REPORT 
OF 
Four Operations for the Removal of 
Cataract without an Iridectomy, and 
by an entirely New Method, 
WITH THE 
Discussion before the Clinical Society of the 
New York Post-Graduate Medical School, 
May 21, 1887'.' 
By FRANCIS VALK, M. D., 
Lecturer on Diseases of the Eye, New York Post Graduate College. 
NEW YORK: 
Press of M. J. Rooney, .1327 Broadway, New York. "REPORT OF FOUR OPERATIONS FOR THE REMOVAL 
OF CATARACTS, WITHOUT AN IRIDECTOMY, 
AND BY AN ENTIRELY NEW METHOD."* 
BY FRANCIS VALK, M. D. , 
Lecturer on Diseases of the Eye, New York Post-Graduate College. 
Mr. President and Gentlemen : 
Since the days of the old flap operation for mature senile cataracts, 
there have been many changes in the method of performing this most 
important and capital operation in all eye surgery. Amongst these 
changes, it seems to me, there have been but two principal objects to be 
attained that would make the operation for cataract perfectly successful 
and complete. By this I mean that if we had some method by which 
we could successfully remove the lens in its capsule and without an iridec- 
tomy. That such an object will ever be attained, remains for the results 
of the ingenuity and experience of the ophthalmologist, but I do not 
think that, up to the present time, any one has succeeded in an opera- 
tion that will accomplish these results and at the same time command 
the confidence of other operators. 
If we quickly review the work that has been done in the past, we 
must first turn to the simple flap operation, which consists of the section 
of the cornea, laceration of the lens capsule, and forcible expression of 
the cataractous lens. 
In this operation we accomplish part of the desired end, that is, no 
iridectomy is performed, but its disadvantages present themselves in the 
forcible expulsion of the lens through the section, carrying the iris with 
it, being doubled backwards on itself, rendering it liable to be more or 
ss Read before the Clinical Society of the New York Post-Graduate Medical 
School, May 21 st, 1887. 2 
less bruised in the passage of the lens, or to become caught in the angles 
of the section, or if not, so prolapsed, that it is difficult and sometimes 
impossible to return the iris to its normal position. 
For these reasons I think this operation was almost totally abandoned 
until about one year ago, and for several years the operation called 
"Von Graefe's modified" was almost universally performed. This 
operation was as follows : Using Von Graefe's narrow-bladed knife, the 
section was made wholly in the corneal tissue, with probably a con- 
junctival flap, and followed by a broad iridectomy, then laceration of 
the lens capsule with the cystotome, and, lastly, expression of the lens 
with the spoon or fingers. 
This has been the favorite operation for several years past by most 
surgeons in this country, though several eminent men have attempted to 
change or modify the operation, for the reason that, although an iridec- 
tomy was supposed to lessen the dangers of any consecutive inflamma- 
tion, and at the same time remove an impediment to the easy exit of the 
lens, yet an iridectomy was not io be desired, for the reasons that it would 
admit too much light, that it disfigures the eye, and that in the removal 
of a portion of the iris, that membrane was apt to be caught in the 
wound or injured by the instruments. Galezowski endeavored to obviate 
this in his operation, by which he lacerated the capsule with the point of 
Von Graefe's knife, while the iris is dilated with atropine and before he 
makes the counter-puncture, then with a large section he forces the lens 
outwards. But this method has the same objections as the old flap opera- 
tion, which will also apply to the later operation of Prof. D. B. St. John 
Roosa, of New York City, in which, without a laceration of the anterior 
capsule, he dislocates the lens in its fossa with the back of the knife, 
after the section of the cornea is partially completed, and then by pressure 
with the spoon or fingers, forces the lens through a large section made in 
the cornea. 
While each of these operations may have certain advantages, and 
sometimes the results are excellent and all that could be desired, yet at 
other times they will partially fail, either in the loss of vitreous, or pro- 
lapse and entanglement of the iris, leaving a disfigured eye; it has there- 
fore occurred to me that some method might be devised by which we 
could at least perform this operation without an iridectomy, and with 
little, if any, violence being done to the eye, or to the iris itself; as if 
we could place the iris in the same position as if an iridectomy had been per- 
formed, and holding it there until the lens passes outwards, we can allow 3 
it to return to its normal position-we would at least gain one of the 
objects most to be desired. 
It is for the purpose of gaining an uninjured iris, and at the same time 
the advantages of the iridectomy, that I have devised a small instrument, 
that seems to me will "quickly, safely and judiciously" assist us in the 
extraction of all cataracts, without an iridectomy, an operation which I 
will endeavor to describe, and one that I have successfully performed 
four times, as the accompanying report of these cases will show, and, as I 
believe, a method that will commend itself to others who desire to safely 
perform this most important operation without any disfigurement of the 
eye. 
