SOME PROBLEMS ENCOUNTERED IN CATARACT SURGERY*

WATSON W. GAILEY, M.D.Bloomington, Illinois

The preliminary studies in cataractsurgery are fully as important as theoperation itself. Before operating it isquite necessary that one should have atleast some notion as to what the endresult might be.

The methods now employed to deter­mine in advance the amount of vision thatmight be expected after operation arenot entirely reliable. It is, of course,important to know the degree of projec­tion for both white and red in all fields.The following test for retinal integrityhas been found to be quite reliable, exceptin cases of dense hypermature cataracts.Two small ophthalmoscopic lights areheld one meter from the eye under ex­amination. The patient is told to fixateon the one light directly ahead and isasked to locate the other light by pointing.The second light is moved into all por­tions of the field. This test passed success­fully makes the surgeon confident of ob­taining a good visual result. after opera­tion--except, of course, in cases of acci­dents or severe complications.

The history of poor vision before theonset of the cataract is reasonable proofof intraocular disease and indicates a poorprognosis for good vision. One must beon the alert in the preliminary study, forcataract frequently complicates glaucoma,detachment of the retina, and choroiditis.An illustration of the visual possibilitiesafter cataract extraction in a case of in­ternal strabismus with amblyopia exanopsia in the squinting eye was observedin a 70-year-old man who had had aninternal strabismus in the right eye sincechildhood. He also had a mature cataract

*Read before the Chicago OphthalmologicalSociety, on December 20, 1937.

855

in this eye, the left eye being similarlyinvolved, with vision of 20/80. The pa­tient disapproved having the maturecataract extracted, for he maintained thatthe vision in this eye had always beenextremely poor. An intracapsular extrac­tion, however, gave him a vision of20/200 which very rapidly rose to 20/20within a period of six months.

Any suggestion of uncompensatedcardiac disease, chronic bronchitis, bron­chiectasis, asthma, hypertrophy of theprostate, hemorrhoids, chronic constipa­tion, high blood pressure, infected teeth,or diabetes should be thoroughly investi­gated and every effort made to rectifysuch conditions before the ocular opera­tion is attempted. Inquiry concerningcough is important. Intraocular tensionshould always be taken. In the writer'sopinion some calamitous cases in his earlypractice could be laid at the door of aglaucoma simplex which was not de­tected prior to operation.

Experience gained in India has ledhim to doubt the possibility of septicteeth having any bearing on inflammatorycomplications following cataract extrac­tion. In hundreds of cases, in practicallyall of which there were septic mouths,no infections occurred. On the otherhand, the patients may have had a highdegree of resistance, or they may have at­tained a secure degree of immunity.

The writer has accepted 185 as themaximum safe systolic pressure for cata­ract surgery.

A complication that all ophthalmolo­gists fear in hypertension is expulsivehemorrhage, or at least a serious late in­traocular hemorrhage. Six expulsivehemorrhages have come into the writer's

856 WATSON W. GAILEY

experience, three of them occurring inone morning five years ago in India; one,four years ago; and the last two have"taken place since June of this year. Nota very pleasant record to reflect upon!In each instance, the blood pressure waslow for the patient's age, well below 185.It has been estimated that the incidenceof expulsive hemorrhage is one in onethousand operations.

In cases of extreme hypertension, theusual methods for reducing-such asrest in bed, the use of sedatives, and mag­nesium sulphate-are put into operation,and in cases resisting these measures,blood-letting is resorted to one hour be­fore operation. Intraocular hypertensionmay perhaps be as great a factor inhemorrhage as arterial hypertension.

Studies with the slitlamp give consider­able information concerning the condi­tion of a cataractous lens and are worthwhile to the surgeon, particularly in thematter of planning which type of extrac­tion shall be attempted.

Patients with diabetic-cataract andsenile cataract with diabetes are hospital­ized for preliminary study by an internist.

On account of the possibility of hemor­rhage, Benedict suggests that since theuse of insulin is conducive to hemorrhage,this medication be discontinued for atleast four weeks before extraction isattempted. However, in checking overpersonal files it does not appear that thereis a greater percentage of hemorrhagesin patients who have been treated withinsulin over those who have had sugarreduction by diet. Unquestionably, thereis greater liability to postoperative iritisand iridocyclitis among diabetic patientsregardless of the methods used in pre­paring the patient for extraction. A traceof albumin is not a contraindication for acataract extraction.

