DESCRIPTION OF A FEW OF THE RARER COM- 
PLICATIONS OCCURRING DURING AND FOL- 
LOWING CATARACT EXTRACTION. 
BY 
CHARLES A. OLIVER, A.M., M.D., 
ONE OF THE ATTENDING SURGEONS TO THE WILLS EYE HOSPITAL ; ONE OF THE OPHTHALMIC 
SURGEONS TO THE PHILADELPHIA HOSPITAL, ETC. 
Reprinted from the Archives of Ophthalmology, Vol. xxv., No. 3, 1896. DESCRIPTION OF A FEW OF THE RARER COM- 
PLICATIONS OCCURRING DURING AND FOL- 
LOWING CATARACT EXTRACTION? 
By CHARLES A. OLIVER, A.M., M.D., 
ONE OF THE ATTENDING SURGEONS TO THE WILLS EYE HOSPITAL ; ONE OF THE OPHTHALMIC 
SURGEONS TO THE PHILADELPHIA HOSPITAL, ETC. 
THE belief that the few following experiences, which 
have been gathered together out of a number of 
less interesting observations of the same character, might 
be of some interest to the medical profession, and the hope 
that the methods adopted to immediately relieve the unex- 
pected conditions here encountered, might prove of some 
value to other observers situated under similar ciruumstances, 
have been the inducements to the writer to place the present 
series on record. 
In every case the acme of good result was obtained by 
prompt and careful attention to conditions that if left alone 
would have most probably led to disastrous consequences. 
Case i.-Breakage and loss of point of von Graefe knife in the 
path of the wound of counterpzmcture ; szibseqzient uncoznplicated 
sinzple extraction with almost normal vision ; szzccessful simple ex- 
traction in fellow eye. 
On the 4th of May, 1894, the writer whilst making the counter- 
puncture for the extraction of a mature cataract in a fifty-two- 
year-old man, found that, even with sufficient force to show a 
distinct bending of the portion of a narrow von Graefe knife that 
was in the anterior chamber, it was impossible, without doing con- 
siderable damage to the organ, to complete the cut. Upon the 
1 Read before the April, 1896, meeting of the Section on Ophthalmology 
of the College of Physicians of Philadelphia. 
Reprinted from the Archives of Ophthalmology, Vol. xxv., No. 3, 1896. 308 
Charles A. Oliver. 
withdrawal of the knife, about one half a millimetre's length of 
the end of the blade was found to be missing. 
The aqueous humor was allowed to re-acumulate, and the tip of 
the knife could be plainly seen through the corneal membrane, 
imbedded in the scleral tissue. Attempts at removal, with both 
a strong magnet and a pair of fine iris forceps introduced through 
an opening made directly over the position of the knife tip, failed, 
without the probability of inducing severe traumatism, to secure 
the foreign object. Atropine was instilled and the eye was lightly 
bandaged. Very little reaction, and only that which was pro- 
duced by the efforts to remove the piece of steel, took place. 
On the 14th of September of the same year, a smooth simple 
extraction through a corneal incision, so made as to avoid the 
position of the foreign material, was made by the writer. A slight 
prolapse of the iris, which was readily reduced by eserine and 
pressure, appeared on the third day. The after-treatment was 
uneventful, and corrected vision rose to nearly normal. 
On the 18th of September, 1895, the fellow lens, which came 
away in its capsule, was successfully delivered by a simple ex- 
traction made under cocaine anaesthesia, as was done with the 
previous operation. Corrected vision with this eye also became, 
almost, if not quite, normal. 
At present writing, nearly two years later, the eye with the 
minute fragment of steel imbedded in the sclera, is perfectly 
quiet, and vision is as good as before. 
Case 2.-Dislocation of crystalline lens into the vitreous chamber 
far up and back of the ciliary body; recovery and delivery with 
a peculiarly shaped wire loop ; perfect result. 
On the 23d of October, 1891, the writer made a smooth corneal 
incision and a clean upward iridectomy as the first parts of an 
operation to remove a hypermature cataract in a sixty-three-year- 
old man. Upon incising the toughened capsule with a cystotome, 
an almost fluid, gelatinous-like material escaped into the anterior 
chamber. At the same time, the nucleus and the capsule were 
dislocated so far up and back of the ciliary body that they could 
not be seen. A wire loop, so bent that the extremity was curved 
at a right angle to the shank of the instrument, was gently carried 
in in such a manner that the nuclear and capsular mass fell down 
upon the concave surface of the wire. Careful downward, fol- 
lowed by gentle upward and outward, traction brought the mass Complications in Cataract Extractions. 
309 
through the corneal incision, leaving a clear pupil; the proced- 
ure being complicated only by the loss of a few drops of vitreous. 
The iris edges were entirely freed and the corneal wound was 
thoroughly cleansed. 
The wound was closed on the following day and recovery was 
undisturbed. 
