ON CATARACT EXTRACTION WITHOUT 
IRIDECTOMY 
BY 
H. KNAPP 
[Reprinted from the Archives of Ophthalmology, Vol. xvi., No. i, 1887] ON CATARACT EXTRACTION WITHOUT IRI- 
DECTOMY* 
H. KNAPP. 
DAVIEL’S method of extraction—i. e., the “simple 
method,” without iridectomy, has of late been re- 
vived and recommended with particular emphasis by French 
oculists, Galezowski, De Wecker, Panas, and others. Thus 
far, it has found only a small number of advocates out- 
side of France, yet what I saw of it in Paris last winter, 
impressed me so favorably that I determined to give the 
method a fair trial. In order to learn what was known 
and thought about it in this country, I brought it be- 
fore the American Ophthalmological Society in July, 1886. 
At that time my experience with it comprised only six op- 
erations. Dr. H. D. Noyes reported on six others, and Dr. 
Griming on two. Both gentlemen had witnessed the opera- 
tion in Paris. 
My present communication is based on twenty-nine suc- 
cessive cases—including the six mentioned above—in which 
I succeeded in extracting the lens without exsecting the 
iris, and on six cases in which I attempted to do so but did 
not succeed. Our French confreres have described the 
method in general and in detail. They claim that they have 
practised it in hundreds of cases, and that the results have 
been excellent, superior to Graefe’s or any other method, 
but they have given us no detailed and conclusive statis- 
tics. Statistics have their fallacies, they are never en- 
tirely objective, always bearing more or less of a personal 
* Read, in part, before the Section on Ophthalmology, N. Y. Academy of 
Medicine, Feb. 21, 1887. 
Reprinted from the Archives of Ophthalmology, Vol. xvi., No. 1, 1887. 55 
On Cataract Extraction without Iridectomy. 
stamp, yet they give us a better insight into our own as well 
as another’s work than we can obtain from general descrip- 
tions, which reflect only our impressions and opinions for 
the time being. When we think more or less favorably of a 
method, we are very apt to overlook, forget, or reason away 
what is adverse to it. Statistics, if we are honest to ourselves, 
hold up hard facts that often astonish us. I consider it a 
decided advantage that some of the larger ophthalmic in- 
stitutions in this country, for instance, the N. Y. Eye and 
Ear Infirmary and the Massachusetts Charitable Eye and 
Ear Hospital, publish in their annual reports detailed sta- 
tistics of that most important of eye operations, the extrac- 
tion of cataract. From this point of view I have compiled in 
tabular form the twenty-nine cases of the operation under 
consideration, so that all may draw their own deductions 
therefrom. See table, page 56, etc. 
I now beg leave to discuss the subject in its various prac- 
tical bearings. 
1.—Preparation of the Patient. 
No patient was operated on the day of entrance into the 
hospital. They were all kept in the hospital one or more 
days, in order to have their eyes thoroughly clean and free 
from irritation. The eyes were washed with soap every 
morning and evening, and Panas’ antiseptic (biniodide of 
mercury, 0.05 ; alcohol, 20.00; dist. water, 1000.00) was in- 
stilled several times daily. 
Only one patient was operated in the new operating-room 
of the Institution, which was built in the closest possible 
adherence to bacteriological principles. From the operating 
room the patient, with bandaged eyes, was led up one flight 
of stairs. The next day I found he had extensive prolapse 
of the iris, although the pupil after the operation had been per- 
fectly round and central. He was restless the first twenty- 
four hours. I do not know how far the moving of the 
patient was to blame for the prolapse, but I have operated 
on all others in their bedrooms, where an operating-chair 
and a drop-light were always on hand. In Paris I have 
seen that the patients are operated in operating-rooms, H. Knapp. 
6 
fc 
Name. 
e 
b£ 
<5 
Character 
of 
cataract. 
Complica- 
tion. 
Date of 
opera- 
tion. 
Operation. 
Reduction of 
iris. 
Healing process. 
i 
M. Don. 
76 
Hard. 
June 
10,’86. 
Regular. 
Spontaneous. 
Plastic iritis. 
2 
A. Balf. 
36 
Soft. 
Od. white. 
II 
“ 
44 
3 
M. Cam. 
55 
Hard. 
14 
“ 
“ 
4 
M. Cas. 
60 
21 
•1 
Plastic iritis. 
5 
C. Woods. 
63 
44 
21 
44 
44 
44 44 
6 
M. Bey. 
52 
f l 
July 9 
“ 
With probe. 
7 
J. Mar. 
65 
Not quite 
26 
“ 
Spont. 
• 
ripe. 
8 
E. Mull. 
52 
Hard. 
27 
Small piece of cortex 
scooped out with spa- 
tula. 
