SELECTIONS FROM OPHTHALMIC PRACTICE. By J. B. Scriven
.
Principal, Lahore Medical School.
Congenital Cataract.?The following three cases are, I think, recording: first, because congenital cataract, though by
worth
rare, is much less common than other forms; and because the variety about to be described seems to occur in England only in one eye. See Mr. Crichetts's paper in the Royal London Ophthalmic Hospital Reports of July 1861, page 188. If I be right in its identity, there certainly are exceptions to this rule in India, for, in these three cases, the cataract was in no
means
secondly,
both eyes,
CASE
I.
Deen, a healthy man, aged 22, (Hospital Register IV, page 357.) Up to the age of 16 his sight was sufficient for ordinary purposes, though, from his earliest childhood, he could not see minute objects, such as needles, letters, &c., distinctly, without squinting inwards with the left eye. About fiye years previous Ahmed
June 1, to
SELECTIONS FROM OPHTHALMIC PRACTICE.?BY J. B. SCRIVEN.
I860.]
admission,
be
began
to find bis vision
getting
worse:
when he
looked with the right eye, objects appeared double, though still distinctly defined. After about two and half months, objects be-
indistinct, the light of a candle appeared as if surrounded by stars, and, at last, the flame itself appeared as if divided into
camo
see any distinct line of demarcation between the sunshine and shade. The left eye began to fail at the same time as the other, but for about five months the effect was that, to see ininuto objects, he had to squint more and more. At the end of the five months, however, this eye also became dim, so that he could see the circumference of objects, but not their
stars, and ho could not
centres. "When admitted on April 9th, 1867, both pupils acted well to light, but were each occupied by a dense white cataract. "With
right eye he could see persons standing before him, but could not count the fingers: with the left eye he could count the fingers, and find his way about in the evening, though not in the day time. Both eyes were in a state of continual involuntary motion. There was no strabismus. When the pupils were dilated with atropine, he could count the fingers with the the
eye, but he denied that there was any improvement in the was now found to have a very imperfect perception of some Persian letters, equal in size to
right
left, with which, however, he
about XL. Snellen: to examine these he
brought them within three inches of the eye. The left eye was therefore the better of the two. The appearances, now that the pupils had been well dilated,
were
as
follows, copied nearly verbatim from the
m*
anterior capsulo which remained, I drew out with tho iris foceps. There was evidently no lenticular substance. No vitreous escaped. The pupil now remained perfectly clear. A little pain and irritation followed this operation, and was subdued by the same remedies as before. The corneal wound healed favourably. On tho 13th of July it is noted that this
perfect recognition of persons, with both eyes, tried Could distinguish tho individual features, but said there was a slight mistiness of the left eye. Tho involuntary movement of the eye balls remained, but nearly ceased when he looked at any object. With the right eyo he could read No. XX. Snellen at seven inches, with the left at five inches ; with No. 4 convex glasses ho could read the same typo at thirty-two inches, and ordinary Persian type at five inches and a half; for this purpose ho used the right eye, but when this was closed, read tho Persian typo man
had
a
separately.
with the left eyo at a three inches and a half.* lie was discharged on the 14th of July. IIo came again in November for u pair of spectacles, which I had procured for hi in from England. Poth pupils were quite clear, and the vision
as at tho tiino of his dischargo; tho involuntary movements of tho eye had greatly diminished. Thus the eye, which originally had least vision, became the best after operation, because, I imagine, tho pupil was central
continued
and intact. CASE
case-
Devee
II.
Dial, aged 24, (Hospital Register XIII, page 199.) on January 18th, 1869, on account of excessive
book :?The
admitted
circular
eyo with fluid, which rendered the very prominent, and had altered tho shape of the wholo eye-ball. This was of about six months' duration, but it was obvious that, in both eyes, there was a denso opaque capsule, occupying the inner half of each pupil. The depth of tho anterior chamber of tho left oyo was fully half an inch, and both iris and lens were tremulous. Tho right eye had a decided internal strabismus. It was found that thero was very little difference between the
right pupil was occupied by a dense, white, nearly body, which did not fill its entire area, but left a dark clearing around it: it was of a bluish white colour, the circumference being much more opaque than the centre, and a dense yellowish spot was observed just outside the centre, joining the
circumferential part. Beyond the white circular mass, very 6ne radiating lines could be seen, with concentrated light and a magnifying lens, extending from its margin into the clearing around it. The white body itself also appeared as if made up of radiating lines. The anterior chamber was very deep, probably from there being no
lenticular substance.