Case 3.-Modified simple extraction ; spontaneous expulsion of 
crystalline lens into the air with the loss of but a few drops of vitreous 
humor ; recovery with normal vision. 
On the 14th of February, 1894, during an extraction with periph- 
eral iridectomy, just after making the capsulotomy, and whilst 
the eye was untouched, the patient, a man, suddenly and without 
apparent cause, became so unruly that he closed the lids violently 
over the eye and as quickly opened them, when the lens was 
forcibly shot over his head upon the pillow beyond, just as if it 
had been driven from a toy gun ; this was followed by the loss of 
a few drops of vitreous humor. The operative field was carefully 
cleansed and the eye was closed by a pressure bandage. 
Upon the third day the corneal wound was united and the 
anterior chamber reestablished. The small clean iridectomy in 
the radial fibres, with the bridge of iris tissue, including the 
sphincter pupillae between the original pupil and the coloboma, 
was plainly visible. Upon the evening of the fourth day, a sharp 
iritis appeared, though it rapidly yielded to leeching, atropine, and 
ice compresses. In a few days all reaction ceased, and the eye, 
with its double pupil, quickly recovered. 
Case 4.-Simple extraction in an unruly patient; spontaneous 
ejection of lens into the air without any loss of vitreous humor ; 
prolapse of iris on the fifth day, with incipient localized iritis ; unin- 
terrupted recovery with round pupil and almost normal vision. 
On the 8th of January, 1894, but five weeks previous to Case 3, 
a similar complication occurred. The patient, a seventy-five-year 
old man, after having had the operation for simple extraction 
carried without accident as far as getting ready for the delivery 
of the lens, suddenly squeezed the lids together. This untoward 
act was immediately followed by the ejection of the greater part 
of the lens over the patient's head, falling upon the pillow just 
back of his ear. The operation was continued and the toilet was 
completed as though nothing had happened. 
On the fifth day, in spite of eserine and bandage which had 310 
Charles A. Oliver. 
been used upon account of several threatenings, the iris bulged 
out of the incision in the cornea for several hours. Four days 
later, by reason of a slight discoloration of the upper-inner part 
of the iris tissue, and the appearance of a couple of faint synechia 
in the position of the iris that had been prolapsed, atropine was 
substituted for the eserine. The pressure bandage was continued. 
In five days' time, the corneal wound was firmly closed. The iris 
was of good tint, the pupil was round and easily dilated, and the 
anterior chamber was thoroughly re-established. 
Complete recovery rapidly ensued, and vision, properly cor- 
rected, rose to almost normal, and has remained so. 
Case 5.-Ectropium, lachrymal obstruction, and senile cataract ; 
modified Dieffenbach and Bowman's operations, resulting in the cure 
of the ectropium and the relief of the lachrymal symptoms ; cataract 
extraction ; evacuation of aqueous humor from the anterior chamber 
by unexpected movement of patient's eye ; operative procedure tempo- 
rarily postponed and lens extracted without accident j lids forced 
down upon eye by patient, producing a prolapse of the iris and the 
vitreous ; excision of protruding portions, obtaining a free iridectomy 
and a clean corneal incision ; recurrent hemorrhages from iris tissue ; 
recovery with good vision. ■' 
In this case, occurring in a seventy-year-old man, at the com- 
pletion of the puncture with a very narrow von Graefe knife, the 
patient suddenly turned his eye inward, enlarging the corneal 
wound and evacuating the anterior chamber. After bandaging 
the eye, and waiting an hour or so, thus allowing the re-formation 
of the aqueous humor and the partial dilatation of the pupil, the 
anterior chamber was entered by a broad von Graefe knife 
through the same wound of entrance, and a well-curved flap, 
situated just within the corneal limbus, was secured. The capsule 
of the lens was freely incised with a cystotome and the lens gently 
delivered by the aid of two spatulas without loss of vitreous, leav- 
ing a clean round pupil. 
After the instruments had been removed and preparations were 
being made for the toilet of the operation, the patient, suddenly 
and without warning, forcibly contracted the lids down upon the 
eyeball and forced out about half a drachm of fluid-vitreous, 
causing the iris to prolapse. A clean cut and well shaped colo- 
boma of the iris was secured by two cuts with the iris scissors 
passed through the oozing vitreous, and a broad bead of vitreous Complications in Cataract Extractions. 
311 
was quickly snipped off with an extremely sharp pair of iris 
scissors. The edges of the wound were carefully cleansed and 
the eye was evenly and smoothly bandaged with a flannel roller. 
In two days, the 20th of September, 1893, the corneal wound 
was healed, and there was some blood in the anterior chamber. 
On the following day the use of atropine was commenced. On 
the fourteenth day a small isolated vascular and painless nodule 
appeared in the iris upon the upper-outer edge of the coloboma. 
Careful examination showed that this nodule was a blood cyst 
formed between the endothelium and the substantia propria of the 
iris. In nine days the blood gradually disappeared and the 
nodule flattened, allowing a faint secondary cataract to be seen. 