Regular. 
9 
O. Dem. 
40 
Hyper- 
mature. 
Aug. 13 
“ 
IO 
H. Alb. 
57 
Hyperm. 
Dacryo- 
Sept. 20 
Considerable manipu- 
Stroked back. 
Striped keratitis. Pupil 
cystitis. 
lation and introduc- 
partially occluded by 
L. Scott. 
tion of instruments. 
Rigorous antisepsis. 
thickened capsule. 
II 
76 
Hyperm. 
Myopia; liquid 
22 
Thickened capsule re- 
Spontaneous. 
Very restless patient, 
throwing himself 
black. 
vitreous. 
moved with forceps. 
Pupil round. 
Lens expelled by ro- 
spasmodically about 
tating on horizontal 
in his bed at night. 
axis. Lower edge es- 
Had to be watched 
caped first. 
and tied. 
12 
Fr. Mull. 
6l 
Hard. 
Regular. 
With probe. 
13 
M. Wallace. 
70 
» 
Oct. 2 
“ 
“ “ 
J4 
Mrs. J. 
64 
Hyperm. 
9 
Escape of vitreous after 
The folded iris left an 
Pretorius. 
expulsion of lens. 
irregular pupil. Heal- 
ing good. 
15 
J. Duffy. 
63 
Hard. 
9 
Regular. 
Spont. 
l6 
Mrs. Jones. 
67 
19 
>. 
With spatula. 
*7 
Mrs. Mills. 
67 
Morsrag- 
F contracted 
27 
Nucleus rubbed out in 
To stroke the 
Next days cotton moist, 
nian chol- 
below. 
pieces. The deaf and 
iris back. 
edges of wound 
esterinic. 
uncontrollable patient 
white, ant. chamber 
had to be etherized 
cloudy, iris dull. 
Careful cleansing 
with Panas’ solution. 
Gradual clearing up. 
18 
Kigg. 
70 
Hard. 
Mac. cornese 
Nov. 1 
Regular. Pupil ap- 
parently clear. Panas’ 
Spont. 
From pupillary area a 
and dacryo- 
shred of capsule 
cystit. 
sol. injected in ant. 
passed over iris to 
chronic. 
chamb. 
nasal corner of 
wound. Closure of 
wound normal; pupil 
round; but pain and 
circumcorneal injec- 
tion and swelling, and 
cloudiness of pupil for 
a long time. The 
shred of capsule 
shrank from periph- 
ery and finally dis- 
appeared. 
19 
Sauter. 
64 
Hard. 
13 
Regular. 
Spont. 
20 
Murr. 
40 
Semi- 
Nov. 
Regular. 
Spont. 
mollis. 
*3 
21 
McLaughl. 
40 
Trau- 
Small foreign 
l6 
Cortex left. 
“ 
matic. 
body in eye. On Cataract Extraction without Iridectomy, 
o 
. G . 
Iris prolapse or 
incarceration. 
Post, synech. 
ngth 
reat 
ent 
lays 
Primary re- 
sult. 
After opera- 
tion. 
Ultimate re- 
sult. 
Remarks. 
<D 
a 
Numerous. 
23 
n 
(eight mos.) 
16 
255 
Atrophy of od five years. 
Other eye less, butS only. 
21 
. 28 
six mos. 
Moderate. 
17 
25 
?8 
Pupil partially obstructed by 
eight mos. 
capsule. Fundus distinct. 
14 
n 
Pupil round, free, partially ob- 
structed by capsule. 
12 
So°5 
Discission 
five weeks 
n 
later. 
Three 
l6 
n 
Od surrounded by atrophic 
filiform. 
13 
eight mos. 
(not fluently.) 
band on nasal side. 
Isinglass plaster applied on 
fourth day. Preferred old 
n 
Iris extensively in- 
carcerated. Pupil 
bandage. 
Numerous. 
28 
fiyu 
Discission 
Old dacryocystitis discharging 
four months 
muco-pus, from which a good 
drawn up, round. 
Prolapse of iris 
later. 
cultivation of staphylococcus 
pyogenes aureus was obtained 
35 
a® 
Prolapse permanent, but free 
from second day. 
from irritation. Eyes greatly 
Slow but good 
closure of wound. 
Two or three 
filiform adhe- 
m 
sunken in orbits. 
sions. 
Three fili- 
form adhe- 
22 
n 
sions. 
No incarceration. 
27 
is”r 
Unmanageable patient. Pupil 
four mos. 
and fundus clear; astigma- 
tism. Pupil eccentric ; no pro- 
lapse. 
23 
-ft°5 
Discission 
seven weeks 
18 
17 
26 
later. 
Prolapse from sec- 
Numerous. 
