CLINICAL HISTORY OF A CASE OF SUCCESS- FUL EXTRACTION OF A PIECE OF STEEL FROM AN IRIS AND LENS BY AN IRI- DECTOMY, WITH SUBSEQUENT ABSORPTION OF THE LENS AND RECOVERY OF NORMAL VISION. Read in the Section of Ophthalmology, at the Forty-third Annual Meet- ing of the American Medical Association, held at Detroit, Mich., June, 1892. BY CHARLES A. OLIVER, M.D., ATTENDING SURGEON TO WILLS' EYE HOSPITAL; OPHTHALMIC SURGEON TO THE PRESBYTERIAN HOSPITAL, ETC., PHILADELPHIA. Reprinted from "Journal of the American Medical Association,'' September 3, 1892. CHICAGO: PUBLISHED AT THE OFFICE OF THE ASSOCIATION. 1892. CLINICAL HISTORY OF A CASE OF SUCCESS- FUL EXTRACTION OF A PIECE OF STEEL FROM AN IRIS AND LENS BY AN IRIDECTOMY, WITH SUBSEQUENT ABSORPTION OF THE LENS AND RECOVERY OF NOR- MAL VISION. BY CHARLES A. OLIVER, M.D., ATTENDING SURGEON TO WILLS' EYE HOSPITAL; OPHTHALMIC SURGEON TO THE PRESBYTERIAN HOSPITAL. ETC., PHILADELPHIA. On the second day of March, 1891, H. M., set. 29 years, a blacksmith, came to Wills' Eye Hospital, complaining that his right eye had become inflamed from the supposed lodg- ment of some foreign substance in the cornea one day pre- viously. Attempts at extraction had made the eye very painful, which was relieved by the use of a weak infusion of tea leaves. Two years previously, the same eye had been struck by a piece of steel measuring roughly about 4 milli- metres square, the foreign body not penetrating the eye, though leaving the organ irritated for several days' time. Vision was in no way subsequently disturbed, and the organ had never become troublesome up to the time of the second accident. At the time of the first examination, a small mass of for- eign substance was found imbedded in the upper inner quadrant of the cornea, about 3 millimetres above the hori- zontal meridian, and in an almost identical position in the underlying iris, there was a round black bead about the size of the head of a small pin, from the upper part of which could be seen, by strong oblique illumination, a line of metallic-like lustre. A faint deposit of precipitates on the membrane of Descemet, with slight pericorneal injection, 2 existed, though there was no evidence of any ciliary tender- ness. Vision with this eye had fallen to slightly less than one-eighth (5-40?), and the accommodative range was lim- ited to the reading of type 0.75 D. from 13 to 30 centimetres. Through the undilated pupil, the eyeground could be fairly seen, it appearing healthy. No abnormality could be seen in the left eye, its vision being one and one-half and the accommodative range extending from 13 to 36 centime- tres for 0.50 D. type. The foreign substance was removed from the cornea, and upon consultation with Dr. Wm. F. Norris, an immediate iridectomy, including the piece of supposed metal, was ad- vised ; the latter procedure, however, the patient refused to accept. Upon this decision, a soothing collyrium of boric acid and a Liebreich bandage were ordered, with a request that he should report in the morning. Upon the following day the patient returned to the hos- pital, stating to the resident surgeon, Dr. Zimmerman, that an exacerbation of pain in the eye during the night, had decided his willingness to return for operation. He was immediately put to bed, bowels were purged, eyes bathed freely, and he was kept quiet until the next clinic day (March 4), when upon reexamination, the anterior chamber was found somewhat shallow, and the lens was slightly swollen and becoming opaque in the position of the situa- tion of the foreign body. At this time, the iris tissue in the vicinity of the traumatism was noted as muddy in appear- ance, with the formation of a synechia at the upper pupil- lary edge, the ciliary region being slightly tender to the touch. In spite of these inflammatory conditions, a narrow incision with an angular keratome was made at a position in the cornea just inside of the limbus, corresponding with that of the foreign body, and an iris forceps passed in and the object (a flat piece of steel of about 1 millimetre in diameter), with the surrounding bruised and inflamed iris tissue, grasped, brought out and excised-making a clean iridectomy. The lens area exposed to view showed the point of the original wounding of the capsule, with the situation of the greatest amount of swelling and opacity. Atropine and a light pressure bandage were applied, and the internal administration of small tri-daily doses of calomel, with rest in bed, was enjoined. In two days' time, the wound in the cornea had healed, the inflammatory symptoms had greatly subsided, and the lens matter had begun to rapidly absorb, until on the 18th of the month, there was but one plug of lens material to be seen, this being situated in the lower portion of the anterior chamber. Eleven days later, the remaining lens mass had disappeared, the eye was quiet, 3 and vision could be brought to almost normal by the use of a + S. 11 D. lens. At the present time, about fifteen months after the acci- dent, there is a perfectly quiet eye, with a narrow coloboma up and in ; an eye which, in spite of a few fine linear folds of capsule at the lower inner border of the pupil, which can be barely recognized during moderate pupillary dilatation, and a faint concentric ring of lens and capsular dfibris, which can only be seen at the periphery of the coloboma, possesses normal acuity of both central and excentric vision, the patient possessing an acuity of 5-5 with - f - S. 11. D. O + C. 0.50 D. ax. 100°, and reading many words of type 0.25. D. fluently at 8 inches distance with an additional convex lens of 4 diopters strength. The case is interesting upon account of the immediate curative effects of an iridectomy which removed an offend- ing substance and its bed of bruised and inflamed iris tis- sue, thus allowing a free, rapid swelling and disintegration of lens matter to uninterruptedly take place during a watch- ful and careful after-treatment; this immediate happy result being supplemented by a subsequent restoration of vision to full acuity, with but little necessary correction of astig- matism, in a comfortable and unirritated organ.