Before speaking of the successive steps of this operation, I will describe 
this new instrument, which I propose to call an Iris Retractor, made for 
me by Mr. Ford, of Hazard, Hazard & Co. This is shaped like a pair 
of iris forceps, about the same size, but with the action crossed, so that 
the instrument can be firmly held when opened and in use; at the 
centre is a small screw, to regulate the distance between the blades when 
opened and holding back the iris. Each blade terminates in a blunt, 
rounded extremity, perfectly smooth, and passing at right angles to the 
blades, turning directly downwards when the instrument is in position. 
In using this little retractor, it is to be held lightly in the left hand, 
or if the operator is ambidexter, it may be held in either hand to suit the 
section and the position of the operator ; then pass the ends of the blades, 
closed, through the section to the pupillary space; the blades are then 
opened with strong, firm pressure (the hand resting upon the forehead, 
if the section is made upwards, or upon the cheek, if the section is made 
downwards), and as you draw the instrument backwards, the rounded 
extremities will catch on the pupillary border, and you can place that 
portion of the iris lying between the blades, about in the position of full 
dilatation of the iris, appearing as if an iridectomy had been performed. 
Then pressing gently but firmly downwards, at the same time stroke the 
opposite part of the cornea with a rubber spoon, and the lens will rise 
upon the blades of the retractor; as it does so, the left hand must be 
slowly lowered, causing the instrument to act as if resting on a fulcrum 
placed at the bend of the blades; then pushing it inwards slightly, the 4 
iris is released, and you remove the instrument with the lens probably 
lying in the concavity of the blades, and the iris will be found in its 
normal position. 
When the retractor is in position, the eye presents the appearance of 
having had a large iridectomy performed, as shown in this drawing, 
being only drawn backwards or towards its periphery to about the posi- 
tion of full dilatation. 
In reference to the slight pressure that is made upon the iris by this 
retractor, I ask to be allowed to quote from Prof. D. B. St. John Roosa's 
paper, on his operation for cataract, read before the New York State 
Medical Society, and reported in the Medical Record, Vol. 27, p. 155. 
"To say that the cutting off of a tissue so vascular, so richly sup- 
plied with nerves, and having such a perfect muscular system, is less 
dangerous than the moderate and momentary pressure of the lens (or 
retractor} upon its yielding structure, is to say something that has gener- 
ally been accepted as true, but, nevertheless, I am disposed to question 
its correctness. I am persuaded that a return to the old method of 
operating when the iris is not cut, whether the capsule be divided by an 
instrument or not, would be a gain for ophthalmic surgery."* 
* The words (or retractor) in italics, in the quotation from Prof. Roosa's paper, 
was inserted by myself. 5 
The various steps that 1 have taken in performing this operation are 
as follows: The patient is properly prepared, but no atropine is to be 
used before the operation, as it is much better that the pupil should not 
be dilated, so that the iris may not be wounded in making the section, 
as if the iris is dilated it will contract as soon as the intraocular pressure 
is relieved, and may fall against the edge of the knife, causing it to be 
lacerated as the section is made. 
Having instilled sufficient of a four per cent, solution of cocaine 
hydrochlorate, the lids are opened with the speculum, and the eye 
washed with a saturated solution of boracic acid. Section is then made, 
wholly within the corneal tissue, with the Graefe knife, either upwards or 
downwards, as may be most convenient. Generally I make the section 
upwards on the right eye, and downwards on the left, but I prefer the 
downward section. In making the section, I keep within the corneal 
margin, and at its completion, turn the knife on its axis, so as not to 
make a conjunctival flap. I now pass inwards the cystotome, and lacer- 
ate the anterior capsule freely, as far beneath the iris as possible, towards 
the limit of the section. 
An assistant now holds the eyeball steady with fixation forceps, draw- 
ing it slightly away from the operator, and the retractor is passed inwards 
through the section, until the ends of the blades are within the pupillary 
space. Firmly open the blades by steady pressure, and draw backwards 
the iris, until the portion within the blades is about in the position of 
full dilatation, as shown in the illustration. Then with the right hand 
make gentle counter-pressure on the opposite part of the cornea with a 
rubber or shell spoon, at the same time slightly depress the retractor, 
and the lens will present at the section. As the lens passes outwards, 
slowly raise the points of the blades and push the retractor inwards under 
the lens, to allow the iris to resume its primary position, and then remove 
the retractor; as you do so, allow the blades to close, completing the 
operation; as the lens clears away, the pupil will be found round and 
clear. 