IS 
®V® 
In secretion at edge of wound 
ond day ; disap- 
micrococci and bacilli found 
pearing later, 
under microscope ; grew and 
leaving eccentric 
liquefied gelatine like staphy- 
pupil. 
lococc. pyogenes. 
33 
Capsule occluding pupil; has to 
be split. 
Two small, 
15 
sVo 
Disc, in five 
n 
on inner side. 
weeks. 
Some, filiform. 
14 
Disc, in ten 
18 
weeks. 
Some, from 
23 
A® 
IS 
injury. 
in ten weeks. H. Knapp, 
6 
£ 
Name. 
6 
u 
< 
Cataract. 
Complica- 
tion. 
0 a • 
v* S3 
Z V 0 
ci 
Q 0 
Operation. 
Reduction of 
Iris. 
Healing process. 
22 
Schuhman. 
6s 
Hard. 
Dacryo- 
18 
Regular and very 
With spatula. 
Two days without ir- 
cystit. 
smooth and quick. 
ritation. Wound unit- 
chronic. 
ed, clean ; clear and 
central pupil. Pa- 
tient restless, got up. 
Pain in third night. 
65 
Infiltration of wound; 
panophthalmitis. 
23 
Schultz. 
“ 
(Dec. 22 
With probe. 
Patient restless the first 
day, pain in eye ; pu- 
pil oval. 
24 
Pahud. 
63 
44 
22 
Patient pressed inordi- 
Stroked back 
Well the first three 
nately. A few drops 
only partially 
days. Then extensive 
of vitr. followed lens. 
traumatic hemor- 
Iris folded at periph- 
ery. 
rhage by rubbing 
with hands, repeated 
three or four times in 
the course of two 
) 
weeks in spite of all 
precaution. 
25 
26 
Mrs. Smith. 
35 
62 
Soft. 
Diabetes. 
Jan. 
5. 1887 
Regular. 
With probe. 
H. Walt. 
Hard. 
12 
14 
Spont. 
27 
G. Schlette. 
60 
“ 
17 
Regular. Some flakes 
With probe. 
No irritation. 
remained in pupillary 
area. 
28 
McArth. 
55 
.. 
Dacryo- 
cystit. sim- 
22 
Regular. 
Spont. 
plex. 
29 
Harris. 
33 
Morgagn. 
3° 
Nucleus expelled by 
Spont. 
Wounds open at ban- 
rotating lower end 
daging for days. 
up. 
Iritis. 
thence carried into the wards on a litter (Panas), or walked 
up stairs (DeWecker), or brought up in an elevator (Fieuzal). 
An operating-room which is used for nothing else and kept 
dust-free is, of course, preferable to a sick-room. Yet, when 
there are no other or only a few patients in a room, the air can 
be kept virtually free from pyogenic germs. It is now well 
known that infection from the air is the least to be dreaded. 
Of all the pathogenic germs, the pyogenic seem, however, to 
be the most extensively distributed in the air, at least they 
are the only pathogenic ones that have, thus far, been directly 
obtained in cultivations from the air. 
The patients commonly received a bath the day before 
the operation, and their heads were washed with soap. 
When they were seated in the operating-chair, the eyes 
and surrounding parts were washed with soap, wiped dry, On Cataract Extraction without Iridectomy. 
Iris prolapse or 
incarceration. 
Synechise. 
Length 
of treat- 
ment. 
Primary re- 
sult. 
After opera- 
tion. 
Final result. 
Remarks. 
Iris prolapsed on 
fourth day when 
wound had 
opened. 
26 
O 
The dacryocystit. had been 
treated for four months, and 
seemed sufficiently improved 
to venture operation. 
Iris incarcerated, 
not prolapsed. 
No synechise. 
Pupil oval. 
29 
ftjtj 
two months. 
Marked astigm. 
Upper part of iris 
drawn back. 
Pupil irregu- 
lar. N o sy- 
nechiae. 
38 
15 
Patient uncontrollable. 
IS 
n 
On second day pro- 
lapse of iris along 
the whole wound, 
covered with the 
conjunctival flap. 
Prolapse gradual- 
ly disappeared 
leaving the whole 
wound free. 
Pupil oblong. 
Sphincter in eye. 
No synechiae. 
Small synech- 
iae above 
and below. 
II 
17 
n 
» 
Disc, on eigh- 
teenth day. 
in four weeks. 
H 
U 
and then washed with corrosive sublimate or Panas’ 
solution of biniodide and alcohol, or carbolic acid -fa. Then 
Panas’ solution was freely instilled into the conjunctival 
sac and over the cornea; the upper lid was turned, and 
its conjunctival surface (more particularly its free edge) 
carefully washed with absorbent cotton moistened with the 
biniodide solution. 