Among cases that present technicalsurgical difficulties are those in which

there is a very shallow anterior chamber.If patients of this character do not haveintraocular hypertension, a Kuhnt flapshould be made first, then a small sectionwhich is enlarged with scissors, and ex­traction of the lens by the capsulotomymethod. Second, are the intumescentcataracts which probably would resistany and all efforts at extraction with cap­sule forceps. These are ideal cases forthe use of the erisiphake, provided thatthe zonule is not too unyielding and thatthere is no posterior-segment bulging fol­lowing section. The same may be said ofthe cataracts having the mother-of-pearlsheen. Third, the small eye is a difficultone on which to operate, but it will befound that rotating this type of eye out­ward with fixation on the internal rectuswill make the section a much easier pro­cedure.

Cases of high myopia with nuclearcataracts and nuclear cataracts with dearposterior cortex should be approachedwith great caution. They are very difficultto clear of cortical matter. In both ofthese types, a preliminary discission withextraction after 24 or 48 hours has yieldednone too good results in the writer'shands.

The writer admits that the Wasser­mann test is not routine in his cataractpractice. Clapp states that postoperativecomplications are more frequent in thepresence of latent syphilis and that heal­ing may be just as rapid in a person withsyphilis as in a normal person free fromaU complications.

The lacrimal sac, if infected, presentsa problem which must be dealt with effec­tively-by excision.

The question of bacterial culturesarises at this point in the discussion.Prior to 1930, cultures were the rule inthe writer's practice. Having followed allthe rules of procedure in a rather limitedpractice, he grew to expect an infection

CATARACT SURGERY 857

every two years. Since 1930, he has dis­carded preoperative bacterial tests andhas been so fortunate as to escape with­out a single exogenous infection. Atabout the time bacterial cultures were dis­continued, preliminary scrubbing of theskin and irrigation of the conjunctival sacwere also discarded, and the questionarises as to which of these two changeshas been responsible for this freedomfrom infection. Since he is not sure, thewriter will make no further changes inthis technique, much as he likes to ex­periment. It should be added, however,that the use of the face mask and rubbergloves has been routine in his surgerysince that time, and may, perhaps, ac­count for this excellent record.

The next problem facing the surgeonis as to the period in the development ofa senile cataract when the patient shouldbe advised that an extraction is indicated.There can be no cut-and-dried ruling, forone must consider the age, visual acuity,physical status, prejudices, and the occu­pation of his patient before determiningthis point. It is a rule with the writerto refrain from advising an operation un­til that time when the patient is thor­oughly unhappy over his plight regard­less of the amount of his vision. It issaid that a vision of 20/70 or worse issufficient excuse for advising cataractextraction. The unhappiness of the pa­tient is a better standard. For instance,if the bookworm can no longer read, orif the worker finds he cannot do his workwith any degree of satisfaction to him­self or employer, then it is high time thathe should be advised to resort to surgery.

What should be done toward prepar­ing the patient for operation? Attention,of course, is given to the lacrimal pas­sages. Some surgeons employ foreignproteins several days prior to the opera­tion. Typhoid H antigen has been givenby some who think it is worth while.

Cleansing of the conjunctiva and the useof antiseptics several days prior to opera­tion is the routine of a great many sur­geons. The writer's only preparation is apad of cotton saturated with an acridinedye kept on the eye twelve hours beforeoperation. No preoperative purgatives ofany kind are administered.

Adequate measures are taken to con­trol a chronic cough. Nervousness ofvarying degree is controlled by propermedication, and nembutal and luminalhave been found to give the best results.Under no circumstances is morphineused. Incidentally, it is a great help inmany cases to employ nembutal for aslong as one week after the operation hasbeen performed. The various drugs usedfor dilatation of the pupil prior to opera­tion are scopolamine, euphthalmine,homatropine, and atropine. Having triedthem all, the writer favors euphthalmine-a S-percent solution, 1 drop everyfifteen minutes for four instillations; thefirst drop to be given two hours beforethe operation is scheduled.

It is well to know before sending thepatient to the hospital whether or not thepupil can be dilated successfully, and nobetter drug than euphthalmine has beenfound, to determine the presence of irisrigidity or posterior synechiae.

