ILLUSTRATIVE CASES.

I will briefly cite a few examples of the V-shaped operation, two that were my first efforts, and two that were recent cases. They were all of the class that are often abandoned as hopeless; hence the visual result is far below the operative success.

Case 1.—History.—F. M., aged 65 years. O. D. complete membranous occlusion of pupil from iridocyclitis, following cataract extraction. The iris and capsule are tensely drawn up toward the ciliary border. Light perception and projection good. Several efforts have been made to incise the membrane, but without success. Admitted to Wills Hospital by the late Dr. Goodman, through whose courtesy I operated.

Operation.—On Jan. 15, 1889, I made two long incisions, almost crucial, and extending beyond the apex of the V, resulting in a W-shaped pupil, on account of the stiff iris membrane (Fig. [42]). With S. + 10 D. he saw 20/50.

Case 2.—History.—J. S., aged 30 years. O. S. injured and enucleated. O. D. sympathetic inflammation, chorioidal cataract; three discissions and one iridectomy, down and in. Membranous occlusion of pupil. I first saw him in 1888 while house surgeon at the Wills Hospital, where iridotomy was skilfully performed nine times by one of the surgeons, the methods being varied and ingenious, but without success, as the incision was invariably closed by plastic exudate. My interest in this series of operations first drew my attention to the subject of iridotomy, and stimulated me to develop the method I have here submitted and which I first tried in Case 1.

One year later this patient came to my clinic at St. Joseph’s Hospital. Iris was discolored, capsule thickened and visible through the coloboma, down and in; areas of scleral thinning, with pigmented chorioid showing through. T—3. Light perception good, projection only fair.

Operation.—On June 17, 1889, I made a V-shaped iridotomy along the outlines of the former iridectomy. The membrane freely opened up into a triangular or pear-shaped pupil (Fig. 43), which proved permanent, but was only useful for quantitative vision, about 5/200. No further test could be made because the disorganized vitreous was filled with floating masses. I have seen him within a year, going about and earning his living. From an operative standpoint I have always considered this early effort one of my most successful cases, chiefly because of the great density of the iris-membrane and the lowered tension of the eyeball.

Fig. 43, (Case 2).—Iridotomy in a soft eyeball, with dense iris-membrane.

Case 3.—History.—Mrs. A. D., aged 45 years. O. D. iridectomy for glaucoma seven years ago. O. S. iridectomy two years ago by another surgeon, at which time there occurred slight incarceration of iris, followed by sympathetic ophthalmitis in O. D. The severe iridochorioiditis resulted in cataract and some shrinkage of globe. The cataracts were extracted from both eyes in 1907, followed by dense opacity of cornea above, iris bombé, shallow anterior chamber, T—2. Here was a soft, distensible, iris tissue with shallow anterior chamber and greatly lowered tension of the eyeball, constituting one of the most difficult conditions to operate on.

Operation.—On May 13, 1907, the eyes being quiet, and light perception and projection fair, V-shaped iridotomy was performed on both eyes. The leucomatous areas in the upper part of cornea necessitated making the pupil below. In O. D. the pupil opened up beautifully (Fig. [44]), but in O. S. a tag of iris hung fast (Fig. [45]) and was again incised two months later. The artist has illustrated the remaining portion of this tag very well. As soon as the iris tissue was incised it retracted, making the pupils larger than the area of incision. The test for glasses, nearly a year later, March 15, 1908, yielded the following result:

O. D. S + 13 D ⁐ C + 4.75 D ax. 105° = 20/40.
O. D. S + 13 D ⁐ C + 3 D ax. 65° = 20/40.

Add

O. D. S + 4 D = J. 10.
O. S. S + 4 D = J. 10.

These were ordered in biconvex torics. She had worn glasses for a year, but claims vision is much better with the new ones. This seems like an excellent result when we consider that these eyes had passed through glaucoma, iridochorioiditis and cataract, followed by membranous occlusion of pupil, lowered tension and fluid vitreous. The high hyperopia and astigmatism show the phthisical condition of each globe. There is marked cupping of both nerve heads and the fields are contracted.

Fig. 44, (Case 3).—Iridotomy in a soft eyeball, with thin mem­brane and iris bombé.

Fig. 45, (Case 3).—Iridotomy showing apex of iris flap after in­ci­sion through adherent fi­bers.

Case 4.—History.—Mrs. B. M., aged 64 years. O. S. struck by a stone in childhood, destroying vision. Dense leucoma above, chorioidal cataract, calcareous deposit; exclusion of pupil. T—1. Lpc. good. Lpj. fair. O. D. recurrent attacks of inflammation for seven years, posterior synechiæ and cataract. Counts fingers at 6 inches. Extraction with iridectomy, both eyes, in 1907. Site of incision has become densely leucomatous. O. D. shows capsular area above, iris drawn up. O. S. complete membranous occlusion of pupil.

Operation.—Oct. 7, 1907, V-shaped incision was executed entirely in the iris tissue of O. D., the pupil spreading out into an ovoid shape (Fig. [46]), leaving area of capsule and small band of iris above. O. S. was operated on Jan, 13, 1908, by the same method, the resulting pupil being almost round (Fig. [47]) owing to the resilient iris tissue.

The test for glasses, March 10, 1908, gave the following result:

O. D. S + 12 D ⁐ C + 1.25 D ax. 135° = 20/50.
O. S. S + 12 D ⁐ C + 1.25 D ax. 135° = 20/70.

Add

O. D. S + 5 D = J. 6.
O. S. S + 5 D = J. 12.

These were ordered in biconvex torics, which she now wears with great comfort. It is worth noting that O. S. still retained good visual acuity, although blinded by an injury nearly fifty years before.

Fig. 46, (Case 4).—Irido-cap­sul­otomy, with band of iris, and capsule in coloboma above.

Fig. 47, (Case 4).—Iridotomy with round central pupil in a resilient iris-membrane.