A drop or two of a three-per-cent, or four-per-cent, solu- 
tion of muriate of cocaine was now let fall on the cornea, fol- 
lowed by another drop or two six or seven minutes later. 
Then the biniodide was again instilled, and the operation 
begun. Ether was given in several cases ; not in as many as 
might have been desired. 
The instruments, of course, had been previously cleansed and 
sterilized, They were washed with soap, boiled water, and the H. Knapp. 
60 
alcoholic solution of biniodide of mercury. For instruments 
with uneven surfaces—forceps and the like—a soap-brush 
was used ; the others were rubbed with freshly washed 
linen. All were wiped dry, polished with the same kind of 
linen, and dipped in the biniodide solution immediately be- 
fore being used, the liquid being left on them. Special care 
was taken in cleansing the cystitome, on account of its 
angles, from which it is more difficult to remove germs than 
from a straight, polished surface. 
The hands of the operator and of his assistants were 
cleansed in the usual way with soap and bichloride of 
mercury. 
2.—Mode of Operating. 
The lids were kept open with a wire speculum, provided 
with a screw. 
The eyeball was steadied with the ordinary fixing forceps 
implanted in the conjunctiva close to the lower corneal 
margin. A Graefe's knife was then, rather quickly, passed 
through the anterior chamber, making a section through 
two fifths of the transparent corneal margin, or less, accord- 
ing to the size of the cataract. 
If the eye is completely free from irritation, I avoid a 
conjunctival flap as a useless complication ; but when there 
is chronic conjunctivitis or dacryocystitis, I consider a con- 
junctival flap of advantage. No doubt it increases the 
danger from primary infection by enlarging the wound, yet 
with antiseptics we can efficiently guard against the primary 
infection, but not so well against the secondary, from which 
the conjunctival flap is a protection. These views are de- 
rived from the series of operations under consideration, 
and they will be spoken of further on. The iris is best 
avoided by passing the knife quickly through the anterior 
chamber. In none of the cases of the present series did the 
iris fall before the blade of the knife, nor was it wounded in 
any way. 
As soon as the section is completed, a cystitome is intro- 
duced and the capsule opened extensively in the centre, the 
manoeuvre being completed with a horizontal stroke in the 
upper part. If the iris is not prolapsed, the point of the 61 
On Cataract Extraction without Iridectomy. 
cystitome may in the last stroke be passed underneath its 
upper part. In several cases pieces of capsule were drawn 
out with the forceps. 
The lens is now expelled by pressing with a rubber spoon 
on the lower part of the cornea, as in Graefe’s method, or 
by pressing on the cornea with the lower lid after the 
speculum has been removed. The latter mode is preferable 
in complicated cataracts, especially when the suspensory 
ligament is defective and the lens dislocated. In some 
cases, in this as in Graefe’s method, when I saw that the 
upper end of the cataract or its nucleus did not present in 
the wound, but wedged itself into the periphery of the pos- 
terior chamber, I pressed it toward the centre of the globe 
with one hand, while pressure upon the lower part of the 
cornea with the other moved the lower edge of the cataract 
up and into the wound. Simultaneous pressure with both 
hands towards the centre of the eyeball expelled the lens 
gently and without accident. I am sure that I am not 
the only one acquainted with this mode of exit, but since 
I have seen some such cases do surprisingly well, I have 
studied and adopted it as a method for a certain group or 
cases. 
The removal of remnants of lens is most important. Panas 
lays the greatest stress on this step. He says “ the perfection 
of the result and the absence of operative complications de- 
pend chiefly on good cleaning of the pupillary space. Pres- 
sure with the fingers, pressure with the curette (he uses 
Daviel’s spoon), repeated introduction of instruments into 
the anterior chamber—we spare neither time nor trouble to 
attain our object, and we succeed.” One must have seen 
Prof. Panas do this to believe what an amount of interfer- 
ence eyes are capable of enduring without injury. He says 
“ the antiseptic method has here, as in lithotrity, changed 
every thing, and nothing need be feared, provided the wash- 
ing out of the anterior chamber {le lavage intra-oculaire) is 
made (as he does it) regularly.” 1 I have endeavored to follow 
Panas’ example, and yet have been cautious with regard to 
scooping the remnants out. I have preferred to let patients 
1 Bulletin de 1’Academie de Medecine, Seance du 5 Janvier, 1886. H. Knapp. 
62 
wait until their cataracts are completely ripe in order to 
avoid extra trouble in the removal of remnants. When 
the pupil was clear, the eye was closed for a short time 
to let the iris resume its natural position. This occurred 
spontaneously in seventeen out of the twenty-nine cases 
(fifty-nine per cent.). In the others the iris was reduced by 
rubbing the cornea with the lids or stroking with a probe 
the folded iris out of the wound and the sinus of the 
anterior chamber back into its normal position. If, in spite 
of my efforts, the pupil was not central and round, I made 
an iridectomy on the spot. 
