Mat 1k
1869.]
SELECTIONS FROM OPHTHALMIC PRACTICE.?BY J. B. SCRIVEN.
ORIGINAL COMMUNICATIONS.
I.
?
SELECTIONS FROM OPHTHALMIC PRACTICE. By J. B.
Principal,
Sceivbn,
Lahore Medical School.
Among the numerous cases of eye disease that present, themselves at tho Medical school ihospital, it appears to me that a few are of sufficient interest to deserve a more public record than that of tho
hospital
case
book.
I have therefore selected, for the present communication, the following three cases of opacity of tho cornea, relieved by iridesis. 'l'his operation was devised by Mr. Crichett, more especially for those cases of central congenital cataract, in which great benefit was derived from dilatation of tho pupil with atropine. It consists in making a puncture, with a broad needle, in the sclerotic, just outside the margin of tho cornea, introducing either hook or forceps through a circle of Gne silk, previously laid < the conjunctiva, drawing out the pupillary margin of the T" s, and tying the silk tightly round it. The silk is prepared tliu ?? for tying in a half knot, and drawn tight upon the iris by an assistant, with two pairs of ciliary forceps. Tho result is a displaced pupil, tapering towards the ligature, where it terminates in a point. Such a pupil retains the orbicular fibres of the natural piipillary margin, so that, on exposure to light, it contracts, not indeed uniformly, but towards the fixed point. The advantage of thus retaining the natural pupil, instead of forming an artificial one, is considerable. An artificial pupil, in which the sphincter muscle does not exist, remains of one uniform size, in all variations of the light, so that, if large enough for a subdued light, the patient is dazzled in a bright one, and vice versa. A pupil displaced by iridesis, in affording an adaptation to the light, by its contraction and dilatntion, is but little inferior to
tho natural
pupil; and, independently of this, by retaining its concert with the ciliary muscle, in the accommodative action of the latter, contributes greatly to the excellence of vision. CASE
I.
Malieea, admitted March 12tli, 1868, aged 40 ; (Hospital Register XI, p. 42). Right eye blind, bare perception of light remaining. On the left eye there wag a leucoma of circular form, extending from the inner margin of the cornea to a little beyond its centre, thus leaving a crescent-shaped portion
the outer side. The man could not find his way about, nor recognise his friends. Vision was not altered by a dull or bright light. The small amount of vision that remained was for objects at his left 6ide, in which situation clear
on
he could count the fingers. After the application of atropine the pupil became well dilated, round, and regular, and he eould count the fingers in front of the eye. Iridesis was
chloroform, producing a conical pupil, extending downwards and outwards opposite the clear crescentshaped part of tho cornea. This man was discharged on the 10th of April, on which day I find the following notes :?" Can recognise people now, and can distinguish even their features, His sight is somewhat dazzled by a eyes, nose, mouth, &e. strong light; ho is obliged to bring objects uear, in order to see
performed,
under
them.
Is
a
carpenter, and says that he has got vision sufficient
for his work." CA8E
II.
male, aged 20, admitted May 17th, 1S13S ; (Hospital HegiBter XIII, p. 49). In the right eye this man had a small nebula, in the centre of the eornca, but a good active pupil behind, and tolerable risiou for uear objects. Aroorah,
a
Mahomedan
89
In the loft eye there was leucoma and synechia posterior. Witii this eye he could count the fingers, and make out the shape of tho letters of No. 8.J Snellen. The vision of this left eye was improved by tho instillation of atropine, which
broke down the synechia, and dilated the pupil evenly and well. On the 21st iridesis was performed in the loft eye, on tho outer side, under chloroform. The result was a conical pupil,
opposite
tho clear part of tho cornea, with its angle at the By this tho man's vision was much improved, and discharged on June 25th. I regret that tho improve-
puncture. lie
was
was not accurately ascertained by the test types. In tliis case, the pupil being widely dilated with atropine, it was found rather dillicult to catch the pupillary margin with tho canula forceps so near the puncture : tho operation, never-
ment
theless, succeeded very well, but the practical lesson to
operate again
011 an
eye under the influence of CASE
was
not
atropine.
III.
Ghaseota, aged 35; (Hospital Register XII, p. 172). A Mahoniedan male, admitted November 25th, 18G3. This man blind. There was louconia of both eyes. The both sides was thick and circular, about the size of pea; that of the loft oyo was at the lower part of the' cornea, of the right, at the lower and outer part. In a subdued light he could couut tho fingers with the left eye, but not
was
practically
opacity a split
on
with the right. After the instillation of
atropine, he could count tho fingers in the shade, and even in a strong light, with both eyes, and could see persons standing before him, but could not distinguish their features. The margin of the pupil, which previously, both in a strong light, was covored by the louconia 011 sides, now became visible on tho left side just above the
011 the right sido at its upper and innor margin. illumination it was discovered that tho lower half of the left iris was adherent to tho leucoma and immoveable, but the upper half free. There was 110 synechia in tho
leucoma, and
I3y oblique
right
eye, tho
pupil being
round and active.