Should the cataract be not fully mature, and some portions of cortex 
be left, you may again introduce the retractor in the same manner as 
before, and with the spoon gently press out the soft cortex remaining. 
The eye is now closed by removing the speculum, a drop of sol. of 
eserine sulphate added, washed with a solution of boracic acid, a little 
white vaseline rubbed on the edge of the lids; and with a pad of absorb- 
ent cotton over the eye, a flannel bandage is neatly applied. 6 
In these c&ses that I now report, I have not used atropine for 
several days after the operations; in fact, would not use it all, only to 
see that the iris was readily movable, as 1 wished to note the effect of this 
manipulation upon this delicate structure, the iris; and in all the cases I 
have had no trouble, as there has been very slight, if any, irritation as the 
cases proceeded towards complete healing. 
My first operation was performed on W , who presented himself 
at my clinic, at the New York Dispensary, with a traumatic cataract of the 
left eye from a blow. V. R. E. = I consented to operate because he 
wished to have it done, and because the blindness on that side was very 
inconvenient and interfered with his work. The operation was performed 
at the New York Post-Graduate Hospital, assisted by Dr. Geo. J. Bull, 
strictly following all the steps of the operation as I have described. On 
laceration of the capsule with the cystotome, the cortex was. found to be 
fluid, and portions came out into the anterior chamber. Dr. Bull now 
held the eye steady with the fixation forceps, and, after the iris was drawn 
backwards, which was done with no difficulty, the nucleus was readily 
pressed outwards with the spoon. As it passed out, I released the iris 
by passing the retractor inwards, raised the points as I closed them, and 
removed the instrument. The iris was found back in its normal position. 
As there were some small portions of cortex remaining in the pupillary 
space, I again passed in the retractor, opened the blades, drew back the 
iris, and with the spoon pressed out gently the remaining cortex. I then 
allowed the iris to return, and withdrew the retractor. No atropine, eye 
closed, and flannel bandage applied. 
I had great difficulty in making this patient realize that I had per- 
formed a very serious operation on his eye, as he was perfectly free from 
pain until he was discharged. 
There was no evidence of any inflammatory action at any time, and the 
eye was opened on the fifth day, when the pupil was found perfectly 
round and clear, with the section healed. The bandage was reapplied, 
and on the seventh day he could readily count fingers. I then ordered 
atropine solution three times a day, simply to see if the iris was perfectly 
free, and on the next day found the pupil fully dilated. The atropine 
was at once stopped, and a shade applied. Two weeks after the oper- 
ation, V. = + i with + and he was allowed to return to his 
work. 
My next operations were upon Ellen C , age 55. Senile cataracts, 
both eyes; in the left fully mature, not so in the right. 7 
R. E., field good in all directions, while in the left the field was only 
fair on the temporal side. 
Assisted by Dr. Geo. J. Bull and Dr. T. T. Gaunt, I operated in her 
room, top floor, tenement house, in the .neighborhood of the Five Points, 
in this city ; so you may judge that our surroundings were not of the best, 
but still her room was clean and neat; and as she was very anxious that 
the operation should be performed, I felt satisfied that she would do well. 
As I made different sections in each eye, I will describe them sepa- 
rately. After each eye had been cocainized with six drops of a four per 
cent, solution, the R. E. was opened with a speculum, and the section 
made upwards. The capsule was lacerated with the cystotome, when 1 
again found the cortex very soft. The retractor was now passed inwards, 
and the iris drawn back. I now made counter-pressure with the spoon, 
and the lens passed out easily, leaving some small portions of cortex 
behind, which in this case I decided to let remain and remove by a sec- 
ond operation if necessary. There was a slight tendency for the iris to 
prolapse in this case, but it readily resumed its position by a few gentle 
strokes of the spoon. A bandage was then applied to the eye. 
Proceeding in the same manuer as with the R. E., I operated on the 
left, making this section downwards, within the corneal tissue. In this 
case, the lens being fully mature, I readily drew back the iris with the 
retractor after the capsule was lacerated, and with gentle counter-pressure 
the lens presented at the section. As it passed outwards, the retractor was 
made to retrace the same steps by first pressing it forwards, depressing 
the handle so as to raise the points, and then removing the instrument. 
As the lens passed free from the section, the iris was found in its natural 
position, with the pupil round and clear. 
Both eyes were now bandaged, and the patient left in the care of her 
ignorant friends with whom she was surrounded. I saw her every day 
after this, and, although she complained of considerable pain in both 
eyes, yet, on removing the bandage on the third day, there was no sign 
of any inflammatory action in either eye, as both lids appeared perfectly 
natural. 