At what age should the intracapsularoperation be supplanted by the extracap­sular method? The majority of surgeonsdo not attempt an intracapsular extrac­tion in patients under 50 years of age.It is surprising to find that many patientsunder that age have friable zonules thatpermit of rather easy intracapsular de­livery. On the other hand, it is equallysurprising to find that in many over sixtyyears of age zonular resistance has beengreat. Hence the rule has been followedto attempt (with care) to extract intra­capsularly all lenses in patients over fortyyears of age.

858 WATSON W. GAILEY

The selection of cases for intracapsularor extracapsular extraction is based uponthe principle of considering all cases assuitable for intracapsular extraction withthe exception of: those complicated byhigh blood pressure or extreme excitabil­ity in the patient; asthmatic patients withchronic cough; those having enlargedprostates, rigid pupils, highly myopiceyes, bulging eyes, glaucoma, and lastlythose with morgagnian cataracts.

Intumescent lenses or smooth capsulesoffer no contraindication to intracapsularextraction, for the erisiphake can be usedsuccessfully in these types.

Nor should a one-eyed patient fall intothe extracapsular class if there are noother contraindications. If a one-eyed pa­tient is not proper material for intracap­sular extraction, the operation should bediscarded.

Success in using the extracapsularmethod in eyes which have suffered oldinflammation, such as recurrent iritiswith adhesions, have not been very greatin number; but such cases have been suc­cessfully handled as a whole when an in­tracapsular extraction has been per­formed ..

Certain conditions present in each in­dividual case determine the method ofsurgical attack, but even so the right tochange the method is reserved after thesection is made. In other words, theophthalmic surgeon should approachevery case with an absolutely open mindand be prepared to shift his attack as theoccasion demands. For instance, one mayfeel that the case in hand is ideal for theperformance of an intracapsular extrac­tion with a round pupil as an end result.However, after the section is made, onemay find a thrusting forward of the pos­terior segment, the patient may be ner­vous, or there may be a tense smoothcapsule which was not in evidence in thepreliminary examination, or a small,

round, rigid pupil. Anyone of these con­ditions may serve as an indication for achange of method.

According to Wright, the preparationof the field of operation is largely a pose,and this writer is inclined to agree withhim. Provided the lashes are clean andthe conjunctiva contains no visible secre­tion, it is rather useless and perhapsharmful to scrub the skin and lashes andto irrigate the conjunctival sac.

To paint the skin of the forehead, lids,cheek, and temple with a solution ofmetaphen, may be somewhat of an affec­tation. It is important, however, to besure that the instruments used within theeye are not contaminated by touching theskin or lashes. It is probable that a greatmany of the old cases of panophthalmitishad their origin in the failure to protectthe eye being operated on from the res­piratory blasts of the operator, assistant,and patient.

The use of rubber gloves in cataractsurgery is a step forward in intraocularsurgery.

Great progress has been made in thelast few years in the matter of anesthesiapreparatory to eye surgery. The writer'smethod has been to use cocaine-4percent every two minutes for six instilla­tions-care being taken to compress thelacrimal sac, thereby preventing the so­lution from seeping through into thenasopharynx. This occurrence might rea­sonably be suspected as a possible causeof postoperative nausea and vomiting.After the last drop of cocaine has beeninstilled the O'Brien method of akinesiais employed. Very few failures have beenexperienced with this method, but whenthey do occur, recourse may be had to theVan Lint procedure. Retrobulbar anes­thesia is employed, 2 C.c. of 4-percentnovocaine solution being used. The injec­tion is made in the lower cul-de-sac, hug­ging the eyeball closely, making the

CATARACT SURGERY 859

injection into the cone anteriorly-thusavoiding the entrance point of the retinalartery. This method of injection is of im­portance, for one is less likely to injureone of the orbital vessels.

One reads of retrobulbar hemorrhages,but this complication may be avoided byusing the technique advocated by HarveyCushing in his brain surgery-namely, toinject very slowly ahead of the advanceof the tip of the needle. This procedurehas been followed for years and not asingle case of retrobulbar hemorrhagehas been encountered; which, after all,proves nothing.

Eight minutes are allowed to elapsebefore the introduction of the speculum.A superior-rectus suture is used in allcases, care being taken to get firmly intothe muscle and not to include a large foldof conjunctiva.

