DELUSIONS 
IN 
EYE SURGERY. 
BY 
JOHN B. ROBERTS, M. D., 
PROFESSOR OF ANATOMY AND SURGERY IN THE PHILADELPHIA POLYCLINIC ; 
PROFESSOR OF SURGERY IN THE WOMAN’S MEDICAL COLLEGE OF 
PENNSYLVANIA ; LECTURER ON ANATOMY IN THE 
UNIVERSITY OF PENNSYLVANIA. 
PHILADELPHIA: 
1889. 
Reprinted from the Medical and Surgical Reporter, 
September, 1889. PRESS OF B. F. ADAMS, 
ELEVENTH AND MARKET STS., 
PHILADELPHIA. DELUSIONS IN EYE SURGERY.' 
To bring before you in an interesting manner topics of practical 
value, relating to surgery, is a much more onerous obligation than to con- 
fine my remarks to the constitutional limit of thirty minutes. The ever 
increasing weariness of his audience must compel every observant speaker 
to fulfil the latter obligation ; but in meeting the other duty he has no 
aid from his hearers, who sit complaisantly waiting for the new and valu- 
able, often never given them. I can do no better perhaps on this occasion 
than give my personal views on some of the subjects constantly brought 
to my attention by daily routine work. Since much of my time is occu- 
pied in that branch of surgery which pertains to diseases of the eye, and 
as there is no special Address in Ophthalmology this year I have thought 
it not improper to touch, to-day, upon “ Delusions in Eye Surgery,” 
which may be looked upon as a sort of supplement to a former address on 
“ Delusions in General Surgery.” 
Ophthalmoscope.—It is a very erroneous idea that no one need 
acquire a knowledge of ophthalmoscopy except that man who expects to 
limit his practice to diseases of the eye. My own experience in discover- 
ing unsuspected Bright’s disease and basal disease of the brain, and above 
all in proving the probable absence of these and similar conditions by an 
examination of the ocular fundus, makes me feel sure that the graduate 
ignorant of the use of the ophthalmoscope is seriously handicapped in the 
race for professional success and income. 
A cheap instrument and an ordinary lamp, or even a candle, are 
all that is needed ; provided the observer have a little practical experi- 
ence in the use of the ophthalmoscope itself. If a good Argand burner or 
lamp is used, it is not even necessary to have a dark room. I seldom 
shut the daylight out of my office in examining the retina and intra- 
ocular structures; and when I draw the curtain over the skylight it is 
never so dark as to interfere with my seeing every object in the room. 
The room with blackened walls, from which every ray of outside light 
i Address in Surgery of the Medical Society of the State of Pennsylvania, for 1889. 4 
ROBERTS, 
and every breath of fresh air is excluded, such as those in which many 
of us have studied ophthalmoscopy, is entirely unnecessary for the practical 
work of the consultation room ; though it is at times needed for interest- 
ing theoretical studies. It is thus seen that no paraphernalia are needed for 
practical ophthalmoscopic work ; while the ophthalmoscope itselfis almost 
as necessary for the satisfactory practice of surgery as is the clinical ther- 
mometer. 
Refractive Errors.—The correction of refractive errors by retinos- 
copy, or other ophthalmoscopic methods is delusive. The observer may, 
I admit, reach a result which is valuable in very young children and 
helplessly ignorant adults, because the more accurate examination by 
means of test lenses and test letters is then unavailable ; but for accuracy 
of result the examination by test lenses is unsurpassed. 
The attempt to correct astigmatism and hypermetropia without 
paralyzing the accommodation muscle with atropine, or other mydriatic, 
is even more delusive and uncertain. I have more than once seen hyper- 
metropes wearing concave glasses given by oculists who had mistaken a 
spasm of accommodation for near-sightedness. This error would never 
have been committed by such learned ophthalmologists, if they had not 
attempted the impossible. My case book shows many long-sighted per- 
sons who on first examination seemed to require a concave lens, but 
whose apparent near-sightedness soon became a long-sightedness under 
the use of atropia or homatropine. 
Such patients when reading may even hold the book close to their 
eyes, thus assuming the very pose of a myope. To prescribe the spectacle 
lens thus indicated would be to give at once better vision, perhaps; but 
future aggravation of symptoms must be the result of such malpractice. 