I afterwards found that her pain, which she complained of for more 
than a week, was due to neuralgia caused by a decayed molar tooth of 
the upper jaw. 
The eyes were opened on the sixth day, and both sections found to 
have healed nicely, with both irides in good position, a clean black pupil 
in the left eye, which you will remember had a mature cataract; but in 8 
the pupillary space of the right eye, I found some masses of cortex and 
capsule that I had allowed to remain at the time of operation. About 
one month after, this was removed by a secondary operation, cutting the 
membrane loose on the temporal side, and removing it through a very 
small section with a fine hook. After the eye had completely recovered, 
her V. = •?§, with -J- convex lens. 
On March 14th, 1887, I operated on Mrs. M. A. Le ; senile 
cataracts, both eyes, but more mature in the left. This operation was 
done at the Post-Graduate Hospital, assisted by Dr. W. H. Fox, before 
the class of matriculates. No antisepsis;, cocaine, four per cent., used; 
and the section made downwards, by what I believe is the method of 
De Wecker of Paris, and wholly within the corneal margin. The eyeball 
was now steadied by Dr. Fox, and passing in the retractor to the pupil- 
lary space, the iris was drawn backwards and slight pressure made, the 
blades of the retractor depressing the corneal margin of the sclerotic; at 
the same time counter-pressure was made with a spoon, and the lens 
quickly presented at the section. The iris was then released as before, 
and the retractor removed. There were some small portions of cortex 
that remained behind; the iris was found in good position and free from 
the wound, with the pupillary space black and round. 
A bandage was applied, and she made good and rapid recovery. No 
atropine was used until the fifth day, when the pupil readily dilated clear 
and round; so it was stopped on the second day. and the pupil returned 
to its normal size. 
Two weeks after operation she had slight conjunctivitis, which readily 
yielded to an astringent solution. On April 15th, 1887, V. L. E. 
with-J-1 convex, and she reads No. 4 Jaeger at 12" with -j- |. 
Such is the history of the four successful operations that I have done ; 
but I would not consider this paper complete did I not say that in one 
case not vet reported I failed in the operation of removing the lens. But 
as the cause of that failure was not due to the method of operating, but 
wholly to unavoidable causes due to myself, it is not necessary to report 
them here. 
In presenting this operation to the favorable notice of the profession, 
I know that it is an entirely new departure from the former brilliant 
methods of operating, and will, no doubt, be criticized from the fact that 
we are compelled to pass more instruments into the eye than the present 
tendency seems to warrant; as in Galezowski's operation, no instrument 
except the knife enters the anterior chamber; the same in that of my 9 
riend Dr. Roosa's operation; while at the same time, there is a disposi- 
tion on the part of some of our best ophthalmologist to return to the old 
flap operation, as performed by Professors Panas and Knapp. But I 
think that these methods have most decided disadvantages from the 
bruising and displacement of the iris, as the lens in its outward passage 
forces the iris back upon itself, causing it to readily prolapse or be caught 
in the angles of the corneal wound. 
Then, in the operation where iridectomy is performed, there is no 
question, that, by cutting off a portion of this vascular membrane, we 
facilitate the exit of the lens, but, at the same time, the operation is much 
more severe, and causes a noticeable defect in the future appearance of 
the eye, as the upper lid will not completely conceal the coloboma of the 
iris; while, by the use of the retractor, we gain, I think, all the advan- 
tages of an iridectomy, at least as far as its mechanical action is obtained. 
Yet the iris is not wounded or impaired in any way, but is simply drawn 
backwards towards its periphery, so as to allow the lens to pass out read- 
ily through the pupillary space. I do not think that this slight manipu- 
lation of the iris, by drawing a portion of it backwards to a position of 
full dilatation, can possibly cause any more injury nor act as a source of 
irritation to this delicate membrane than that of forcing the lens through 
the pupillary space. 
There is no question that the hand must be steady, and the move- 
ments gentle in the extreme, while at no time can any hurried movements 
be made ; but should any accident threaten the success of the operation, 
the retractor can be at once removed from the eye by simply raising up 
the points of the blades, when the iris is at once set free ; while, if a small 
amount of vitreous presents at the section, I should still hold the iris 
back and with the spoon endeavor to bring the lens forward. 
In presenting this small number of cases for your consideration, I car 
only say that I have been more than pleased with my continued success, 
and would only ask a fair trial of its merits. 10 
CLINICAL SOCIETY NEW YORK POST-GRADUATE 
MEDICAL SCHOOL AND HOSPITAL. 
Meeting held May 21st, 1887. 
Dr. D. B. St. John Roosa in the chair. 