Several instillations of adrenalin havealways been given just before making thesection and the thought has recently pre­sented itself that the use of this drugmay encourage secondary hemorrhageinto the anterior chamber. It is said thatthe normal iris does not bleed.

One or two drops of adrenalin havebeen injected subconjunctivally at the6-0'clock position for the purpose ofmaintaining dilation after the section hasbeen made. The procedure has been help­ful but by no means infallible.

Fixation may be made at the 6-0'clockposition or slightly below the point ofintended counterpuncture with either con­junctival or scleral fixation forceps. Allmanner of forceps, both single anddouble, have been used, but a fine-toothedscleral fixation forceps such as Elschnig'sor O'Brien's, when properly applied hasgiven the best results. One should bethoroughly convinced that the scleralfixation forceps will maintain its grip be­fore the puncture is made, for there isnothing more exasperating than inade-

quate fixation. Fixation forceps shouldbe given the same affectionate care thatone gives to his knives.

Much has been said about the nervousor jittery patient, but very little is saidabout the jittery surgeon. If the same­sized dose of nembutal were administeredto the surgeon as to the patient, manycataract extractions might prove to becalmer procedures.

Control of the eye in case of a con­junctival tear or failure at fixation maybe maintained by grasping the superior­rectus muscle with fixation forceps andcompleting the incision. This procedure,however, is a very difficult one, and aboutthe time one becomes proficient in thetechnique, he finds he has no further usefor this method.

The incision in the bulging eye is aneasy procedure, but one approaches thistype of eye with considerable misgivingas to what will follow the incision. Thedeep-set eye is another type, and acanthotomy may well be performed inall of these cases, for it makes the sectionso much easier.

In the making of sections, one of thegreatest errors is in making the counter­puncture too deep, and to avoid this com­plication the tip of the knife should notbe allowed to disappear from view beforemaking the counterpuncture. When pre­mature loss of aqueous from the anteriorchamber occurs, leaving a flat eye withthe iris in position to be fouled, one ofseveral procedures may be followed. Ifthe incision is well on its way, it is wiseto withdraw and finish with the scissors.A second measure is to withdraw and re­fill the anterior chamber, select a smallerknife, and proceed with the section. Athird method which has been employedsuccessfully, is to fill the anterior cham­ber with the knife blade still in position,by having the assistant apply the tip ofthe irrigator to the flat surface of the

860 WATSON W. GAILEY

blade, and refill before proceeding withthe section. In case the knife is insertedupside down, the blade should be with­drawn, the anterior chamber refilled, andthe section then finished with a smallerblade.

For good healing, a proper conjunc­tival flap is paramount. A small flap isfully as good as, or better than, a largeone, and there is much less likelihood ofa complicating hemorrhage. A 2-mm. flaplaterally, and a 3- or 4-mm. flap at theapex is quite ideal, but is not always ob­tainable.

Blood in the anterior chamber follow­ing section is not a serious complication;it can be dealt with by the simple methodof irrigation. Seldom does one encounterhemorrhage that can not be controlled,even in diabetics. At any rate, one mustbe sure that the anterior chamber is clearbefore introducing the capsule forceps.

The immediate presentation of vitreousfollowing the completion of the sectionis a complication that requires instantcalm action. The writer's procedure hasbeen first to lift the speculum carefullyand remove it as gingerly as possible;next, to apply a conjunctival suture ortwo; and lastly, with the careful use ofa wire loop, to extract the lens-and thensay a prayer.

No method known to the writer willcounteract the contraction of the pupilwhich occasionally follows the emptyingof the anterior chamber after the sectionis made.

Among ophthalmic surgeons there areadvocates of full iridectomy, iridotomy,double iridotomy, peripheral iridectomy,and double peripheral iridectomy. In ad­dition there are those who advise makingthe iridectomy after the lens has beendelivered. A small peripheral iridectomy,either single or double, before extractionof the lens is advocated.

