The Indian operation of couching for cataract

by Robert Henry Elliot

Fig. 20 (No. 119).—Right eye, upper half.

Fig. 21 (No. 46).—Left eye, lower half.

When we come to speak of the changes found in the vitreous, we shall have occasion to refer to the frequency with which the hyaloid body is represented by a shrunken cone with its apex at the optic nerve and its base in the neighbourhood of the ora serrata. This form, which is well known to pathologists, is due to the anatomical attachments of the vitreous body, and to the fact that the latter undergoes shrinkage after being thickened and opacified by the presence of inflammatory exudate. In studying the present collection, one cannot fail to be struck with the fact that the exudate, which fixes, or helps to fix, the lens in its pathologic position, is one with, and part of, this cone-shaped new formation. Before leaving the consideration of this group, we must once again point out that no hard-and-fast line separates it from the preceding one, and that intermediate links between the two can easily be pointed to.

In 11 globes, dislocated cataracts were found matted between the iris and ciliary body in front and the completely detached retina behind. It is very difficult to say what the nature of the original cataracts was, since all that one can now find is a nucleus, usually rather dark-coloured, imbedded in a mass of inflammatory tissue (Pl. III., Fig. [19]). These nuclei are undergoing steady reduction in bulk as the result of phagocytic action. In 7 of the 11, the lens remnants lie either within the complete capsule or in its near neighbourhood. The interior of the capsule is usually found to have been invaded by the mass of inflammatory and organising tissue which mats together all the structures (i.e., the iris, the ciliary body, the remains of the lens, and the detached retina), and which occludes the angle of the anterior chamber. The completeness of the dislocation varies greatly. In some cases the lens is hardly moved from its usual position, and lies in front of the anterior hyaloid membrane, whilst in others it is displaced into the vitreous cavity. In one instance the detachment of the retina and the inflammatory changes are sharply limited to the lateral half of the eye towards which the cataract was dislocated, but this case belongs more to the next group than to the one we are now discussing.

There are three outstanding and very important features common to these cases: (1) In the great majority of them there is evidence that the operation was followed by severe iridocyclitis; (2) 9 of the 11 were shrinking eyes with low tension; and (3) the time which had intervened between the couching and the enucleation was between one and two years in every case save one, in which it is probable that the furnished statement of three months was inaccurate. It will be noticed that the histories are much shorter than those in the previous group. This, together with the other two points mentioned, indicates that we have to deal with a condition widely different from that in any of the previous groups. Here the inflammatory process had been induced by a septic infection of the eyes of a decidedly more virulent character, though it fell short of that acme of infectivity, which leads in so many cases of the Indian operation to panophthalmitis and destruction of the globe within a few weeks.

We come next to a group of 5 cases, which have one feature in common—viz., that the cataract, though dislocated backwards, lies distinctly in front of the anterior hyaloid membrane, and therefore outside the vitreous cavity (Pl. III., Figs. [20] and 21). In 3 of them the solid parts of the lenses have been pushed back from their original position in such a way that they act like wedges, forcibly keeping the anterior hyaloid membrane in a plane posterior to that which it would normally occupy. Out of these 5 cataracts 4 were cortico-nuclear; the fifth was too much altered for it to be possible to state what its nature was. In certainly 4 out of the 5 moderately severe iridocyclitis had followed the couching, but the exudative process was a much less severe one than that which characterised the specimens of the previous group. The consequence was that there was no such matting of all the parts concerned as is there seen. In every case the detachment of the retina was complete or nearly so, but in not one was the lens enwrapped in its folds. This we may attribute to two causes: (1) a merely contributory one, that the vitreous cavity was not invaded; and (2) that the infection was less virulent, and the inflammation consequently less severe, than in the members of the previous group.

There is a small group of 3 cases in which the remains of the lens lie in situ in the periphery of the capsule, whilst the central portion has disappeared. These resemble the peripheral after-cataracts not infrequently seen following the extraction of a not fully mature lens.

In conclusion we have to mention 2 specimens in which the condition found was so unusual that it would scarcely have been possible to have anticipated its occurrence.

The first of these was one of the earliest globes sectioned. A Morgagnian lens, entire in its capsule, was found thrust behind the retina. It lay against the scleral coat close to the ciliary body; it had detached the retina over a large area in the neighbourhood of the ora serrata, and had led to a complete separation of it on that (the nasal) half of the eye. The edge of the detached retina had contracted adhesions to the front of the lens capsule, and was much puckered in that neighbourhood, doubtless as the result of cicatrisation.