There
was no
perceptible
tremor of the
iris. The left pupil was occupied, at its upper and inner side, by dense ?white mass, becoming thinner and bluish at its upper part. A largo crescent of clear pupil was left below. Two a
small dense white fragments were seen somewhat anterior in position to the larger mass. The anterior chamber was as deep as on the other side, and the iris of this eye (left) was tremulous. On the 12th of April I operated on the right eye, under chloroform. Two shouldered needles were introduced through the cornea, and the opaque mass that occupied the
pupil was completely detached from its connexion. An opening was then made at the outer margin of the cornea, through which the canula forceps was introduced, and the membrane drawn out. Some small fragments remained, which were removed by a spoon. Considerable irritation followed, but, by the application of leeches, fomentations, and atropine, this gradually subsided, and he left the hospital, with considerably improved vision, on the 30th April, 1867. In May, 1868, he came again, with the view of having the left eye operated on. In this eye, as the opacity extended right up to the upper margin of the dilated pupil, and probably under the iris, I was afraid to adopt the same proceeding as in the other, lest I should fail to remove the whole of it. Chloroform having been administered, I therefore proceeded in the ordinary method of scoop extraction, making the upper section, about one-fourth of the circumference of the cornea, and removing a portion of iris; I then passed the point of the pricker round the opaque body, in order to separate it from its connexions, and afterwards introduced Bowman's scoop behind it; I was surprised to find that only the posterior capsule came away, the
distension of the left cornea
vision of the left and right eye.
lie could seo the hand in front
him, but could not count the fingers. Tho left (distenled eye) was slightly more misty than the right. He said that his vision had been the same as long as ho could remember, but ho now complained of pain and smarting in tho left eye, whioh induced him to como to hospital. Poth eyes were in a state of continual involuntary movement, and there was a good deal of photophobia, in consequence of which examination was exceedingly difficult.
of
A section of the cornea was made in tho left eye, with view of relieving tho tension, removing a portion of iris, extracting the cataract. Pleoding, however, came on from fundus of the eye a3 soon as tho section was completed, nothing further could bo done.
tho and tho
and
CASE III.
Allayar, aged 30, (Out-patient Pook,
March
6th, 1809).
Plind
from birth. With the
right eye ho could barely count tho fingers; with the left eye he could not do so. Had slight internal, strabisof one eyo, sometimes of the other. Eyeballs mus, sometimes
in
perpetual
motion.
Pupils
acted well.
with atropine, the following appearances The anterior chamber in both eyes
wero
On
dilating them
noted:?
was very deep. Tho cataract in the right eyo consisted of densely whito capsule, of tho area of the pupil, but leaving occupying the greater part below. This crescent was comparatively clear, a narrow crescent to have a thin membrane, like a bit of gauze, at one
yet appeared marked with* several small white specks. spot in its inner half,
? On examination by means of a prism, it was fouud that this not the power of binocular vision; and I learn that now ( March has a distinct external etmbismus of the left eye, the same eye to his own account, used to 9quint internally.
cording
had 31st) ha that, ac-
man
THE INDIAN MEDICAL GAZETTE.
112
The circumferential part of the capsule had the figure of a ring, which appeared to be of some thickness, as if formed by two layers of membrane. Immediately within this ring was a dark and nearly clear space, also forming a ring, the centre of which was occupied by a disk of perfectly opaque white membrane, that, at certain points, joined the outer capsular ring, across the clear circular space. [See the drawing.] Occasional slight tremor was noticed in this cataract. The anterior chamber in the left eye was equally deep, the cataract occupied the whole pupillary area, and appeared to consist of a dense white membrane, having a thicker part, like a bit of chalk, about one-eighth inch in diameter, extending from its centre up to the upper border. Altogether below this, and near the lower margin of the pupil, there was a slit in the membrane, passing across that part of the pupillary area, and turning up on both sides. Below this
appeared to be thicker than at other parts. impossible to find out how much this man's vision was improved by the atropine, as he was very unwilling to give any information on the subject, lest further treatment should be proposed?a proceeding to which he would not consent, believing that nothing could be done for a man that had been born blind. The following sketch, made at the time, will give some idea of the appearance of his eyes, after the instillation of atropine:? slit,
It
the membrane was
r^-y
iKJj Left eye. Eight eye. All these three eases liad the same kind of cataract, that is to say, membranous, with little or no lenticular substance; all had the same oscillation of the
depth cally
eyeballs,
of the anterior chamber.
