Operative Procedures in 
Corneal Lesions. 
BY C M. HOBBY, M. D., IOWA CITY. IA. 
Paper react before the Iowa State Medical Society 
January 26th, 1882. 
The introduction of myotics, into 
ophthalmic practice, lias so changed 
the methods of treatment of corneal 
lesions, that older expedients, which 
were proving their value, have been of 
late ignored to a considerable extentr 
or at least not utilized as frequently as 
they might have been with advantage. 
I refer especially to syndectomy, Hue- 
misch's operation of cutting through 
the base of certain forms of corneal 
ulcer, and paracentesis of the cornea. 
In cases of vascular pannus of long 
standing, where increase of tension is 
not present, to indicate other proceed- 
ures, the writer has found syndectomy 
of decided benefit. The only apparent 
reason for its neglect, is in the failure 
to secure good results from incomplete 
syndectoinies. To lie of value a zone of 
conjunctiva must he removed com- 
pletely around the cornea. Saemisch’e 
operation has more than answered my 
expectation, not] only in rodent ulcers, 
but also in those which are indolent, 
and where time was of great import- 
ance to the patient, I have not failed to 
resort to paracentesis of the cornea 
where large abscesses existed, although 
in common with the general profession- 
al experience, 1 have not found it as 
necessary in hypopiou as was formerly 
supposed 
The object of this paper is, more es- 
pecially, to call attention to those cor- 
neal lesions, which are associated with, 
and probably caused by, adhesions or 
the iris to the capsule, posterior syne- 
chia. It is unqestionably the fact that 
very many cases of iritis go unrecog- 
nized, and that in a considerable pro 
portion of those which are recognized posterior syneehiae result. The effect 
of these adhesions, in the great majority 
of cases, is to produce recurrences of 
iritis, ultimate exclusion of the pupil, 
and thus secondary (jlawuma. I am 
aware that the opinion of many oph- 
thalmic surgeons practicing in large 
centers of population runs counter to 
that of the surgeons of twenty-five 
years ago in this respect, and we meet 
with the assertion that adhesions of the 
iris, so long as they are limited to not 
more than one-fourth of the periphery 
of the pupil, and on one side, are 
not productive of mischief. In the 
larger cities, patients have opportuni- 
ties for the early recognition and skil- 
full treatment of iritis, which are want- 
ing in thinly settled districts; and from 
this reason, I believe, the proportion of 
cases of secondary or chronic iritis is 
less than it otherwise would lie. My 
experience would indicate that the ma- 
jority of cases of iritis are considered at 
first as cases of neuralgia, and I see 
many times more cases of iritic adhe- 
sion, than I do of simple primary iritis. 
It is in this class of cases, that I have 
encountered three varieties of corneal 
lesion, which have apparently resulted 
from the synechlae left by former iritis. 
As a rule, in all the forms the tension 
of the globe is increased, but in conse- 
quence of the haziness of the cornea, 
and capsular deposits, satisfactory oph- 
thalmoscopic examination is impossible. 
In the first form, the characteristic 
lesion has been, a circumscribed infil- 
tration of the cornea, preceded by in- 
tense supra orbital pain, and followed 
by tedious sloughing of the superficial 
layers, the gray bottomed ulcer event- 
ually becoming vascular, the process of 
repair accompanied by an encouraging 
relief from pain, only too soon to be 
broken in upon, by.a repetition of the 
process, with each attack the vascular 
pann us extending. 
The second variety was characterized 
by diffuse, deep, non-vaseular infiltra- 
tion of the cornea, extending from one 
side and gradually spreading over the 
cornea, in these cases also, paroxysms 
of supra-orbital neuralgia have occurred 
with greater or less periodicity, and 
with them each time peri-corneal injec- 
tion. The third variety has been character- 
ized by the occurrence of the so-called 
bullous keratitis. In all these cases, the 
recurrence of the attacks, the occasional! 
periodicity and the increased tension, 
indicate a process allied to the glau- 
comatous. If we accept Wccker's defini- 
tion of glaucoma, “ The expression of a 
disturbance of equilibrium betioeen secre 
tion and excretion, with increase in the con- 
tents of the eye and increased tensionit 
is a form of glaucoma, and in this class 
of cases it may either be due to the 
blocking up of tiie spaces of transuda- 
tion in consequence of chronic inflam- 
mation, or increased secretion in conse- 
quence of chronic congestion; and here 
is where, it seems to me, the danger 
from a single synechia, however small, 
exists. The constant demands for 
movement made upon the iris in 
changes of light and accommodation, 
are interfered with, the iris becomes 
irritable, and there results, if nothing 
jg'prse, a chronic congestion, ever 
ready to pour fluid into the chambers 
of the globe faster than it can be re- 
moved by natural processes. 
’ When complete exclusion of the pupil 
results., we have the iris itself pushed 
forward and blocking up the spaces of 
transudation. 
The indications tor treatment of cor- 
neal lesions depending upon synechia 
of the iris, arc these: First—In those 
cases where synechia exists without ex- 
clusion of the pupil: to release the iris 
from the strain caused by the adhesion. 
This can be accomplished by an iridec- 
tomy which shall destroy the integrity 
of the sphincter p upillae; the removal of 
the iris need not be broad, nor need it 
extend to the circumference, although 
if the tension were greatly increased 
it would be advisable to so extend it. 
Second - where complete exclusion of 
the pupil exists; the action of the sphinc- 
ter being already destroyed, to restore 
communication between the anterior 
mid posterior chambers, and to relieve 
the place of transudation This will re- 
quire a broad iridectomy extending to 
the corneal margin. It is very proba- 
ble that many of the failures to relieve 
the chain of morbid processes induced 
by posterior synechia, have been due 
either to attempts to break up adhesion* 
without cutting the iris, or where iridec- 
tomy was made, to adhesions of the iris- 
in the corneal wound. This last can, 
as a rule, be prevented by the use of 
Eserine.