Particles of lens, blood, etc., during the operation were 
wiped away with absorbent cotton dipped in the alcoholic 
solution of biniodide of mercury. 
The last part of the operation was the washing out of the 
anterior chamber. After the speculum had been removed, 
the upper lid was held up with the forefinger of my left 
hand, the patient was directed to look downward, the nozzle 
of an E. Meyer’s lachrymal syringe—which was used for no 
other purpose—was introduced into the wound, and a few 
drops of the biniodide solution thrown into the anterior 
chamber, the nozzle of the syringe passing along the section 
so as to moisten the wound with the antiseptic from one 
end to the other. I have avoided injecting large quantities 
of liquid into the eye, my object being to sterilize the 
region of the wound, not to kill germs nor to cleanse the 
pupil by the stream of liquid. When the operation had 
been quickly performed, and no instruments except the 
knife and cystitome introduced, I limited the injection to 
the lips of the wound, and in a few cases did not use the 
syringe at all, but dropped the antiseptic over the wound 
with an ordinary atropine dropper. There are no germs 
within the eye, and the few that may possibly be introduced 
with the instruments from the conjunctiva are not likely to 
multiply in an eye that has been operated on smoothly and 
cautiously. It is a different thing if the cornea and iris 
are bruised by the pressing of a large lens through an insuf- 
ficient wound, and if the capsule has been indiscriminately 
lacerated, especially if particles of cataract and shreds of 63 
On Cataract Extractio?i without Iridectomy. 
iris and capsule remain in the section. These conditions 
prepare the soil for the multiplication of bacteria, and 
demand the use of efficient antiseptics. In such a case I 
would irrigate the conjunctival sac and syringe out the 
anterior chamber freely with the alcoholic biniodide or a 
watery bichloride (i : 5000) solution. 
When the operation was finished, I instilled two drops of a 
one-per-cent, solution of sulphate of eserine. Of late, I have 
also put a small quantity of eserine ointment (o. 10 to 10.00 of 
vaseline) into the conjunctival sac. The closed eyelids were 
covered with a compress of linen gauze, which was smeared 
with an ointment consisting of 0.15 of benzoate of mercury 
to 10.00 of vaseline cold cream. A pad of absorbent cotton 
steeped in the biniodide solution was spread over the gauze, 
so as to form a mould over the eyelids ; then dry absorbent 
cotton was placed on the wet cotton and on the lids of the 
other eye, both held in position by a flannel roller applied 
in the manner of the old binoculus bandage, which, in my 
opinion, still remains unexcelled. 
3.—After-treatment. 
The patients were put to bed with as little disturbance as 
possible, and requested to lie on their backs as quiet as they 
could. They sat up in bed while taking their meals, and got 
out of it to satisfy calls of nature. Rest is considered to 
be of the greatest importance, not only as favoring primary 
union in general, but more especially in this method of ex- 
traction, in order to prevent prolapse of iris. To darken the 
room is by no means necessary, and never has been, for the 
bandage is a sufficient protection from too bright a light. 
The next day the dressing is renewed without opening 
the eye, except when there is inflammation. In most cases 
there is a small quantity of mucus on the gauze, probably 
conjunctival epithelium necrosed by the action of the anti- 
septic. If otherwise the gauze is dry, the new bandage is 
left undisturbed for two days. Then the eye is opened and 
inspected. If the pupil is round and central and no irrita- 
tion present, the eye is cleansed and bandaged again without 
any instillations. If the pupil is oblong, eserine solution H. Knapp. 
64 
is instilled, and eserine salve put in the conjunctival sac; if 
the pupil is round and central, the wound closed, but circum- 
corneal injection or some pain is present, atropine is in- 
stilled. I am inclined to use atropine earlier and more 
frequently than is recommended in the simple extraction. 
Wherever shreds of lacerated capsule come in contact with 
the pupillary edge of the iris, synechiae are apt to develop. 
In the present series there were synechiae in ten cases 
out of twenty-nine ; in no case were they extensive, nor 
did they lead to the formation of a dense pupillary mem- 
brane, yet many of them might have been ruptured had I 
instilled atropia earlier. 
Of the accidents occurring during the operation, two cases 
of escape of vitreous are to be noted (Nos. 14 and 24). In 
both a few drops followed the exit of the lens. The iris lay 
folded in the upper part of the anterior chamber, and it was 
impossible to reduce it either by rubbing or the probe. The 
wounds united well, without prolapse or incarceration. 
