Some Exceptional Features in 
Cataract Extraction. 
By SWAN M. BURNETT, M. D., Ph. D., 
Washington, D. C. 
Professor of Ophthalmology and Otology in Georgetown University; Director 
of the Eye and Ear Clinic at the Central Dispensary and Emergency Hos- 
pital ; Ophthalmic Surgeon to the Children's and to Providence Hospitals, 
Washington, D. C. 
[Reprinted from Virginia Medical Monthly, July, 1895.] 
Thanks to a perfected technique and aseptic conditions, 
the history of a cataract extraction has become, like that of 
happy nations, monotonously dull. A slight iritis, an oc- 
casional tardiness in healing, confinement in bed for one 
day or three at most, to the room for a week, and to the 
house for ten days or two weeks, is, in the general run of 
cases, all there is to record. Only in about 10 or 12 per 
cent, of cases are there more serious complications to chron- 
icle, and in from 0.5 to 5 per cent. V-0 is appended as fin- 
ishing the history of the case. 
And yet it cannot be said that the operation of cataract 
extraction is perfected, and that nothing more remains to 
be done. That in a certain percentage only of cases vision is 
made f, is not sufficient to satisfy the demands of science; 
it requires, moreover, that "V-0" be eliminated. 
Again, a large number of operators-principally of the 2 
German school-still insist that a mutilation of the iris is 
necessary to the surest success. The capsule of the lens 
remains always as a possible cause of future trouble, and in 
at least 50 per cent, of the cases the occasion of a secondary 
operation with its attendant risks, if the most nearly perfect 
results are to be attained. 
The ideal operation for cataract is an extraction of the lens in 
its capsule without loss of vitreous through an intact pupil. 
The presence of the capsule in the eye after the removal 
of the opaque lens is a more potent factor in post operative 
troubles than its simple structure would indicate as possi- 
ble. In fact, we would be safe in referring 90 per cent, of 
the inflammatory troubles, in the iris particularly, which 
occur after operation, to the capsule. In the first place, it 
is almost impossible to entirely empty the capsule of soft 
lens substance. The remaining corticalis swells, falls into 
the anterior chamber, except perhaps in some cases, where 
peripheral capsulotomy is done, and becomes a source of 
irritation. Bits of the transparent capsule may get into the 
wound and retard healing, thus making possible the en- 
trance of germs to the interior of the eye. That the pres- 
ence of the capsule plays a more important part in the pro- 
duction of post operative inflammation than incarceration 
of the iris in the wound, is shown by the fact that in those 
cases where the lens comes out in the capsule with a loss of 
vitreous, and where there is almost of necessity a mass of 
iris left in the wound, the healing, as a rule, takes place with 
but little inflammatory re-action. 
I will not here go into a discussion of the merits of the 
" simple " and " combined " operation. The choice between 
the two has come now to be a matter of judgment for each 
individual operator, and the confidence he has in his skill 
for the particular operation. For my own part, I have done 
the simple operation without iridectomy ever since the in- 
troduction of cocaine. I never voluntarily made an iridec- 
tomy in any case. If the iris is difficult to replace (which I 
usually effect by rubbing with the upper lid), or if it shows 
a tendency to prolapse, I make the iridectomy after the 3 
expulsion of the lens, which is as easy then as before its de- 
livery. The size of the cataract I have found no obstacle 
in extraction through an intact pupil. A large amount of 
soft corticalis would lead me, if anything would, to an iri- 
dectomy. 
Extraction of the lens in its capsules has been followed, I 
believe, as a fixed practice, by only one operator-Pagens- 
techer, of Wiesbaden. Others have given it a tentative 
trial, but finally abandoned it. 