A second hemorrhage, this time from the outer pillar of the iris, 
which became absorbed in two weeks, took place. 
The after-history was uneventful and careful correction gave an 
excellent acuity of vision. 
Case 6.-Extraction with iridectomy ; wound healed in twenty- 
four hours and reopened the third day by an accidental blow from an 
attendant's elbow ; reunion of incision, with subsequent attainment of 
normal vision. 
On the 18th of March, 1895, a perfectly smooth extraction with 
iridectomy in a sixty-year-old woman did well, and remained free 
from all irritation until an attendant, who was resting for a few 
minutes in bed alongside of the patient, inadvertently raised her 
hands over her head and struck the operated eye with her elbow. 
The wound opened and gaped and was occupied by a small 
blood clot. Atropine was instilled, the eye was firmly bandaged 
with a flannel roller, and the patient was placed in bed. 
In a few days the wound firmly united, when active treatment 
was gradually reduced and discontinued in two weeks. Later, 
corrected vision became normal. 
Case 7.-Extraction in capsrile with narrow iridectomy; acci- 
dental injury to eye on second day with recurrent hemorrhages from 
iris tissue ; recovery with nearly normal vision. 
On the 8th day of June, 1892, for necessary reasons, the writer 
removed an immature cataract from a sixty-five-year-old man. 
A broad incision with a narrow von Graefe knife, made sufficiently 
wide to allow an easy egress of the lens during delivery, was 
made. A broad horizontal cut in the upper part of the capsule 
was obtained with a cystotome. The lens was gently delivered Charles A. Oliver. 
312 
and found to be entirely covered with its capsule. The wound 
surface was irrigated. No loss of vitreous took place. 
Upon the morning of the second day, an attendant, whilst 
dressing the eye, accidentally knocked his hand against the organ, 
and broke open the corneal incision, producing sharp ocular pain 
and the formation of recurrent blood clots in the anterior cham- 
ber. Ice compresses upon pressure bandages, rest in bed, and 
atropine soon relieved the conditions. 
A correcting lens brought the vision to nearly normal. 
Case 8.- Uncomplicated simple extraction ; imperfect closure of 
corneal incision with leakape of aqueous humor ; forward displace- 
ment of the iris with annihilation of the anterior chamber ; com- 
mencing iritis with formation of anterior synechiaj breakage of 
synechia with restitution of pupillary space ; perfect result. 
On the 14th of November, 1895, the writer did a smooth and 
uncomplicated simple extraction upon a healthy man of seventy- 
nine years of age. Without apparent reason and with the most 
judicious care, the wound failed to heal and the anterior chamber 
remained open. On the fifth day, two minute anterior synechiae 
situated just at the pupillary edge determined the employment of 
mydriatics. Scopolamine in | per cent, strength was freely though 
carefully used in conjunction with firm pressure. These, with 
unirritating flushings with boric acid solution, soon broke several 
fine flat and a few string-like synechiae, allowing the iris to fall 
into its proper place, the pupil to become practically round, and 
the corneal wound to firmly unite. 
A subsequent capsulotomy for a faint though disturbing sec- 
ondary cataract brought vision to normal. 
Case 9.-Simple extraction of hypermature cataract in a sixty- 
two-year-old woman suffering from recurrent mania ; post-operative 
insanity ; good result. 
On the 6th of April, 1894, the writer removed a hypermature 
cataract without any accident from a sixty-two-year-old woman 
by simple extraction. The cortex was degenerated into a milky- 
white fluid. The corneal wound was healed on the third day. 
Upon the morning of the third day the patient became mania- 
cal and tried to tear the dressings from her eye. She was some- 
what quieted by the hypodermatic use of hyoscine. During the 
night of the same day, she endeavored to take her life by jumping 
out of the window, but was prevented by the prompt assistance Complications in Cataract Extractions. 
313 
of an attendant. Subsequently, she tried to smother herself in a 
small closet. In spite of these circumstances, which later were 
unceasingly guarded against, the eye made an excellent recovery. 
It was afterward learned from her family that years previously 
she had had recurrent attacks of mania. 
Remarks.-Careful consideration of these cases will 
show how important it is to thoroughly and quickly appre- 
ciate the best course of action to be taken during such 
emergencies. 
The inability of immediate recognition of the unexpected 
condition or dilemna ; the merest tittle of difference of 
opinion of what next best to do ; the slightest hesitancy in 
planning how to endeavor to get rid of any disturbing fac- 
tor; and the want of knowledge how at times to make an 
error or a fault subserve an useful purpose, must all show, by 
the recital of experiences of others, how important informa- 
tion regarding such accidents as these must be when the 
time of emergency appears. 
As each operator finds himself face to face with a compli- 
cation that he has never heard of or that he has never had the 
privilege to have seen before, such empiricisms as given in 
this article, it seems to the writer, must have some worth 
and use: in this spirit the present communication is given. "Cbc Iknickcrbocker press, 1Rew york