A System of Operative Surgery, Volume 4 (of 4)

by Unknown

As little manipulation as possible should be carried out when once the vitreous has shown itself about to present, and unless the iris be obviously in the wound no attempt should be made to replace it.

Loss of vitreous may be the result of subchoroidal hæmorrhage, which may only make itself manifest after the patient has been put back to bed.

Loss of vitreous is frequently accompanied by hæmorrhage into the vitreous, as is seen subsequently by the floating opacities therein. As a rule these clear, and useful vision is obtained.

Detachment of the retina may follow loss of vitreous even months after operation. This complication seems more liable to occur if the vitreous which is lost in the first instance be normal and not of the fluid type.

6. Intra-ocular hæmorrhage (see Glaucoma Iridectomy, [p. 224]).

Remote. 1. Panophthalmitis is a result of infection of the wound. It usually makes its appearance about the third day and must be treated by evisceration. Occasionally the purulent material is limited to the line of the incision or even to the anterior chamber; in the latter instance the wound should be opened up and the anterior chamber washed out with peroxide of hydrogen solution (10 vols. %). Microscopic examination of the pus should be made and a vaccine prepared and administered; in two cases so treated by the author a good recovery resulted.

2. Escape of the aqueous beneath the conjunctiva usually occurs about the third day, owing to the conjunctival wound having healed without the opening into the globe being properly shut off. This is accompanied by considerable pain, with chemosis and some œdema of the upper lid. It is usually distinguishable from acute iritis by the pupil being evenly dilated and discoloration of the iris being absent. The condition usually subsides in three or four days, when the wound in the globe has become shut off.

3. Acute iritis not infrequently occurs after extraction. It usually comes on about the third day and may be accompanied by hypopyon. It may settle down under atropine, leeching, and dry heat, but may also pass on into the more chronic form; adhesion of the iris to the capsule, however, frequently results. More rarely the disease may not make its appearance till two or three weeks after the operation (latent sepsis), the patient suffering from recurring attacks of hypopyon. In these cases in which the hypopyon persists, washing out the anterior chamber with peroxide of hydrogen (10 vols. %) and the administration of a vaccine is of service.

4. Chronic irido-cyclitis is usually primary, but may occasionally follow an acute attack of iritis. Of all the disastrous complications, this is by far the worst. It may not only destroy the sight of the eye on which the operation has been performed, but may set up sympathetic ophthalmia in the other eye. The eye does not settle down well after the operation, there being usually some prolapse of the iris or capsule into the wound. It remains injected or flushes up on exposure to light. After a time (usually about the end of the third week) keratitis punctata makes its appearance, and the tension of the eye may become decreased or occasionally increased. The disease may resolve or go on to shrinking of the globe. Energetic treatment with atropine and hot fomentations locally, with the internal administration of iron, is indicated. The administration of staphylococcus vaccine causes only temporary improvement in most instances. In six cases so treated by the author the improvement was only temporary, in spite of the fact that there was a definite local reaction to the vaccine and in two cases the staphylococcus albus was isolated from the fluid in the anterior chamber. If at the end of two months the eye be red and well-marked keratitis punctata be present, and if the pupil be beginning to be drawn up and the eye shows no tendency to improve, enucleation should be seriously considered; this is especially advisable if the projection of light has become defective, showing that the retina is probably detached. If any signs of sympathetic irritation, such as mistiness of vision, ciliary flush, or photophobia, appear in the eye which has not been operated on, the exciting eye should be enucleated. On the other hand, if well-marked inflammation has developed in the sympathizing eye, which may also be cataractous, and the other eye has a fair amount of vision, it becomes extremely questionable whether it is advisable to enucleate the exciting eye. Every case must be judged on its own merits according to the extent and severity of the disease. In a few cases in which the incarceration of the capsule in the wound leads to a very chronic cyclitis, its division with a cutting needle will sometimes lead to subsidence of the inflammation. It is most important that every eye that has been operated on should be examined for the presence of keratitis punctata, especially before allowing the patient to use the eye or before another operation is performed on it.