year and Herman Knapp at the thirty-seventh. Edward Jackson, at the A. M . A. meeting in 1916, reported in detail a number of cases so operated over the age of twenty-five and, in his conclusions, stated "For monolateral cataract up to middle life discission is to be con­sidered as a proper procedure."

Since hearing Dr. Jackson's paper I have been encouraged to follow the conclusion, above quoted, with such good results that it has seemed worth while to place them on record with the hope that others may be encour-.Hged to employ the operation.

In general I follow the technic as advised by Jackson and Beard, the im­portant point being to make the needle puncture outside of clear cornea. In several recent cases I have combined, with the first needling, a Curran peripheral iridotomy in hopes that it would serve to lessen the pressure from undue swelling of the lens. I t has seemed to work out that way; al­tho the absence of such symptoms, in the few cases so operated, may have been merely coincidental.

In using this modification butyn anesthesia should be used, or the pupil contracted with eserin, as it is prac­tically impossible to perform the irid­otomy with the pupil dilated. The iridotomy is done first, then the needle is turned and the lens punctured to its center. Even more liberty may be taken and the lens cut freely. This was done in case five with complete absorption after one needling and no

washout required. In a number of older patients, where it has seemed worth while to secure a round pupil, I have done the Curran operation as a substitute both for a preliminary iridectomy and for the Chandler peri­pheral iridectomy. In those cases it was done as a preliminary operation. At the extraction there was no ten­dency of the lens to tear the small hole.

If further experience with the Cur-ran iridotomy should verify my idea, it could be combined with the Homer .Smith preparatory capsulotomy to pre­vent obliteration of the anterior cham­ber, which sometimes happens. I t would add to the convenience of this procedure by permitting a longer in­terval to elapse between the capsul­otomy and the extraction. Further­more it might extend the usefulness of discission to include all immature cataracts. In these the soft tor tex should absorb leaving only the nucleus to be removed, thru a relatively small and therefore safe incision.

The behavior of a case operated the day this is being written is the cause of the above suggestion. At the pre­liminary iridectomy the patient jerked at the moment of the incision, caus­ing the point of the keratome to punc­ture the lens thru the iris. At the extraction, seven days later, the lens was so soft and gummy that it had to be practically scooped out. Irrigation was necessary to remove it completely. Even the nucleus was mushy altho the man was well past sixty. Had I known the condition, the lens could have been removed thru a small incision, as in the washouts after discission.

Several years ago Dr. Jackson, in an editorial stated that a method of break­ing up the lens, so that it could be re­moved piecemeal thru a small incision, might finally prove to be the solution bf the cataract operative problem. If

54

DISCISSION OF LENS AFTER TWENTY-FIFTH YEAR 56

is barely possible that the above men­tioned procedure might gain that end, at least in the early immature cases. At any rate I intend to try it out on the next suitable case. I f successful the advantages of a simple extraction thru a small incision will be attained.

In order to save time the results in my thirteen cases will be given in a table appended hereto. I t will be noted that the object of the operation, a clear pupil, was secured in all cases and that the only ones with reduced vision had a definite cause, outside of the opera­tion, of which we were aware before operating.

I feel that this method should be thought of for all cases up to the forty-fifth year, possibly even later in im­mature cataracts. I have a woman un­der my care now who is blind in both eyes as a direct result of operations by the Smith-Indian method, when she was thirty-two years of age. There is

little doubt that she would have good sight in both eyes had discissions been done or, for that matter, anything but an intracapsular operation.

CONCLUSIONS.

Disadvantages. The only specific disadvantage is the duration of the treatment. This could be materially shortened by stirring the lens freely and doing a washout in all cases.

The advantages are: 1. Safety. 2. Simplicity. It can be done as an

office procedure from start to finish saving time, expense and absence from employment.

3. A better cosmetic result than any operation except a successful sim­ple extraction.

4. A visual result possibly better than that of a simple extraction be­cause of the absence of astigmatism.

TABLE OF CASES OF DISCISSION.

it

o

Η 28

30

fHigh J myopia

27 r Traumatic 38 <! cataracts 48 L

[Oongenital

I stellate

^Congenital

1 zonular

Premature senile cataracts.

31

38

38

47

13 47 12

« 2 S ε ε o υ

20 /30 Τ 20 /40 ι Pupillary region clear.

(fundus changes. 2 0 / 4 0 J

2 0 / 2 0 1 2 0 / 1 6 J-

Reduced vision due to myopic

2 0 / 2 0 J

2 0 / 1 6

2 0 / 1 6

2 0 / 1 5 0

2 0 / 4 0 J

2 0 / 1 6

20 /20

Pupillary region clear in all three.

^Pupi l lary regions clear.

Pupillary regions clear. Double partial optic atrophy, noted before operation, was the cause of reduced vision.

Pupillary region clear.

Pupillary region clear. Patient's misbehavior at washout prolonged it unduly, and resulted in moderate striped keratitis. Such behavic caused loss of the eye.

in an operation, might have

12 /70 Pupillary region and other media crystal clear. Macular degenerative changes, noted before operation, was cause of reduced vision. Developed, ' - i . -

•ith li severe iridocyclitis wi the pupil and finally of prolonged duration

during" an attack of flu, lypopion, resulting in blockage of

t i e pupil and finally requiring a scissors operation. ' ' of treatment.