In adults approaching the senile period atropine must be employed 
with caution, as it may in rare instances induce glaucoma and cause 
dangerous inflammatory symptoms. Fortunately patients at this age 
have less focusing power in the ciliary muscle, and seldom require my- 
driatics in determination of the refractive condition. 
Another popular delusion with which I often have to contend and 
which medical men frequently share with the laity, is that a myopic or 
near-sighted eye is a strong eye. Patients fear blindness because of the 
pain and nervous symptoms associated with hyperopia or long sight, but 
consider near-sightedness a mere disadvantage in vision, compensated for 
by the supposed strength of a near-sighted eye. Nothing can be further 
from the truth than this opinion. Hypermetropic eyes do not become 
blind ; but myopic eyes may from choroidal, sclerotic and retinal changes. 
Progressive myopia of a dangerous type is fortunately not excessively 
frequent, but its power of destroying vision is well known to oculists. 
This delusion as to the harmlessness of myopia deters many from early 
consultation with the ophthalmologist, whereby precious time is often 
lost and changes allowed to become established that might have been pre- 
vented by rational treatment. 
Again, it is often difficult to convince persons that the wearing of 
correcting lenses is a therapeutic or prosthetic measure. They argue that 
to begin the use of spectacles is deleterious because thereafter the patient DELUSIONS IN EYE SURGERY. 
cannot see without them ; forgetting that while in some cases the neces- 
sity for their use is temporary, in others it is continuous because of the 
pathological condition of the eye. As the orthopaedic surgeon prescribes 
crutches, braces, or high sole shoes, sometimes as a means of cure, some- 
times as an adjuvant to an irremediable condition, so the ophthalmic 
surgeon uses his prisms and his cylindrical and spherical lenses. It is 
astonishing too how many intelligent persons believe that any defective 
sight, less than total blindness, ought to be relieved by spectacles. To 
speak of a man being partially blind when the exterior of the eye shows 
no blemish seems to them a falsehood ; and they expect lenses to correct 
the so-called k‘ near sight.” 
Many physicians seem unfamiliar with the fact that a tilted head 
or half closed eye is frequently not an affectation but an indication of 
astigmatism or other refractive defect. The unusual pose or grimace in 
such cases is due to the effort to see distinctly and is readily curable by 
suitable spectacles. 
Strabismus.—An ophthalmic delusion resulting in disastrous conse- 
quences to vision is the belief that strabismus, or cross eyes, occurs in 
young children as a result of imitation of a strabismic companion or 
attendant. As a result of this erroneous belief the child is reprimanded 
and intelligent medical skill neglected. The muscular deviation at last 
becomes constant or so marked that the parents are driven to consult an 
oculist. Then they hear to their surprise that the deformity is due to a 
congenital optical defect in the eyes; and are told that the visual power of 
the defective organ has been by delay hopelessly lost. The disfiguring 
deviation can be rectified by operation to be sure, but the eye remains a 
partially blind one during the remainder of life. All should be familiar 
with the connection between hypermetropia and strabismus, and should 
teach every parent that cross eyes always need immediate attention from 
a skilled oculist. 
Silver Nitrate.—The erroneous belief that silver nitrate is a panacea 
for sore eyes has caused loss of vision to many persons. It is seemingly 
used by some physicians in all ocular inflammations without an attempt at 
diagnosis. Every ophthalmologist of experience has seen irremediable 
blindness from complete circular adhesion of the iris to the anterior cap- 
sule of the lens, because the attending physician failed to recognize a 
syphilitic iritis. The latter has dropped solution of silver nitrate or other 
astringent into the eye, thinking he had inflammation of the conjunctiva 
to deal with ; and thus has permitted plastic material to glue the iris and 
lens together as a result of the iritic inflammation. It should be known 
to all medical men that silver nitrate, though a good remedy in conjunc- 
tival disease, can, even in that case, be readily substituted by other 
remedies and that its use in iritis is malpractice. It would be better if 
the general practitioner never prescribed silver nitrate for any ocular in- 
flammation ; since even in conjunctivitis it may do harm by staining the 
tissues if used for too long a period. 