and a
similar increased
Cases 2 and 3 had been
practi-
Case 1, Ahmed Deen, for the first 16 years of his life had tolerable vision, but there is no doubt that the disease was congenital in hiui as well as in the others. A very interesting question, however, arises here, viz., what was the condition of this man's eyes during these 16 years ? It certainly was not that which existed when he applied to me, for then he was practically blind; whereas, formerly, he could see
blind from birth.
sufficiently
conscious of
a
for
ordinary
defect; he
was
Nevertheless, he
purpjses.
obliged
was
u
squint" in order to this squinting gradually
to
examine minute objects. It appears that increased, and that he first became aware of positive disorder of vision in the right eye, by the occurrence of uniocular diplopia,
by division of the candle flame into stars, and, left, by a clouding of the centres of objects. This history suggests a central opacity in each lens, more dense in the left, accompanied possibly by some original deficiency, though not total absence of lenticular substance. In the total absence of lenticular substance, the man could scarcely have had the amount of vision which, he assured me, he possessed, and yet, when he was operated on, there certainly
followed in the
noue in either eye. It seems, therefore, most likely that a small central opacity existed from birth, and that it gradually increased, at the expense of the lenticular substance, till blindness was the result. A3 to the treatment of these cataracts, Ahmed Deert's case
was
illustrates it
pretty fully. The most essential point is complete removal, and that mode of procedure is the best, which most surely effects it. Any fragment that remains (and these cataracts have a great tendency to break up into fragments) certainly
sets up iritis of a very unmanageable kind. Whether the operation by the canula, forceps, or scoop extraction, therefore, should be adopted, depends upon the case, and ought to be well weighed hy the practitioner beforehand. Some of these patients probably have also imper-
fections ot the
retina,
so
that vision may
congenital
not
be as
good,
after
[June 1,
I860.
as the appearance of the organ might lead one to The doubt that must necessarily exist upon this point, as well as the difficult}*, or impossibility in some instances, of complete removal, suggests caution in prognosis.
operation,
expect.
Nevertheless, by scrupulous care in operating, and by energetic treatment of any after irritation, a useful amount of sight may be obtained in a fair proportion of the cases. I
.
Principal, Lahore Medical School.
Congenital Cataract.?The following three cases are, I think, recording: first, because congenital cataract, though by
worth
rare, is much less common than other forms; and because the variety about to be described seems to occur in England only in one eye. See Mr. Crichetts's paper in the Royal London Ophthalmic Hospital Reports of July 1861, page 188. If I be right in its identity, there certainly are exceptions to this rule in India, for, in these three cases, the cataract was in no
means
secondly,
both eyes,
CASE
I.
Deen, a healthy man, aged 22, (Hospital Register IV, page 357.) Up to the age of 16 his sight was sufficient for ordinary purposes, though, from his earliest childhood, he could not see minute objects, such as needles, letters, &c., distinctly, without squinting inwards with the left eye. About fiye years previous Ahmed
June 1, to
SELECTIONS FROM OPHTHALMIC PRACTICE.?BY J. B. SCRIVEN.
I860.]
admission,
be
began
to find bis vision
getting
worse:
when he
looked with the right eye, objects appeared double, though still distinctly defined. After about two and half months, objects be-
indistinct, the light of a candle appeared as if surrounded by stars, and, at last, the flame itself appeared as if divided into
camo
see any distinct line of demarcation between the sunshine and shade. The left eye began to fail at the same time as the other, but for about five months the effect was that, to see ininuto objects, he had to squint more and more. At the end of the five months, however, this eye also became dim, so that he could see the circumference of objects, but not their
stars, and ho could not
centres. "When admitted on April 9th, 1867, both pupils acted well to light, but were each occupied by a dense white cataract. "With
right eye he could see persons standing before him, but could not count the fingers: with the left eye he could count the fingers, and find his way about in the evening, though not in the day time. Both eyes were in a state of continual involuntary motion. There was no strabismus. When the pupils were dilated with atropine, he could count the fingers with the the
eye, but he denied that there was any improvement in the was now found to have a very imperfect perception of some Persian letters, equal in size to
right
left, with which, however, he
about XL. Snellen: to examine these he
brought them within three inches of the eye. The left eye was therefore the better of the two. The appearances, now that the pupils had been well dilated,
were
as
follows, copied nearly verbatim from the
m*
anterior capsulo which remained, I drew out with tho iris foceps. There was evidently no lenticular substance. No vitreous escaped. The pupil now remained perfectly clear. A little pain and irritation followed this operation, and was subdued by the same remedies as before. The corneal wound healed favourably. On tho 13th of July it is noted that this
perfect recognition of persons, with both eyes, tried Could distinguish tho individual features, but said there was a slight mistiness of the left eye. Tho involuntary movement of the eye balls remained, but nearly ceased when he looked at any object. With the right eyo he could read No. XX. Snellen at seven inches, with the left at five inches ; with No. 4 convex glasses ho could read the same typo at thirty-two inches, and ordinary Persian type at five inches and a half; for this purpose ho used the right eye, but when this was closed, read tho Persian typo man
had
a
separately.