As to sutures, any suture is better thannone. Conjunctival sutures, even six orseven, are inadequate. It would seem thatclosure of the deep wound is the propersolution. Various types of corneoscleralsutures have been tried, but none hasbeen found that is easy of application andat all times pleasing. The difficulty maybe in not adhering to one technique longenough to grow really proficient in it. Afirm, secure corneoscleral suture properlyapplied-a peripheral iridectomy-reallyperipheral-and followed by injection ofan air bubble into the anterior chamber,should avoid prolapse of the iris in manyinstances. It might not be amiss, at thispoint, to make the observation that pro­lapse of the iris is not confined to theround-pupil cases. Perhaps the prolapsesoccurring in full iridectomy extractionsdo not prove to be so annoying as thosewhich complicate round-pupil operations,but they seem to occur all too frequently.This makes the supposition almost a cer­tainty that the sudden release of aqueousis responsible for many prolapses. Pro­lapse of the iris immediately followingthe section is annoying, particularly so ifone's efforts at repositioning prove futile.A single or double peripheral iridectomyat this stage often relieves this tense sit­uation. This complication is indicative ofa moderate thrusting forward of the pos­terior segment and the surgeon is wiseif he is on the alert, for vitreous presen­tation is quite prone to follow extraction.

In cases of late prolapse of the irisattempts to replace an iris with a curvedspatula slid under the conjunctival flaphave been anything but satisfactory.Some authors report having obtainedgood results by employing this procedurefollowed by the use of eserine. Perhapsthe poor results were due to selecting thewrong time or perhaps the technique wasat fault.

CATARACT SURGERY 861

The problem of prolapse of the iris isnot so often how it should be repairedbut when it should be given attention.Unfortunately, prolapses seem to growin size and bulbousness as time elapses.Despite this, the writer's best results inrepair have been accomplished after theeye is white. It may be that this involvestoo much waiting. For the larger varietya Kuhnt flap is dissected back, the pro­lapse excised, the wound touched lightlywith a cautery point and closed with thisconjunctival flap. For the small knuckles,very good results have been obtained byusing the late Dr. Harold Gifford'strichloracetic cauterization procedure.This method is painless if one waits un­til the sclera is white. It may be queriedwhether the desire to secure a roundpupil is not for the purpose of ticklingsurgical vanity rather than to excludeexcessive light; to make pretty eyes atthe risk of occasioning the patient somedistress and perhaps delivering to him aneye not so useful as it might have been.

A rigid pupil may be found to becaused by an atrophic iris or by a com­plete posterior synechia of the pupillaryborder or again by a mid-peripheral ad­hesion of the iris to the lens. In thesecases it is well to perform a full iridec­tomy and to follow this with a very.care­ful separation of the iris from the lenswith a thin spatula. If the pupil is foundto be free and rigid because only of itsatrophic state, dividing the iris with ablunt deWecker scissors at the 6-o'clockposition has proved a method which per­mitted successful delivery.

As to the application of the capsuleforceps, it is well to grasp the lens aslow down as possible. Just how muchcapsule bite to take is a question for theindividual operator to decide for himselfin each case. Either too large or too smalla bite is conducive to rupture of the cap­sule. Capsule forceps require as tender

care as do fixation forceps. As to howmuch pull and how much push thereshould be in intracapsular extraction,these factors must also be determined atthe time of operation by gauging theamount of resistance encountered. Thewriter employs much pushing and verylittle pulling; that is, using the grasp onthe lens as a leader and his strabismushook as a pusher, he simply guides thelens in its tumbling process upward andoutward. Tearing of the capsule, ofcourse, complicates matters, and it is agreat comfort to have a Fisher needle athand ready to spear the lens in case thiscomplication should occur.

It is a good rule in both extracapsularand intracapsular attempts if the capsuleis ruptured to inspect carefully the anglesof the wound for any signs of capsule re­mains. Irrigation is very valuable in re­moving cortical remnants and the Hil­dreth lamp, clumsy as it is to manipulate,is of great help in determining the pres­ence of cortical matter and tags of cap­sule. The writer has never had the temer­ity to enter the anterior chamber withforceps for the purpose of removingfragments of cortex.

In performing an extracapsular cata­ract extraction, there can be no argumentconcerning the use of the multiple sharp­toothed capsule forceps, care being takento remove as large a segment of the an­terior capsule as is possible in order toleave a large central gap.

In the intumescent type of cataract anerisiphake may be used, if after the sec­tion is made there are no signs of push­ing forward of the posterior segment.