As a matter of necessity, we must, on occasion, however, 
take the lens away in its capsule if we are to extract it at 
all. This is notably the case w'here the lens is dislocated, 
either wholly or partially. Even where the lens is floating 
in the posterior chamber, it is possible to extract it success- 
fully without the loss of much vitreous. Two such cases I 
have reported in a paper published in Knapp's Archives of 
Ophthalmology A 
There are other indications also for an attempt to extract 
in the capsule and through an intact pupil. Those I shall 
refer to now particularly are evident thickening and tough- 
ness of the capsule, and almost all forms of degenerated 
cataract. 
In the latter, there is almost invariably a fluidity of the 
vitreous, and it is much easier to handle this with an intact 
iris than when an iridectomy is made; and besides, in most 
of these cases, the zonula is very weak, if not already 
broken. 
In some of these conditions, particularly in dislocation 
of the lens, it is advised, in most of the text-books, to re- 
move the lens by means of a spoon or scoop. This is un- 
pardonably bad surgery. A surgeon is never justified in in- 
troducing an instrument into the eye for the removal of a cata- 
ract. A proper manipulation will succeed in delivering a 
lens in every case where delivery is possible. The intro- 
duction of a scoop or any other instrument into the eye 
only increases the dangers, both present and prospective. 
* Contributions to Clinical Ophthalmology.-Knapp's Archives, Nos. 2 
and 3, 1892. 4 
It has been my exceptional good fortune to make lately 
three extractions of cataract in the capsule without the loss 
of any vitreous through an intact pupil, followed by per- 
fect healing, thus realizing the ideally perfect extraction. 
A short history of these cases is as follows: 
Case I.-Mr. R W., aged 68. Right eye, he states, began 
to fail about two years ago. There is now a complete opacity 
of the lens in that eye; the capsule looks smooth, but the 
lens is evidently hard. Anterior chamber deep, pupil nor- 
mal, and responds well to light. Tension normal. Extrac- 
tion on April 13th, 1895. In making the incision,! noticed 
some movement on the part of the lens, and this was fur- 
ther apparent when I came to make the capsulotomy. The 
capsule was tough, and the whole lens yielded to the pres- 
sure of the cystotome. I knew from this that I had to deal 
with a ruptured zonula, and resolved to extract in the cap- 
sule. I told my assistant, who was holding the upper lid 
(I never use a speculum), to be prepared to drop the lid as 
soon as the lens was delivered, expecting a gush of vitreous 
to follow its exit. The fixation forceps were removed, and 
with the back of the spoon alone I made gentle pressure 
backwards and upwards, while the patient looked strongly 
downward. The lens soon became engaged in the pupil 
and wound. The spoon was then made to follow, with grad- 
ually decreasing pressure, the lens as it passed out of the 
wound, and as soon as it was delivered the upper lid was 
dropped. Not a drop of vitreous escaped. When the eye 
was opened a few seconds later, it was found that the iris 
has returned almost entirely, and a little gentle rubbing of 
the lids was sufficient to make its reentrance complete, with 
a round and perfectly black pupil. The wound was nicely 
coapted. As there is nothing left to guard the vitreous but the 
delicate hyaloid membrane, I deem it wise to be unusually 
careful of such cases for the first forty-eight hours. I enjoin 
perfect quiet, and use Ring's mask as a protector, to be con- 
stantly worn for the first three days and at night for a week 
or more. I am satisfied that many prolapses of the iris are 
due to self-inflicted traumatism on the part of the patient. 
The patient left the bed on the second day, and resumed it 
thereafter only for sleep at night. There was absolutely no 
pain, and nothing more than a slight hyperemia of the iris, 
due to the stretching. On the fourth day, the pupil re- 
sponded promptly to atropine, and the convalescence was 
uninterrupted. Already on the 29th, with + IOS.+ 3.180 5 
V=TV The corneal astigmatism was 5 5 D, and, as is al- 
ways the case after cataract operation, contrary to the rule. 
When the corneal astigmatism comes down to its normal 
degree, as it will in the course of three months, his vision 
will undoubtedly be f. 