Atropine.—It is much safer to use a four grain solution of atropine 
whenever there is doubt as to the character of the inflammation than to 
use silver nitrate or any other astringent solution. If the case is one of 0 
ROBERTS, 
iritis the atropine will prevent inflammatory adhesion, if used early 
enough and in sufficient strength ; if conjunctivitis or inflammation of 
the cornea exists the atropine will not do harm. It is only in patients 
with a tendency to glaucoma that the use of atropine is to be feared. As 
these patients are comparatively few and usually of advanced life the 
danger of harm being done by erroneous diagnosis is not very great. 
Under forty years atropine can scartiely ever do harm ; and above that 
age only seldom. 
Scarification.—Silver nitrate has been the cause of much indirect 
harm because of the belief that it is indicated in all ocular inflammations. 
I seldom use it, even in conjunctivitis, except in the purulent form of 
that disease. I believe it equally true that many professed ophthalmol- 
ogists have a delusive fear of scarification in conjunctival engorgement 
and inflammation, and use instead various astringent remedies much less 
effectual in effecting a speedy cure. The immediate ease often given to 
my patients by free superficial scarification of the swollen and angry look- 
ing conjunctiva, and the rapid return to health resulting from its daily 
or bi-weekly repetition convince me of its great value in both acute and 
chronic inflammation of this mucous tissue. I supplement this treat- 
ment by hot water bathing and astringent eye-washes used at home. 
Foreign Bodies.—A curious popular delusion it is which teaches 
that a particle of dust or cinder blown into an eye by the wind may best 
be removed by rubbing the uninjured eye. Many have found by experi- 
ence that rubbing the unaffected eye is quickly followed by relief of pain 
in, and rapid recovery of, the other eye ; while rubbing the organ into 
which the sharp particle has blown usually results in increased pain and 
discomfort. This apparent proof by experience is negatived by the ex- 
perience of those who rub neither eye, but simply wait with the injured 
eye quietly closed, until the tears wash out the offending mote. This is 
the philosophy of the cure. If the eye is rubbed, the sharp edged par- 
ticle is embedded by pressure in the conjunctiva or cornea and cannot be 
removed by the flow of tears due to the irritation of its contact. If the 
patient, however, will content himself with simply closing his eyelids 
with the eyes rolled downward, the flow of tears will in a few moments 
carry the little particle of dust outside of the conjunctival sac. Hence it 
is that while he occupies his meddlesome fingers with rubbing the well 
eye, he allows the painful eye to cure itself by physiological therapeusis. 
Cataract Extraction.—There are some curious delusions, or super- 
stitions I may almost call them, about the extraction of cataract. Some 
operators never use a knife for the corneal incision after it has been once 
previously used for that purpose. If there is no one in his vicinity who 
can put a keen edge and point on the knife, and the surgeon is unable to 
do so himself, I can understand his need to send cutting instruments to 
a metropolis occasionally; but I fail to perceive how a single corneal in- 
cision can so dull a knife as to require its retirement from further service. 
I have used the same edge time and again for several operations of this 
kind ; and am constantly using resharpened knives which have done 
duty in my own and other hands for many years. DELUSIONS IN EYE SURGERY. 
7 
Success in ail branches of surgery depends much more on dexterity 
of the fingers than the newness of the knife. A good surgeon should be 
able to put a creditable edge on his own knives ; though in the case of the 
delicate knives of eye surgery this is hardly to be expected. 
For years the dressing and after-treatment of cataract extraction 
have been most abominable and unreasonable. After operation on even a 
single eye, both eyes have been so bundled up with cotton and bandages 
that the unhappy patient has been kept in absolute blindness for two 
weeks or more, the tears and secretions from the wounded organ dammed 
up within the lids, and the cutaneous surface of the lids and cheek 
macerated with what secretion succeeded in passing the barrier of the 
closed and compressed eyelids. In addition the patient is often kept 
in an absolutely dark room, through whose closed windows and doors a 
breath of fresh air can scarcely enter. 
Is it strange that severe conjunctivitis, keratitis, or iritis, is often 
found when the surgeon removes the heating dressings to take a timor- 
ous and momentary glance at the offended organ ? 
Recently light has dawned upon such mistaken and traditional 
surgery ; and many ophthalmic operators have come to adopt methods 
similar to those which I was taught by Levis some fifteen years ago and 
which I have always followed in every cataract I have ever operated 
upon. The fact that he in his most extensive practice had seldom ever a 
failure from causes due to the operation or treatment, and that I in a less 
number of years’ experience have had results not much inferior to his 
prove to me at least the advantage of simply closing the eyes with half 
ellipses of adhesive plaster applied to the upper lid. This is done in such 
a manner as to allow the secretions to drain away constantly and permit 
the frequent instillation of atrophia without disturbing the dressing. 