Dr. Valk read a paper upon "Four Cataract Operations by a New 
Method." 
Dr. Roosa invited Dr. Hermann Knapp to take part in the discus- 
sion. The Society was honored by the presence of Dr. Knapp, a valu- 
able critic upon all ophthalmic matters, but especially upon cataract 
operations. 
Dr. Knapp thought the method described by Dr. Valk an ingenious 
procedure; he had some operations where it seemed to him that this 
method of procedure was what he wanted to assist the exit of the lens, 
and inquired who was the manufacturer of the retractor. 
Dr. Valk replied, Mr. Ford, of Hazard, Hazard & Co., but it was 
necessary to look for an instrument with a smooth surface, all were not 
perfectly finished. 
Dr. Roosa remarked that as the speaker had been kind enough to 
allude to his extraction of the lens in the capsule, he would say that he 
adopted this method in every case of late cataract extraction. The 
removal in the capsule, so far as he could see, prevented the after closure 
of the pupil and the nullification of the operation. Except in rare cases, 
he found it possible to extract the lens without iridectomy. No more 
brilliant operations had ever been done than by Alfred Graefe while the 
speaker was a student in Vienna, without iridectomy. An objection to 
Dr. Valk's instrument would come from the general principle to keep all 
instruments out of the eye. One hundred cases at least would be neces- 
sary to establish its value. Dr. Valk had however the testimony of 
Dr. Knapp in its favor; and who shall speak after the king? All know 
of Dr. Knapp's great experience in cataract operations, both in Heidel- 
berg and in this city. Dr. Valk could have no higher approbation. 
Extraction in the capsule he thought destined to a greater following. 
One of his assistants had done it six times, and another twice recently. 11 
It had been feared that loss of the vitreous would be more apt to occur 
with extraction in the capsule than without. This fear had however not 
been sustained. Further, all were apt to overestimate the loss of the 
vitreous and to underestimate the iritis resulting from division of the 
capsule, necessitating a second operation, especially deplorable in very 
old people. The speaker thought the extraction in the capsule the best 
operation which he performs. Even if the iris were distorted, it was 
a safe eye, and he had watched some of the cases for six years. Cataract 
operations should be adapted to the individual case more than was now 
done. 
Dr. Valk thought that in removal of the lens in the capsule his retractor 
would be valuable in replacing preliminary iridectomy. 
Dr. Knapp thought the operation of extraction in the capsule without 
iridectomy especially valuable for old degenerated cataracts with chalky 
or fatty decomposition. Twice he had had the anterior chamber inun- 
dated with this material with the result of an iritis, not suppurating but 
plastic, the same as could be obtained from croton oil. One of the 
pupils cleared, the other was still muddy. In a case of cataract fifteen 
years old, not white but yellow, and dusky yellow at that, the lens came 
out, more or less of the putrid liquid escaping. This peculiar iritis had 
closed the pupil, and iridectomy would be required in order to give 
good sight. Removing the lens in the capsule obviated all of this 
trouble. He had done this operation without iritis and with brilliant 
results. In this operation, however, prolapse of the iris was the thing to 
be guarded against. If thoroughly sterilized in the flame of a spirit 
lamp or by chemical means, he would not fear to introduce such an 
instrument as Dr. Valk's into the eye. Whether the iris would go back 
or not he could not say. 
Dr. Valk stated that he had done four operations by this method 
and that the iris had readily returned to its former shape. 
Dr. Kearney inquired whether cicatricial tissue had the same tendency 
to contract where the wound was hermetically sealed. In tenotomy, 
while adventitious tissue grows, it does not contract. Did Dr. Knapp 
think that there was this difference between the results of a plastic and a 
suppurative inflammation. 
Dr. Knapp had seen contraction in cicatrices of the iris where there 
had been no suppurative inflammation. 
Dr. Roosa wished to add that he would extract in the capsule not 
only for over-ripe cataracts, but also for those which ripen slowly. The 12 
patient was thus not incommoded by waiting. He would remove the 
immature cataract also in the capsule. 
Dr. Roosa, before adjourning, referred to the completion of the fifth 
year of the School's history. This had been the most prosperous of any. 
The Society had this evening received eighteen new associate members ; 
the College had had two hundred matriculates during the year. New 
York City was destined to be a great medical centre. The Post Graduate 
School and the Polyclinic had done a great work in waking up the col- 
leges of the city to what was expected of them. So important had post- 
graduate schools become, that it was probable that we should have 
discussions as to who invented them before long. While we regret that 
we have not the facilities granted to Baltimore for original research, we 
look hopefully to the future. All things great in every department 
gravitate to New York, and it cannot be doubted that the great coming 
university will be located here.