Case II.-M. K., a colored woman, aged 55, had lost the 
right eye from some inflammatory trouble, which left an 
almost total lucoma of the cornea, many years ago. She 
reported, when admitted to my clinic at the Emergency 
Hospital on April 26, 1895, that the left eye had began to 
fail only two or three years ago. This, however, seems im- 
possible, for the cataract which was present in that eye was 
evidently old, or at least showed such degeneration as we 
seldom find except in very hypermature cataracts. The lens 
was evidently shrunken, and the capsule was thrown into 
quite prominent folds, radiating from the center. The an- 
terior chamber was deep and the iris was slightly tremu- 
lous. The pupil responded well to light, and the projection 
was fair. The indications for extraction in the capsule were 
here imperative, and accordingly I determined to attempt 
its removal in the manner I have indicated in the paper 
before referred to. The lid being held by an assistant, the 
conjunction is grasped by the fixation forceps at some little 
distance behind the lower corneal margin, and as soon as 
the counter-puncture is effected considerable pressure is 
made with the forceps backward and towards the center of 
the eyeball. As the section progresses upwards this pres- 
sure is continued or increased slightly in order to tilt the 
lens forwards against the iris and hold it there. When the 
section is completed,the lens should be engaged in the pupil, 
and an increase of the same pressure is sufficient to deliver 
it. In this case, the lens, being somewhat shrunken and 
apparently totally detached at its upper portion, came 
promptly against the iris under the backward pressure with 
the forceps, and bulged it forward so that the knife, as it 
passed upward, cut a slice out of the iris about midway be- 
tween the sphincter and the base. When the section was 
completed the lens had already entered the pupil, and a 
gentle increase of pressure caused it to pass through and 
out of the wound, the pressure being lightened gradually 
as the lens was slowly extruded. There was no escape of 
vitreous, and a little gentle rubbing with the lid reduced 
the prolapsed iris. The wound coapted nicely. On open- 
ing the eye on the third day,a complete healing was found, 
and there was nothing to retard the progress of a perfect 6 
convalescence. On examination with the ophthalmoscope, 
an extensive choroiditis was discovered, which made any- 
thing like good vision impossible, but she was able to get 
about alone and wait upon herself, which was an immense 
gain over helpless blindness. This choroiditis probably ex- 
plains the origin and character of the cataract. The inflam- 
mation of the uveal tract led to malnutrition of the lens 
and its subsequent degeneration. There is usually also, in 
such cases, a fluidity of the vitreous which makes the ab- 
sence of its prolapse in this case the more remarkable. 
Case III.-B. A., a colored woman, 60 years of age, was 
admitted to my clinic October 1st, 1894, with complete cata- 
ract of the left eye. There was no satisfactory history of 
the case, nor were we able to find out how long the cataract 
had existed. The lens was milk-white, which was sus- 
picious of cataracta morgagni, but there was no other appear- 
ance of degeneration. The iris was not tremulous, nor was 
there other evidence of a ruptured zonula or displacement 
of the lens. In making the section, however, it became 
evident that the zonula was weak, and on completion a 
slight pressure was sufficient to deliver the lens in its cap- 
sule through the intact pupil. No vitreous escaped. It 
was seen then that the capsule contained a very small nu- 
cleus and a large quantity of fluid. It rolled about in the 
palm of the hand like a globule of mercury. The iris re- 
turned without difficulty, and the healing went on without 
accident as in the other cases, and the ultimate vision was 
good. Illiteracy of the patient prevented a thorough test- 
ing of visual acuteness. 
These cases show the brilliant side of cataract extraction 
where art seems to have triumphed completely over nature 
but there is, alas! another side which shows how futile may 
become our best endeavors, and which should impress upon 
us the fact that the last word has not yet been said in regard 
to the management of this most important operation. 
That an operation has been smoothly performed and un- 
der the most approved modern aseptic conditions, is not an 
absolute guarantee that all will go well. That suppura- 
tions are rare-much rarer than before the introduction of 
aseptic methods-is true; but we have not, for all that, 
entirely abolished the possibility of infection. The danger 
does not seem to be passed when we have an apparently 7 
perfect healing of the wound, and the question of auto- 
infection is not by any means settled one way or the other. 