4.—Wound Complications. 
There were two cases of incarceration of the iris (Nos. 10 
and 23). 
The first was in an exceedingly nervous man with a hyper- 
mature cataract, the removal of which had been very laborious. 
The pupil, at the end of the operation, had been completely 
round. Two days later, when the eye was opened, a considerable 
portion of the iris lay in the wound without protruding. It was 
covered by a conjunctival flap. The anterior chamber was restored. 
There was plastic iritis, but no suppuration, though the patient 
suffered from chronic dacryocystitis. The wound closed com- 
pletely, no iris was seen lying in the outer layer of the wound. 
Four months after the operation S f-g- was raised to by a dis- 
cission. 
The second case was the man spoken of previously as having been 
operated on in the operating-room, and led up one flight of stairs. 
He was restless for the first twenty four hours and had some pain in 
the eye, but when he lay quiet, after having been told that rest was 
of the greatest importance, the pain disappeared and the recovery 
henceforth was undisturbed. S two months after the 
operation, with marked astigmatism. 65 
On Cataract Extraction without Iridectomy. 
There were four cases of prolapse of iris occurring within 
the first three days after the operation. 
In case No. 22 the iris was seen lying in the centre of the 
corneal wound, suppuration being fully developed. 
In the case of puriform inflammation (No. 17) the iris was 
noticed in the centre of the section. It disappeared from view 
when the inflammation subsided. The pupil was drawn up, the 
whole sphincter being in the anterior chamber. 
The third case referred to an old man, who in his sleep used to 
throw himself about in spasmodic fits. His was the only case in 
which the prolapse remained ; the recovery being slow but free 
from inflammation, and the pupil perfectly clear, though drawn 
up. 
In the fourth case (No 27) the iris protruded beyond the 
corneal wound in its whole extent, but was covered with a con- 
junctival flap. During the recovery, which was quick and un- 
disturbed, the whole iris disappeared from the outer aspect of the 
wound. The pupil was oblong, the sphincter completely in the 
eye ; no synechia. 
In former times I was in the habit of abscising all 
traumatic prolapses of iris. Of late I have become more 
conservative with regard to this point. I noticed that pro- 
lapses left to themselves mostly disappeared or cicatrized in 
a surprisingly smooth manner, and it seemed to me that 
they gave rise to sympathetic trouble less often than when 
I had abscised them. If I get the cases early, before adhe- 
sions with the cornea have formed, I remove the prolapsed 
iris and stroke the rest back into the anterior chamber, 
i. <?., I make a clean iridectomy. Prolapses from ulcers or 
wounds that are suppurating I never cut. The iris is a 
barrier against the entrance of the germs into the interior 
of the eye, a fact which not only is clinically well known, 
but which I saw verified by experiments on rabbits in which 
the uncut iris showed itself very resistant to the action of 
pyogenic bacteria. 
The healing process was, on the whole, satisfactory. The 
two cases of suppurative inflammation, of which the one 
ended in recovery, the other in loss of the eye, were owing 
to individual complications, not to the method. H. Knapp. 
66 
Posterior synechia were left in ten cases, but they were 
not extensive. 
More or less pupillary obstructio?i from the lens capsule 
required discission in six cases; in three others it has to be 
done now, and probably in some others later. 
Traumatic after-hemorrhage (No. 24) occurred in a patient who, 
with the best will, could not control his hands during his sleep nor 
avoid hurting his eye against the bedding or the wall. He was a 
stout asthmatic man, who would throw himself about in spite of 
all precaution and restraint. The blood totally filled the anterior 
chamber and hung out of the wound in clots. The hemorrhage 
occurred in a less degree four other times. The blood was ab- 
sorbed and left a good eye. 
Plastic capsulitis with congestion of the iris and ciliary body 
occurred in one case (No. 18), which was rather remarkable. 
From the centre of the pupil a shred of capsule passed over the 
anterior surface of the iris to the inner corner of the wound. It 
kept up an irritation and I was tempted to open the wound and 
extract it with a pair of forceps, for I feared that it might be the 
carrier of infection, the patient suffering from chronic dacryo- 
cystitis. When the irritation set in the wound was already 
perfectly closed, and there seemed to be no longer any communi- 
cation with the conjunctival sac, if indeed it had ever existed. 
Under atropine, leeches, and rest I noticed that the shred became 
smaller and finally disappeared. In the pupil there is now a 
somewhat dense capsule, which can be split with a knife- 
needle. 
