History of Iridotomy / Knife-Needle vs. Scissors—Description of Author's V-Shaped Method

by S. Lewis Ziegler

Fig. 14.—Occlusion of pupil (Walton).

Fig. 15. New pupil after incision with iris-knife (Walton).

During the following seventeen years no notable advance was made, the scissors method still retaining its hold on the profession, until in 1869, von Graefe, after long reflection, became convinced of the dangers of that method, and communicated to one of his pupils, M. Meyer, his method of simple iridotomy performed with the knife-needle. Meyer[19] quotes his views as follows:

“For such cases von Graefe has suggested another method of operation, the principle and execution of which are contained in the following note written for us by that illustrious savant in 1869:

“When, in consequence of a cataract operation, the lens is absent, and when there is highly developed retro-iritic exudation, with disorganization of the iris tissue, flattening of the cornea and the other sequelæ of a destructive iridocyclitis, I substitute simple iridotomy for iridectomy, which is the operation hitherto performed, generally without success. The operation consists in inserting a double-edged knife, resembling in shape a very sharp pointed lance-knife, through the cornea and newly formed tissues till it pierces the vitreous body, and immediately withdrawing it; and, while withdrawing it, enlarging the wound in the membranes without increasing the size of the corneal wound. Experience shows that such plastic membranes attached to the atrophied iris and to the capsule of the lens have a tendency to contract sufficient to maintain, to a certain extent, the opening which has been made.

“If, in the ordinary method of iridectomy, combined with laceration or extraction of the false membranes, we find that the artificial pupil usually becomes closed, we must attribute this to an excessive vulnerability, which immediately sets up proliferation in those tissues which have been touched, and which are endowed, in consequence on their structure, with an irritability altogether peculiar. We know that even the transitory reduction of the intraocular pressure, which follows the evacuation of the aqueous humor, is sufficient to give rise to hemorrhage in the anterior chamber, which interferes with the perfect success of the intended operation; but most of our failures in the ordinary methods are due to the irritation caused by the forceps and the traction on the surrounding structures. Simple iridotomy is free from such inconveniences; it is, so to speak, a sub-corneal act, and enjoys the immunity which belongs to subcutaneous operations.

“I have also reduced the corneal wound to a minimum, by using small falciform knives. These are passed through the false membranes, which are then cut from behind forward.”

Von Graefe thus proposed two methods, (1) by cutting from before backward with a double-edged lance-knife, according to the method of Heuermann, and (2) by cutting from behind forward with a sickle-shaped knife, after the original suggestion of Cheselden. Later in the same year, as he lay on his last bed of illness, he became so absorbed in the study of this subject that he sent a telegram to the Heidelberg Congress[20] (September, 1869), in which he advocated the method by the sickle-shaped knife-needle as the best procedure. His last message to his colleagues showed, therefore, that through mature conviction he strongly favored the use of the knife-needle, and the making of a sub-corneal incision in the iris-membrane without evacuating the aqueous humor. His untimely death, however, prevented him from further perfecting this procedure and presenting it to the profession.

Galezowski,[21] in 1875, published a somewhat similar method in which he used his falciform knife, aiguille-a-serpette (Fig. [16]), which he introduced through the cornea and iris-membrane, making either a horizontal or a vertical incision, with a “go-and-come” (sawing) movement, after the suggestion of Adams. If this single cut was not sufficient, he made a linear incision of the cornea with a Graefe knife, drew out the iris and cut it off with scissors. By a process of evolution, however, he perfected the former procedure and eliminated the scissors. This latter method was published in the third edition of his book in 1888. He punctured the cornea and iris-membrane with the sickle-shaped knife, making first a horizontal incision by the sawing movement of Adams, and finishing with a second cut in the vertical direction, thus forming a T-shaped incision. In actual practice, however, he almost always prolonged this second cut, thus making a crucial incision after the manner of Guérin.[12]