Incidentally, Dr. Barraquer told thewriter a number of years ago that oneof the dangers often spoken of in con­nection with the extraction of the cata­ractous lens by the erisiphake was thepossibility of sucking up the entire liquidcontent of the globe. This, he explained,

862 WATSON W. GAILEY

was impossible if the corneal flap wasturned back and if a cotton-wound ap­plicator was applied to the anterior sur­face of the lens in order to determine thepresence of vitreous; if there was novitreous present, the extraction of thelens with the erisiphake was withoutdanger.

An eye having a shallow anteriorchamber may show a slight increase intension-perhaps only a relative one-inwhich case it is well to perform a decom­pression operation first or a capsulotomyoperation with a broad deep iridectomy.

A cataract extraction in an eye that haspreviously been trephined should holdno fears for the surgeon. Proceed regu­larly, performing a broad iridectomy. Itis .not necessary to make elaborate con­junctival flaps and no serious complica­tions have ensued in these cases.

Some surgeons speak of a collapsedcornea following section as they wouldof a calamity. This state often follows awell-made retrobulbar injection. Thisoccurrence seems to the writer to be arather happy one when it does take placein his practice.

Immediate needling of the posteriorcapsule after extraction is a practice tobe deplored, for it permits a herniationof the vitreous body into the anteriorchamber.

Particularly in diabetics, slow restora­tion of the anterior chamber is not un­common. This complication may be at­tributed to a jagged incision or to a poor­ly coapted wound or perhaps to frag­ments of the capsule lying in either angle.In several cases which persisted beyondthe tenth day removal of the bandagebrought about immediate filling of thechamber with aqueous.

Unquestionably diabetics are moreliable to hemorrhage, and it is equallytrue that a section made with a largeconjunctival flap or bridge may be com-

plicated by excessive bleeding. Adrenalinshould be employed sparingly in prepara­tion for cataract extraction, for it is rea­sonable to assume that it might be a fac­tor in the etiology of postoperativehemorrhage. Most secondary hemor­rhages occur on the fifth day. Just whythey select this day to appear, is notclear. The use of the bedpan might besuspected as the cause of some secondaryhemorrhages as well as of a great manycases of iris prolapse. Great stress hasbeen laid on the avoidance of any strainor exertion of any kind such as turningin bed. Great importance has been giventhe proper posture of the patient whohas undergone cataract extraction. Theposture fear, is probably overdone, andpatients in the writer's practice are beinggiven more and more liberty. At leastthe majority of us have graduated fromfixing the head with sand bags. On twooccasions, however, it has been seriouslyregretted that the patient's hands werenot tied during sleeping hours.

A great many remedies are recom­mended to hasten the absorption of asmall amount of blood in the anteriorchamber, all of which have been triedfrom time to time; in recent years, how­ever, it has seemed better to refrain fromany of these hastening methods, for ithas been found that blood will becomeabsorbed without help. Why irritate thepatient with dionin, heat, or other reme­dies when absorption will occur in prac­tically all instances regardless of treat­ment?

If the hemorrhage is of such amountthat one is worried as to the possibilityof ultimate absorption, it is best to openthe chamber, irrigate, or remove the clotwith forceps. In early cases, dionin isnot used because of the possibility ofmaking the patient sneeze.

It is rather distressing when one findsthat a quiet hemorrhage into the pos-

CATARACT SURGERY 863

terior segment has occurred during con­valescence. This complication, in thewriter's practice, has terminated sometimes well and some times disastrously.

It is doubtful whether benefits are de­rived from subconjunctival injection ofnormal salt solution and the use ofdionin, but they are nevertheless alwaysemployed empirically. Just how benefi­cial they are, it is not easy to say, but itis felt that some measures to promoteabsorption should be used whether or notthere is proof of their efficacy. Diathermyhas been used by some surgeons and, itis claimed, with good effect.

The use of eserine in extracapsularcataract extraction is somewhat on theorder of jumping out of the pathway ofa bicycle to be hit by a tank, for wheneserine is used after round-pupil, extra­capsular extraction there may followentanglement of the iris in cortical mat­ter, and it may become quite difficult todilate the pupil should an iritis ensue.

In his practice the writer has never ex­perienced vomiting by the patient at thetime of operation. In recent months, ifnausea occurs following operation, eventhough it be of the slightest degree, tendrops of dilute hydrochloric acid aregiven on the assumption that most elderlypeople are afflicted with hypochlorhydria.This controls nausea with astonishingeffectiveness.