The case ofpuriform kerato-iritis (No. 17) presented a good 
deal of interest. The cataract was white, not gray. The field of 
vision was contracted in its lower part. Prognosis unfavorable, 
but, as the other eye had an immature cataract of the same na- 
ture, I advised an operation. When the capsule was opened 
milky cortex overflowed the anterior chamber. The nucleus came 
out in pieces. The pupil was clear and central after the iris had 
been stroked back. When the antiseptic was injected into the 
anterior chamber the patient made a sudden start, which was 
followed by prolapse of the iris, and she kept up such a constant 
motion of the eye that I was unable either to stroke the iris back 
or to cut it off. I therefore anaesthetized her with ether, reduced 
the iris, and injected the antiseptic. The pupil was clear, round, 67 
On Cataract Extraction without Iridectomy. 
and central. The next day the gauze was moist. On the fourth 
day the edges of the wound were whitish, the cornea hazy, the 
anterior chamber dull ; a small' portion of iris lay in the wound. 
By cleansing the wound and washing the conjunctival sac out 
three times daily the inflammation gradually subsided. The pupil 
was drawn up, but the wound was normal. No sloughing of the 
cornea, no retraction of the scar, no diminution of the size and 
tension of the globe had taken place. Sight has improved up to 
about -g and promises to be further improved by a discission. 
I would say that the inflammation in this case had not 
been purulent, but lymphatic, had not cultivations from the 
wound secretion given us a well-characterized growth of 
staphylococcus pyogenes. Evidently, infection of the 
wound had taken place, but the inflammation was not 
intense enough to destroy the eye. 
The case of panophthalmitis (No. 22) teaches a lesson which is 
not new. I treated the conjunctivitis and dacryocystitis for 
months, and did not operate till the discharge had ceased. 
Yet the conjunctiva was still red and somewhat swollen. Opera- 
tion regular. Antiseptic precautions rigorous. No reaction for 
two days. Wound closed, clean ; anterior chamber, iris, pupil, and 
sight normal. Then patient got up in the night, sought for his 
purse in the dark, and went about as if he were well. Toward 
morning pain set in ; in the afternoon I found the edge of the 
wound infiltrated. The upshot was panophthalmitis. 
Two things might, and probably would, have averted this 
issue : (1) If the patient had continued to be quiet, the 
wound would probably not have been irritated and infected, 
as its aspect had previously been excellent. (2) If I had 
made a conjunctival flap it would probably have prevented 
the germs from invading the corneal wound on the third day. 
In all cases of conjunctivitis and dacryocystitis I shall 
henceforth—unless my views change—make a conjunctival 
flap. The conjunctival flap does not obviate, it perhaps 
favors, primary infection—i.e., infection during the operation. 
But against this we may protect our patient by scrupulous 
asepsis and antisepsis. Sterilizing the conjunctival and 
lachrymal sacs before the operation, irrigating the wound 
during the operation, and sterilizing the anterior chamber H. Knapp. 
68 
and the conjunctiva after it, will prevent primary affection, as 
it did in the case under consideration. When the eye has to 
be kept bandaged for a few days, the bacteria, multiplying 
in the conjunctival sac, may come in contact with the edge of 
the conjunctival wound, where, as experiments demonstrate, 
they do no harm, but the conjunctival flap, the inner sur- 
face of which is united to the underlying tissue, prevents 
them from reaching the edge of the corneal wound. If the 
lips of the wound do not apply accurately, but, as frequently 
occurs, the corneal lip projects somewhat over the scleral, 
bacteria will have easier access, and, if the patient be rest- 
less and move his eye, they are directly stroked into the 
wound, the wound is not only more efficiently inocu- 
lated, but the abundant tissue juice, poured out from its 
irritated lips, furnishes an appropriate nutriment for the 
microbes. 
The safest treatment in dacryocystitis is, of course, to de- 
stroy the sac, postponing the operation until the conjunctiva 
has become white. 
5.—Results. 
The visual acuteness obtained has been as follows 
No. of 
No. of 
s. 
cases. 
S. 
cases. 
n 
2 
A°ij 
. I 
u 
3 
sV(T 
. 
. I 
» 
4 
sVxr 
. 
. i 
3 
2"oir 
. I 
w 
5 
’2‘0‘TT 
. 
. I 
6 
o 
. I 
If with regard to the perfection of the operative results, 
we call those cases ideal recoveries in which the pupillary 
area is not obstructed by inflammatory products, the pupil 
is central and movable, even if a few filiform adhesions 
are present, we have obtained eighteen perfect or ideal re- 
coveries among twenty-nine cases—i.e., 66 %. 
There was one case of loss. All the imperfections in the 
healing process that have been noted can be called un- 
important ; namely, a few cases of oval or displaced pupil, 69 
On Cataract Extraction zvithout Iridectomy. 
and three cases in which the capsular obstruction was made 
somewhat denser by inflammatory products, yet not so 
much as to require any other after-operation than a simple 
discission with a knife-needle. 