Iridesis was performed on the right eye, on November 29th, the pupil being drawn downwards and inwards, opposite the clear portion of cornea. On the 14tli of December, an artificial pupil was made, the clear inner part of the cornea, in tho left eye, a bit of iris being seized with the iris forceps and cut off. The result is shown in the accompanying sketch.
opposite
0. 0.
Opacity. Opacity,
p. p.
Pupil, displaced
1, 1.
Point of ligature of of
in in artificial right eye, eye, artificial in in left. left.
the iris.
Eight eye. Bight eye.
Left eye. Left eye.
I had considerable difficulty in trying this man with the test Ho could not read, and lacked either the will or the intelligence to define carefully the shape of Snellen's figures,
types.
lie could
tinguish through
displaced
see all the objects around him, however, and dismany of their details. He recognised a tree, seen the window, as a poepul. The right eye, with the pupil, was decidedly the best, although there had
been more vision in the left before the operations. With the right eye he could make out certain figures, which were drawn for -him, i inch in diameter, at three inches distance; ho
could do the same with the left eye, though less perfectly ; at four feet distance made out No. 50 Snellen, though not very
accurately.
The reason of my
operating
on
this man's left eye
by iridec-
tomy, when iridesis had succeeded so well in the other, wuj that, in the left, the iris was partially adherent; u free pupillary inargiu is essential to the success of iridesis.
THE INDIAN MEDICAL GAZETTE.
90 In the three
foregoing
cases,
I used tlie canula
forceps
to
draw out the iris, as it is much more certain than the hook. In this operation, no blood gets into the anterior chamber ; a mere drop may escape externally from the puncture in the sclerotic. Almost no irritation is set up, and the ligature gene-
rally comes away, of itself, in a couple of days. Chloroform is absolutely necessary to secure the complete quietude of the patient. Marked improvement of vision, on dilatation of the pupil by atropine, may be taken as an index of its applicability, whether in congenital cataract, or in opacity of the cornea. Lahore, January 28th, 1869.
[May 1/"I860.
1869.]
SELECTIONS FROM OPHTHALMIC PRACTICE.?BY J. B. SCRIVEN.
ORIGINAL COMMUNICATIONS.
I.
?
SELECTIONS FROM OPHTHALMIC PRACTICE. By J. B.
Principal,
Sceivbn,
Lahore Medical School.
Among the numerous cases of eye disease that present, themselves at tho Medical school ihospital, it appears to me that a few are of sufficient interest to deserve a more public record than that of tho
hospital
case
book.
I have therefore selected, for the present communication, the following three cases of opacity of tho cornea, relieved by iridesis. 'l'his operation was devised by Mr. Crichett, more especially for those cases of central congenital cataract, in which great benefit was derived from dilatation of tho pupil with atropine. It consists in making a puncture, with a broad needle, in the sclerotic, just outside the margin of tho cornea, introducing either hook or forceps through a circle of Gne silk, previously laid < the conjunctiva, drawing out the pupillary margin of the T" s, and tying the silk tightly round it. The silk is prepared tliu ?? for tying in a half knot, and drawn tight upon the iris by an assistant, with two pairs of ciliary forceps. Tho result is a displaced pupil, tapering towards the ligature, where it terminates in a point. Such a pupil retains the orbicular fibres of the natural piipillary margin, so that, on exposure to light, it contracts, not indeed uniformly, but towards the fixed point. The advantage of thus retaining the natural pupil, instead of forming an artificial one, is considerable. An artificial pupil, in which the sphincter muscle does not exist, remains of one uniform size, in all variations of the light, so that, if large enough for a subdued light, the patient is dazzled in a bright one, and vice versa. A pupil displaced by iridesis, in affording an adaptation to the light, by its contraction and dilatntion, is but little inferior to
tho natural
pupil; and, independently of this, by retaining its concert with the ciliary muscle, in the accommodative action of the latter, contributes greatly to the excellence of vision. CASE
I.