Of course, in the vast majority of cases, when the third or 
fourth day has passed without any serious symptoms, and the 
wound seems well coapted, we consider that we are "out of 
the woods," and are possessed of a sense of security as to 
the final issue. But occasionally we have an experience 
which shatters our faith in our assumed accurate knowledge 
of all the conditions attending the course of healing and 
renders our humiliation extreme. The following is such 
an instance: 
Case IV.-W. T., white, aged 68. Had been operated on 
by me at Providence Hospital six years ago for cataract of 
the left eye with a good result-in spite of an incarceration 
of the iris in the wound due, undoubtedly, to his restless- 
ness. He was a very bad subject, and hard to control. 
When admitted to my clinic at the Emergency Hospital on 
April 2d, 1895, the cataract in the right eye was ripe, the 
pupil good, with all the indications fora successful operation. 
In spite of his want of control of himself, the operation was 
completed without any accident. The soft corticalis was 
removed without difficulty and the iris reentered promptly, 
leaving a black round pupil. On the fourth day a moderate 
iritis set in. The lips of the wound seemed well coapted, 
but the anterior chamber was still shallow, indicating that 
there was a portion of the incision which had not entirely 
healed. The anterior chamber was restored in about a 
week, and in ten days the iritis had subsided, leaving three 
or four slight synechia. At the end of the sixteenth day 
after the operation, he was discharged. There was at that 
time no pain and but a slight injection of the conjunctiva 
around the base of the cornea. A week after his discharge, 
he returned with the pupil and the lower third of the ante- 
rior chamber filled with pus, the edges of the wound yel- 
low, very pronounced chemosis of the conjunctiva, and 
much pain. He stated that this condition had developed 
suddenly two days before-that is, three weeks after the 
operation. He knew no cause for it, he persisted in aver- 
ring, and stated that he had simply stayed quietly about the 
house. His general unreliability leads us to doubt this, 
and the probabilities arc that he engaged in excesses of 
some kind. He was taken back in the hospital and treated 
rigorously. The edges of the wound were cauterized with 8 
formaline of half strength and a weaker solution (1 to 1000) 
used as a cleanser every three hours. Nevertheless, the 
cornea slowly melted away and a panophthalmitis set up, 
which ended in an abscess, which perforated behind the 
cornea on the outer side. The stump was removed as soon as 
the acute symptoms had subsided. On opening the eye 
after enucleation, it was found filled with pus. The heal- 
ing was prompt, and he was discharged a week later. 
This is the second eye I have lost from panophthalmitis 
after cataract extraction since the introduction of strict 
asepsis. The first one, however, could be referred to a re- 
moval of the bandage by the patient the first night after 
the operation, which gave opportunity for infection, and 
which promptly showed its effects on the second day. But 
this second one is exceptional in my own experience, and 
my researches fail to show any other (though, of course, 
there may be such on record,) in which so long a time as three 
weeks has elapsed before suppuration showed itself. In 
the pre-aseptic days, I had one case in which suppuration 
occurred a week after the operation, and after the patient 
was up and about. In this instance, it followed an exposure 
to cold in severe weather in an unwarmed water-closet. 
When, then, can we consider ourselves absolutely safe 
after cataract extraction? Wherein is the danger, and 
where does the enemy hide himself? It is certain that the 
germs got into the eye from some quarter. Did they enter 
at the time of the operation and remain quiet for three 
weeks? Did they get in through some open space in the 
wound which had not healed promptly, or were they carried 
there by the circulation? But whatever may be the expla- 
nation, the lesson we are to learn is that our precautions be- 
fore, during, and after the operation, are to be increased in 
vigor if we are to eliminate completely tlie danger of sup- 
puration after cataract extraction. 
916 Farragut Square.