with the left eyo at a three inches and a half.* lie was discharged on the 14th of July. IIo came again in November for u pair of spectacles, which I had procured for hi in from England. Poth pupils were quite clear, and the vision
as at tho tiino of his dischargo; tho involuntary movements of tho eye had greatly diminished. Thus the eye, which originally had least vision, became the best after operation, because, I imagine, tho pupil was central
continued
and intact. CASE
case-
Devee
II.
Dial, aged 24, (Hospital Register XIII, page 199.) on January 18th, 1869, on account of excessive
book :?The
admitted
circular
eyo with fluid, which rendered the very prominent, and had altered tho shape of the wholo eye-ball. This was of about six months' duration, but it was obvious that, in both eyes, there was a denso opaque capsule, occupying the inner half of each pupil. The depth of tho anterior chamber of tho left oyo was fully half an inch, and both iris and lens were tremulous. Tho right eye had a decided internal strabismus. It was found that thero was very little difference between the
right pupil was occupied by a dense, white, nearly body, which did not fill its entire area, but left a dark clearing around it: it was of a bluish white colour, the circumference being much more opaque than the centre, and a dense yellowish spot was observed just outside the centre, joining the
circumferential part. Beyond the white circular mass, very 6ne radiating lines could be seen, with concentrated light and a magnifying lens, extending from its margin into the clearing around it. The white body itself also appeared as if made up of radiating lines. The anterior chamber was very deep, probably from there being no
lenticular substance.
There
was no
perceptible
tremor of the
iris. The left pupil was occupied, at its upper and inner side, by dense ?white mass, becoming thinner and bluish at its upper part. A largo crescent of clear pupil was left below. Two a
small dense white fragments were seen somewhat anterior in position to the larger mass. The anterior chamber was as deep as on the other side, and the iris of this eye (left) was tremulous. On the 12th of April I operated on the right eye, under chloroform. Two shouldered needles were introduced through the cornea, and the opaque mass that occupied the
pupil was completely detached from its connexion. An opening was then made at the outer margin of the cornea, through which the canula forceps was introduced, and the membrane drawn out. Some small fragments remained, which were removed by a spoon. Considerable irritation followed, but, by the application of leeches, fomentations, and atropine, this gradually subsided, and he left the hospital, with considerably improved vision, on the 30th April, 1867. In May, 1868, he came again, with the view of having the left eye operated on. In this eye, as the opacity extended right up to the upper margin of the dilated pupil, and probably under the iris, I was afraid to adopt the same proceeding as in the other, lest I should fail to remove the whole of it. Chloroform having been administered, I therefore proceeded in the ordinary method of scoop extraction, making the upper section, about one-fourth of the circumference of the cornea, and removing a portion of iris; I then passed the point of the pricker round the opaque body, in order to separate it from its connexions, and afterwards introduced Bowman's scoop behind it; I was surprised to find that only the posterior capsule came away, the
distension of the left cornea
vision of the left and right eye.
lie could seo the hand in front
him, but could not count the fingers. Tho left (distenled eye) was slightly more misty than the right. He said that his vision had been the same as long as ho could remember, but ho now complained of pain and smarting in tho left eye, whioh induced him to como to hospital. Poth eyes were in a state of continual involuntary movement, and there was a good deal of photophobia, in consequence of which examination was exceedingly difficult.
of
A section of the cornea was made in tho left eye, with view of relieving tho tension, removing a portion of iris, extracting the cataract. Pleoding, however, came on from fundus of the eye a3 soon as tho section was completed, nothing further could bo done.
tho and tho
and
CASE III.
Allayar, aged 30, (Out-patient Pook,
March
6th, 1809).