Malieea, admitted March 12tli, 1868, aged 40 ; (Hospital Register XI, p. 42). Right eye blind, bare perception of light remaining. On the left eye there wag a leucoma of circular form, extending from the inner margin of the cornea to a little beyond its centre, thus leaving a crescent-shaped portion
the outer side. The man could not find his way about, nor recognise his friends. Vision was not altered by a dull or bright light. The small amount of vision that remained was for objects at his left 6ide, in which situation clear
on
he could count the fingers. After the application of atropine the pupil became well dilated, round, and regular, and he eould count the fingers in front of the eye. Iridesis was
chloroform, producing a conical pupil, extending downwards and outwards opposite the clear crescentshaped part of tho cornea. This man was discharged on the 10th of April, on which day I find the following notes :?" Can recognise people now, and can distinguish even their features, His sight is somewhat dazzled by a eyes, nose, mouth, &e. strong light; ho is obliged to bring objects uear, in order to see
performed,
under
them.
Is
a
carpenter, and says that he has got vision sufficient
for his work." CA8E
II.
male, aged 20, admitted May 17th, 1S13S ; (Hospital HegiBter XIII, p. 49). In the right eye this man had a small nebula, in the centre of the eornca, but a good active pupil behind, and tolerable risiou for uear objects. Aroorah,
a
Mahomedan
89
In the loft eye there was leucoma and synechia posterior. Witii this eye he could count the fingers, and make out the shape of tho letters of No. 8.J Snellen. The vision of this left eye was improved by tho instillation of atropine, which
broke down the synechia, and dilated the pupil evenly and well. On the 21st iridesis was performed in the loft eye, on tho outer side, under chloroform. The result was a conical pupil,
opposite
tho clear part of tho cornea, with its angle at the By this tho man's vision was much improved, and discharged on June 25th. I regret that tho improve-
puncture. lie
was
was not accurately ascertained by the test types. In tliis case, the pupil being widely dilated with atropine, it was found rather dillicult to catch the pupillary margin with tho canula forceps so near the puncture : tho operation, never-
ment
theless, succeeded very well, but the practical lesson to
operate again
011 an
eye under the influence of CASE
was
not
atropine.
III.
Ghaseota, aged 35; (Hospital Register XII, p. 172). A Mahoniedan male, admitted November 25th, 18G3. This man blind. There was louconia of both eyes. The both sides was thick and circular, about the size of pea; that of the loft oyo was at the lower part of the' cornea, of the right, at the lower and outer part. In a subdued light he could couut tho fingers with the left eye, but not
was
practically
opacity a split
on
with the right. After the instillation of
atropine, he could count tho fingers in the shade, and even in a strong light, with both eyes, and could see persons standing before him, but could not distinguish their features. The margin of the pupil, which previously, both in a strong light, was covored by the louconia 011 sides, now became visible on tho left side just above the
011 the right sido at its upper and innor margin. illumination it was discovered that tho lower half of the left iris was adherent to tho leucoma and immoveable, but the upper half free. There was 110 synechia in tho
leucoma, and
I3y oblique
right
eye, tho
pupil being
round and active.
Iridesis was performed on the right eye, on November 29th, the pupil being drawn downwards and inwards, opposite the clear portion of cornea. On the 14tli of December, an artificial pupil was made, the clear inner part of the cornea, in tho left eye, a bit of iris being seized with the iris forceps and cut off. The result is shown in the accompanying sketch.
opposite
0. 0.
Opacity. Opacity,
p. p.
Pupil, displaced
1, 1.
Point of ligature of of
in in artificial right eye, eye, artificial in in left. left.
the iris.
Eight eye. Bight eye.
Left eye. Left eye.
I had considerable difficulty in trying this man with the test Ho could not read, and lacked either the will or the intelligence to define carefully the shape of Snellen's figures,
types.
lie could
tinguish through
displaced
see all the objects around him, however, and dismany of their details. He recognised a tree, seen the window, as a poepul. The right eye, with the pupil, was decidedly the best, although there had
been more vision in the left before the operations. With the right eye he could make out certain figures, which were drawn for -him, i inch in diameter, at three inches distance; ho
could do the same with the left eye, though less perfectly ; at four feet distance made out No. 50 Snellen, though not very
accurately.
The reason of my
operating
on
this man's left eye
by iridec-
tomy, when iridesis had succeeded so well in the other, wuj that, in the left, the iris was partially adherent; u free pupillary inargiu is essential to the success of iridesis.
THE INDIAN MEDICAL GAZETTE.
90 In the three
foregoing
cases,
I used tlie canula
forceps
to
draw out the iris, as it is much more certain than the hook. In this operation, no blood gets into the anterior chamber ; a mere drop may escape externally from the puncture in the sclerotic. Almost no irritation is set up, and the ligature gene-
rally comes away, of itself, in a couple of days. Chloroform is absolutely necessary to secure the complete quietude of the patient. Marked improvement of vision, on dilatation of the pupil by atropine, may be taken as an index of its applicability, whether in congenital cataract, or in opacity of the cornea. Lahore, January 28th, 1869.
[May 1/"I860.