Surgeons differ widely as to how oftenthe operated-on eye should be dressed.After many trials of different procedures,it has been found that the patient is notharmed and that the surgeon is in betterposition to detect complicating disturb­ances early, to say nothing of maintain­ing peace of mind, if he makes dailydressings.

It has been some years since the writerhas had a case of postoperative mania.This might be explained by the fact that1e does not bandage the unoperated-on

eye for more than 24 hours and quiterecently he has graduated to the pointwhere no covering is made on the un­operated-on eye from the very beginning.

Pain in the operated-on eye is fortu­nately not a frequent symptom, but whenit does occur, it is, in most instances,inexplicable. Pain, however, does war­rant inspection. I f nothing serious isfound at this time, ernpirin compoundusually affords immediate relief.

Backache has been a more frequentsymptom than eyeache, This conditionoccurs more frequently among females,because they are swaybacked and the re­laxation that occurs under sedatives on ahard operating table tends to produceneuralgic symptoms in the muscles of thelumbar region. This discomfort is oftenavoided by furnishing an adequate sup­port both on the operating table and afterthe patient is returned to bed. Backacheis often caused by an accumulation ofgas in the lower bowel. Local heat andmassage are usually effective, but it isoften necessary to resort to a colon tubeif there is distension as well. .

Atropine is an invaluable drug, butlike all good things its application issometimes overdone. Careful postopera­tive administration of this drug is invalu­able, but one should be cautious to useno more than is absolutely necessary. Ifone is desirous of having a dilated pupil,gauge carefully the strength and amountof the solution or ointment to be used, forit is only too easy to render the patienthypersensitive to this drug, which in itselfis a most undesirable complication.

The novocaine-tumor problem may bedismissed with the statement that theseare caused by the use of old solutions andthat they seldom require removal.

Spastic entropion following cataractextraction is an annoying occurrence.When it does happen, it is well to resortimmediately to the Zeigler method of

864 WATSON W. GAILEY

cauterizing the lower lid. This complica­tion is quite prone to produce other moredisastrous ones.

Postoperative iritis and iridocyclitisare disturbing complications. Intravenousinjections of typhoid paratyphoid A andB mixed vaccine give the surgeon ameasurable foreign protein.

The Cordes method has been used, ofgiving five million the first day, seventhe second, nine on the third, and ten onthe fourth. Some authors advise startingwith 25 million, but the dosages describedby Cordes are very effective. Large dosesof salicylates are used routinely in thesecases.

The relief of postoperative detachmentof the retina has not been good in thewriter's hands. Tears were located inmost of the cases, but efforts at repairhave been fruitless.

How long to keep the eye covered andprotected by a shield is sometimes verydifficult to determine. The difference inopinion on this point among eye surgeonsis great. It has been found comfortingto continue dressings through the four­teenth day and to continue the wearingof the Fox aluminum shield at night foran additional week.

The writer has had no experience inperforming early needlings, for he hasalways preferred to wait for a white eye.As to the best methods to employ, thisshould depend upon the type of case athand, but in any instance the surgeonshould use the method or methods givinghim the best results. For very dense mern-.branes, a keratome may be employed to

open the globe and a Noyes scissors fordividing the membrane. For the lessdense membrane-but tough, notwith­standing-the Duggan method is effec­tive; for thin membrane, the ordinaryclassic method of discission, using aknife needle. In all cases there shouldbe as little trauma as possible, and drag­ging on the iris or ciliary body must beavoided. For this reason, the Dugganmethod of discission is preferred; par­ticularly in those cases in which it isprobable that more than average resist­ance will be encountered to efforts atsplitting the membrane.

Aftercataracts of the inflammatorytype should be given plenty of time togrow quiet and white before discission isattempted.

Postoperative glaucoma occurs all toofrequently and one should be continuallyon the look-out for this complication. Itshould be the first thing to come to mindin any case in which there is loss ofvision. For the correction of this type ofocular hypertension, better results havebeen secured with cyclodialysis than withany other procedure.

The writer has set the tenth day as anarbitrary time for his cataract patientsto go home, yet he has never outgrownthe dread of seeing them go home on thetenth day, particularly so, if the eye isnot white.

Even though we are provided with allmodern methods, problems seem to lurkat every twist and turn of the surgeon'spathway and serious complications occurall too frequently.