Plind
from birth. With the
right eye ho could barely count tho fingers; with the left eye he could not do so. Had slight internal, strabisof one eyo, sometimes of the other. Eyeballs mus, sometimes
in
perpetual
motion.
Pupils
acted well.
with atropine, the following appearances The anterior chamber in both eyes
wero
On
dilating them
noted:?
was very deep. Tho cataract in the right eyo consisted of densely whito capsule, of tho area of the pupil, but leaving occupying the greater part below. This crescent was comparatively clear, a narrow crescent to have a thin membrane, like a bit of gauze, at one
yet appeared marked with* several small white specks. spot in its inner half,
? On examination by means of a prism, it was fouud that this not the power of binocular vision; and I learn that now ( March has a distinct external etmbismus of the left eye, the same eye to his own account, used to 9quint internally.
cording
had 31st) ha that, ac-
man
THE INDIAN MEDICAL GAZETTE.
112
The circumferential part of the capsule had the figure of a ring, which appeared to be of some thickness, as if formed by two layers of membrane. Immediately within this ring was a dark and nearly clear space, also forming a ring, the centre of which was occupied by a disk of perfectly opaque white membrane, that, at certain points, joined the outer capsular ring, across the clear circular space. [See the drawing.] Occasional slight tremor was noticed in this cataract. The anterior chamber in the left eye was equally deep, the cataract occupied the whole pupillary area, and appeared to consist of a dense white membrane, having a thicker part, like a bit of chalk, about one-eighth inch in diameter, extending from its centre up to the upper border. Altogether below this, and near the lower margin of the pupil, there was a slit in the membrane, passing across that part of the pupillary area, and turning up on both sides. Below this
appeared to be thicker than at other parts. impossible to find out how much this man's vision was improved by the atropine, as he was very unwilling to give any information on the subject, lest further treatment should be proposed?a proceeding to which he would not consent, believing that nothing could be done for a man that had been born blind. The following sketch, made at the time, will give some idea of the appearance of his eyes, after the instillation of atropine:? slit,
It
the membrane was
r^-y
iKJj Left eye. Eight eye. All these three eases liad the same kind of cataract, that is to say, membranous, with little or no lenticular substance; all had the same oscillation of the
depth cally
eyeballs,
of the anterior chamber.
and a
similar increased
Cases 2 and 3 had been
practi-
Case 1, Ahmed Deen, for the first 16 years of his life had tolerable vision, but there is no doubt that the disease was congenital in hiui as well as in the others. A very interesting question, however, arises here, viz., what was the condition of this man's eyes during these 16 years ? It certainly was not that which existed when he applied to me, for then he was practically blind; whereas, formerly, he could see
blind from birth.
sufficiently
conscious of
a
for
ordinary
defect; he
was
Nevertheless, he
purpjses.
obliged
was
u
squint" in order to this squinting gradually
to
examine minute objects. It appears that increased, and that he first became aware of positive disorder of vision in the right eye, by the occurrence of uniocular diplopia,
by division of the candle flame into stars, and, left, by a clouding of the centres of objects. This history suggests a central opacity in each lens, more dense in the left, accompanied possibly by some original deficiency, though not total absence of lenticular substance. In the total absence of lenticular substance, the man could scarcely have had the amount of vision which, he assured me, he possessed, and yet, when he was operated on, there certainly
followed in the
noue in either eye. It seems, therefore, most likely that a small central opacity existed from birth, and that it gradually increased, at the expense of the lenticular substance, till blindness was the result. A3 to the treatment of these cataracts, Ahmed Deert's case
was
illustrates it
pretty fully. The most essential point is complete removal, and that mode of procedure is the best, which most surely effects it. Any fragment that remains (and these cataracts have a great tendency to break up into fragments) certainly
sets up iritis of a very unmanageable kind. Whether the operation by the canula, forceps, or scoop extraction, therefore, should be adopted, depends upon the case, and ought to be well weighed hy the practitioner beforehand. Some of these patients probably have also imper-
fections ot the
retina,
so
that vision may
congenital
not
be as
good,
after
[June 1,
I860.
as the appearance of the organ might lead one to The doubt that must necessarily exist upon this point, as well as the difficult}*, or impossibility in some instances, of complete removal, suggests caution in prognosis.
operation,
expect.
Nevertheless, by scrupulous care in operating, and by energetic treatment of any after irritation, a useful amount of sight may be obtained in a fair proportion of the cases. I