6.—Comparison of the Two Methods. 
If we compare the simple extraction with the extraction 
combined with iridectomy, we find as advantages of the 
former the following : 
1. It preserves the natural appearance of the eye. 
2. The acuteness of vision, other things being equal, is 
greater. 
3. Eccentric vision and “ orientation ” (correct localiza- 
tion of objects in the visual field) are much better, adding 
a great deal to the comfort and safety of the patient. 
4. Parts in direct connection with the ciliary body, such 
as shreds of the capsule and iris, are not so liable to be 
locked up in the wound and thus transmit morbid conditions 
to the most vulnerable part of the eye, the ciliary body. 
5. It may not necessitate so many after-operations. 
As disadvantages may be mentioned : 
1. The technique of the operation is more difficult in all 
its parts : (ci) The section must be larger, to let the lens pass 
through an aperture, the size of which is diminished by the 
iris lying in it; it must be more accurate to secure coapta- 
tion, and it must be more rapidly performed in order to 
prevent the iris from falling before the knife. (b) The 
opening of the capsule requires a deeper introduction of the 
cystitome into the anterior chamber. (c) The expulsion of 
the lens is more difficult, and (d) the cleansing of the pupil- 
lary area is much more troublesome than in the combined 
extraction. 
2. Prolapse of iris and posterior synechiae are more nu- 
merous. 
3. It requires a quieter and more manageable patient 
during and after the operation than is needed in the com- 
bined extraction. 
4. It is not applicable to all patients, whereas combined 
extraction can be used as a general method. H. Knapp. 
70 
7.—Indications for the Iridectomy. 
This brings me to the last point which I want to consider, 
namely, when should an iridectomy be made. 
1. When in case of fluidity of the vitreous and rupture of 
the suspensory ligament of the lens, the cataract on pressure 
does not present in the wound, but only vitreous escapes. 
This occurred in the case of Mr. E. S. R., set. sixty-five, oper- 
ated on Oct. 11, 1886. After a regular corneal section, fluid 
vitreous escaped. When the cystitome was pressed on the capsule, 
the lens receded. The speculum was removed, and an unsuccess- 
ful attempt made to expel the lens by pressure through the lids. 
A further escape of vitreous was the only consequence. The 
speculum was reinserted, a small piece of iris exsected, the specu- 
lum removed, and the lens in its capsule pressed out with the lids, 
without further loss of vitreous. Recovery undisturbed. Sight good. 
2. When the section is insufficient and the iris, in the 
attempt to expel the lens, has been pushed into the wound, 
and vitreous presents or escapes. 
This happened in the first patient on whom I tried the method. 
The exsection of the protruding iris made the completion of the 
operation easy. Result good. 
3. When during the operation the iris has been bruised 
or injured. 
This happened in the case of Brother C., set. sixty-seven, who 
had a hypermature cataract. During a tedious attempt to extract 
the thickened centre of the anterior capsule with a pair of forceps, 
the iris was caught between the branches, and so much bruised 
that I thought it advisable to exsect the injured portion. After 
this was done the lens came out easily, and the whole capsule was 
then extracted without an effort. Recovery and result good. 
4. When the sphincter is unyielding, more especially 
when a peripheric piece of iris falling before the knife has 
been exsected. I would rather cut a rigid sphincter than ex- 
pose the patient to prolapse of vitreous in the attempt to 
overcome its contraction by undue pressure.1 
5. When the iris, after the expulsion of the lens and 
cleansing of the pupillary field, proves irreducible. 
1 I successfully acted on this principle in a case operated on, Feb. 27, 1887. 71 
On Cataract Extraction without Iridectomy. 
This happened in three patients, all of whom, after the iri- 
dectomy, made a good recovery. I include in this category 
all cases in which the pupil does not become perfectly central 
and round. They indicate lack of elasticity of the iris tis- 
sue, and are not to be trusted, though in some of them the 
paralysis of the sphincter may be transient. It is better 
to exsect a piece of iris on the spot than to run the risk 
of a subsequent prolapse. When a prolapse is found on 
the second day, it may or may not be cut, but after the 
second day it is advisable, I think, not to touch it. The 
experience in the series under consideration has been in 
favor of leaving it alone. 
To conclude, I may be allowed to express my opinion 
on the value of the method of extraction without iridec- 
tomy, as follows : 
Simple extraction is an operation of the highest order, and 
practicable in the majority of cases with the same degree of 
safety as the extraction combined zvith iridectomy. In a con- 
siderable minority, however, the latter method is preferable ; 
in a number of cases the indications for the iridectomy mani- 
fest themselves before, in others only during, the operation. g. p. putnam’s sons, printers, 
NEW YORK.