I am convinced also that it is a delusion to compel patients to wait a 
long time for spontaneous ripening of senile cataract, when the vision of 
both eyes is already so defective that business or pleasure is seriously in- 
terfered with. I have, I believe, hastened ripening of the cataract in 
such a condition by preliminary iridectomy and massage of the anterior 
capsule ; and I have within a few weeks, in another instance, certainly 
hastened cure by extracting the lens while not fully riper. As the patient 
on the twenty-ninth day after operation had, with correcting lens, vision 
equal to vfH, which is nearly perfect vision, the success of the operation 
on the still unmatured cataract cannot be questioned. Such an excellent 
result at so early a date is seldom equalled in operations on fully ripened 
cataracts; and is the more surprising here because the man, who went 
about the room after the first day, had not only a fall during convalescence 
but also a severe attack of malarial neuralgia, which kept him in bed for 
several days during the latter part of that period. 
Glaucoma.—An appalling delusion is that which mistakes glau 
coma, a very serious disease of the eye, for neuralgia of the brow. All 
physicians should recollect that pain about the brow, coming on in par- 
oxysms and associated with deterioration of vision, may be a symptom 
of glaucoma ; and that glaucoma, whether acute or chronic, goes on to 8 
DELUSIONS IN EYE SURGERY. 
total destruction of vision. The blindness may lie complete in a few days 
or hours in acute glaucoma ; or may not amount to absolute loss of vision 
until months or years have elapsed in chronic glaucoma. The neuralgic 
pain of glaucoma is more apt to be felt down the side of the nose than is 
the pain of any orbital neuralgia. At least this seems to me to be a 
clinical fact. No absolute diagnosis is possible without ophthmoscopic 
examination : but the character of the pain, the impaired vision, which 
by the way improves between the paroxysms of pain, the colored halo 
when the patient looks at a candle flame, and the insensitiveness of the 
cornea when touched with the end of a piece of thread are good rational 
indications of the imminent danger. Glaucoma should always be sus- 
pected when such conditions, or several of such symptoms, are present. 
Artificial Eyes.—There is a curious belief in regard to artificial eyes, 
which pertains however to manufacturers of glass eyes rather than to the 
surgeons who insert them. It is that the upper edge of the glass shell 
must have a notch in it to correspond with the elevation made by the 
pulley-like attachment of the superior oblique tendon. The truth is that 
no such notch is needed and that glass eyes made, as it is supposed, to fit 
into the left orbit frequently do better for the right orbit; and that on the 
other hand right eyes of glass are often the best for the left orbit. I never 
attempt even to keep my large stock of glasseyes separated into “ rights ” 
and “ lefts,” but have them promiscuously arranged, except as to color. 
Whether the notched edge goes up or down makes no difference. It is 
simply a question as to what shape sits best and looks most natural. 
The cicatricial changes made in the orbit by the original disease or by the 
operation determine the shape of glass eye most satisfactorily worn. It 
is entirely unnecessary to have a notch in either edge of the glass shell. 
Exophthalmos.—It is to-be regretted that the profession clings to 
the idea that it is difficult to relieve the unseemly bulging of the eyes, 
which sometimes persists after exophthalmic goitre has been successfully 
treated. A similar protrusion of the globe occasionally remains after 
operations for strabismus. These disfiguring conditions can be completely 
removed by the simple operation of freshening the edges of the eyelids at 
the outer can thus and putting in one or two sutures. The procedure if 
done under cocaine is so trifling as scarcely to justify the name of opera- 
tion. 
Iritic Adhesion.—Finally, I shall call attention to the unreasonable 
objection to operating on eyes hopelessly blind from complete adhesion of 
the iris to the anterior capsule of the lens. In these cases I believe an 
attempt should be made to restore some degree of vision by iridectomy 
and extraction of the lens. This is, I think, not very often attempted, 
because the prospects of success are far from good. Still, as vision is 
entirely destroyed, there is no danger of losing anything from undertak- 
ing an operative procedure; hence one that offers even such a slight 
chance of success should be advocated.