The Indian operation of couching for cataract

by Robert Henry Elliot

A further light is thrown on the above figures by a study of the table showing the duration of vision after couching. Of the 45 successful cases, 23 of them, or more than 50 per cent., had been couched less than two years before; 9 more had been couched between two and three years, and 11 from three to ten years. In two this detail was unmarked. The great preponderance of short histories in the cases of successful operation is significant.

Against the vaidyans’ figures we may place the statistics of the Madras Hospital, even so long ago as 1903, and before a rigid system of antisepsis had been introduced. Recoveries numbered 96 per cent., poor results 2 per cent., and failures 2 per cent. These figures would indicate that the coucher was losing 60 per cent. more eyes than the hospital did even then. If the vast number of eyes submitted to couching be taken into account, this 60 per cent. of avoidable loss totals up to a staggering figure. Nor must we disregard the fact that, even amongst the successes, the average vision obtained is greatly in favour of the Western surgeon.

The table showing the causes of failure will repay a careful study. The figure for iritis and iridocyclitis comes to 35·76 per cent. of the total number of cases; glaucoma accounts for 11·05 per cent., imperfect dislocation of the lens for 8·94 per cent., retinal detachment for 3·53 per cent., optic atrophy (including one case of optic neuritis supervening as a septic complication of the operation) for 2·59 per cent., retinitis pigmentosa and retinitis punctata albescens for 0·49 per cent., retinochoroiditis for 1·41 per cent., vitreous opacities (admittedly a very vague term) for 1·18 per cent., and failure due to operation on a congenitally imperfect eye for 0·23 per cent.; 3·53 per cent. are, unfortunately, unaccounted for owing to deficiencies in the notes.

In the great majority of cases ruined by iridocyclitis the inflammation made its appearance within a few days after operation; but there were instances in which this complication was delayed for a long period. Our notes show three cases in which it came on from one and a half to three years after operation, one case after seven years, and one after ten years. There are also a few doubtful cases in which a history of three or four months of useful vision preceded the inflammatory attack. In one case at least, sympathetic ophthalmia would appear to have destroyed the other eye two years after operation.

Similarly, it was found in most cases of glaucoma that the access of high tension came on within a few days of operation. There were six exceptions to this rule, three commencing from two to ten months after the couching, one five years, one six years, and one fourteen years after. From a clinical point of view, the cause of the onset of glaucoma in these cases is obscure. Many of them appear to be associated with iridocyclitis, but we must leave this matter for the present. We shall have occasion to deal with it much more fully under the heading of pathology.

Imperfect dislocation of the lens accounted for failure in 8·94 per cent. of all cases operated on. In such cases the suspensory ligament appeared to have been incompletely torn, with the result that the lens swung, as it were, on a hinge. Sometimes this hinge lies above, and the cataract falls quite out of the line of sight when the patient is recumbent, but flaps back to block the pupil when the erect attitude is assumed. In other cases, even when the hinge is laterally placed, the same thing may happen, but much more rarely.

From a clinical point of view, detachment of the retina figures in only 3·53 per cent. of the total cases; but it is unlikely that this represents the true figure. In a number of instances an ophthalmoscopic examination was quite impossible, either because the pupil was blocked, or because no fundus reflex could be obtained. Our pathological material has shown that in many such cases the retina was totally detached, whereas, in arriving at the figure above given, we were dealing only with those instances in which the diagnosis was established by the aid of the ophthalmoscope.

Ten of the cases in which failure was ascribed to optic atrophy showed no improvement in vision after operation. Their histories indicate that the atrophic condition was present before operation, and there seems to be a fair presumption that the coucher mistook the condition for cataract, or at least failed to recognise its true nature. In one case acute optic neuritis appears to have supervened as a septic complication of the operation. This throws an interesting light on those pathological specimens in which a cone of exudate is to be seen passing from an inflamed optic nerve to the ciliary body.

In six cases there was evidence of choroido-retinitis with secondary optic atrophy. Four of them showed no improvement after operation, whilst two were improved thereby; subsequently even these two lost their vision by the progress of the retinitis. In the four cases the retinitic condition was evidently antecedent to the operation, and was either mistaken for cataract or at least was not recognised. It is impossible to say positively, from the history of the other two, whether it existed prior to operation, but it possibly did.

In one case of retinitis pigmentosa, in one of retinitis punctata albescens, and in eleven of glaucoma, the vaidyan appears to have mistaken the condition present for cataract. At least, the vision was not bettered even temporarily by the operation in any of these patients.