A Contribution 
TO 
THE SURGICAL TREATMENT 
OF 
Membranous Opacities in the Vitrous, 
Charles Stedman Bull, M. I)., 
New York. 
\From Transactions American Ophthalmological Society, 1888.] 
HARTFORD, CONN.: 
Press of The Case, Lockwood & Brainard Company. 
,i 888. A Contribution 
TO 
THE SURGICAL TREATMENT 
OF 
Membranous Opacities in the Vitrous, 
By Charles Stedman Bull, M. D., 
New York. 
[From Transactions American Ophthalmologic al Society, 1888.] 
HARTFORD, CONN.: 
Press of The Case, Lockwood & Brainard Company. 
1888. A CONTRIBUTION TO THE SURGICAL TREATMENT 
OF MEMBRANOUS OPACITIES IN 
THE VITREOUS. 
By CHARLES STEDMAN BULL, M.D., 
NEW YORK. 
Pathology teaches us that membranous and cord-like opaci- 
ties in the vitreous humor are not usually freely movable or float- 
ing, owing to the continuity of the original septa, which is more 
or less completely preserved, and to the consistency of the in- 
tercellular substance of the vitreous humor contained within 
these septa. When, however, the processes of retrogressive 
metamorphosis and degeneration set in, and the intercellular 
substance becomes fluid, then these membranous opacities may 
become freely movable, unless they have formed adhesions to 
the retina, choroid, or optic nerve, and even then they may 
often be seen to wave and flutter with every motion of the eye- 
ball. These membranes, no matter how delicate and cobweb- 
like they may be, resist all internal medication or local applica- 
tions, even though persisted in for a long time, and such are the 
vitreous opacities which seem suitable for operation. Von Grcefe 
was the first to suggest the possible advantage of surgical in- 
terference in such cases, and he gives in detail the history of a 
case of a young woman, aged nineteen, in whose left eye a 
moderately thick membrane extended all across the posterior 
part of the vitreous. Vision in this eye was reduced to count- 
ing fingers at eighteen inches, and the patient could read some 
words of Jaeger No. 20 with spherical + (1. Von Grcefe rotated 
the eyeball strongly inwards, and then plunged a keratonyxis 
needle through the sclera, between the external and inferior 
recti, just in front of the equatorial region, parallel to the plane 
of the iris and behind the lens, and divided the membrane in 
several places from before backwards. In a few days the pa- 
tient could read Jaeger 8 with sph.-f- (1, and, 3 weeks later, she 
could read Jaeger 3 with the naked eye. The ophthalmoscope 4 
Bull : Surgical Treatment of 
showed a retraction of the membrane from the center towards 
the periphery, and a subsequent absorption of its remains. 
Ten months after the operation not the slightest trace of opac- 
ity could be discovered in the vitreous, eccentric vision was 
perfectly normal, and central vision was almost normal. (See 
Archivfiir Ophthalmologic, IX, 2, page 102, 1863.) In the ex- 
perience of the writer, this operation has proved positively use- 
ful in some cases. There are some opacities of the vitreous, 
such as are seen after hemorrhages or inflammatory processes 
in the choroid, which are capable of undergoing retrogressive 
metamorphosis, and disappear wholly or in part. But we often 
meet with membranous opacities which resist all treatment, and 
not only materially affect the vision, but become still more dan- 
gerous through their traction on the retina at their points of 
adhesion. If we succeed in dividing such membranes, we not 
only gain a direct optical effect and improve the vision, but may 
also start up an absorptive process which may produce further 
contraction, and also by reducing the tension in the membrane, 
lessen the danger to the retina. If the cornea and lens be 
transparent, the position of these membranes may be located 
with tolerable accuracy. When in a choroidal process the in- 
filtration encroaches on the region of the papilla, the opacity in 
the vitreous is almost certain to occur in its posterior part, in 
the form of threads, or patches, or membranes, which are often 
directly connected with the optic papilla by adhesions to the 
sheath of the central vessels. On the other hand, the farther 
forward the choroidal infiltration occurs, and the nearer to the 
ciliary processes, the more anterior are the opacities in the vit- 
reous likely to be. Other things being equal, the posterior 
opacities are more easily reached by the needle or knife in the 
proposed operation, the less the danger of injuring the lens, 
and the more favorable are the results likely to be. (See Berg- 
meister, Archiv fur Ophthalmologic, XX, 2, page 95, 1874.) 
The writer has done this operation in seventeen cases of chronic 
membranous opacities in the vitreous, and presents the histories 
of these cases with the results obtained to the Society for its con- 
sideration. In some of the cases the ordinary discission or 
keratonyxis needle was employed ; in others, a broader needle Membranous Opacities in the Vitreous. 
5 
with a double cutting edge ; while in still others, where the 
membrane appeared to be tough and thick, a very slender cata- 
ract knife was the instrument selected. -Cocaine was employed 
in all cases. Wherever the peculiarities of the case admitted, 
the point selected for the puncture was just in front of the 
equator of the eyeball, and just below the lower border of the 
external rectus muscle. In a few cases the puncture was made 
on the nasal side of the eyeball, just below the lower margin of 
the internal rectus muscle. The operation is a very brief one, 
and, where possible, was preceded and followed by a rapid 
ophthalmoscopic examination. There seems to be no danger 
of any loss of vitreous through the minute puncture made in 
the sclera, and almost as little probability of any annoying or 
disturbing hemorrhage. Care should be taken to make the 
puncture always posterior to the ciliary processes, and to avoid 
any undue pressure on the eyeball by the forceps, which are 
used in rotating the eye inwards or outwards, as the case may 
be. Little or no reaction follows, save in exceptional cases, 
and a protective bandage is needed for but two or three days. 
I. Selah M., aged forty-five, first seen Oct. 12, 1885. Has 
always been myopic, but has never worn glasses. About 
eighteen months before the left eye had become inflamed with- 
out any apparent cause, though he has been rheumatic for years. 
The attack was accompanied by some pain and marked loss of 
vision, and the inflammatory symptoms did not subside until 
nearly four months had elapsed. Since then there has been no 
relapse, and vision has somewhat improved, but is still ex- 
tremely defective. Present condition : R. E. with cyl.-D 
2.50, axis 90° = clear-fundus normal, except a small 
conus on temporal side of disc. L. E. -> jj 0~, unimproved. Cor- 
nea clear, iris normal in color and reaction, lens transparent, 
except for some faint striae at periphery. Under a dilated pupil 
there is seen a broad, thin membranous opacity, running from 
the nasal margin of the optic disc downward, forwards, and 
outwards to the lens. Both ends fixed, and the membrane be- 
coming broader as it neared the lens. The rest of the vitreous 
was apparently clear, but the course of the membrane covered 
both the disk and the region of the macula. There were traces 6 
Bull : Surgical Treatment of 
of an old choroiditis, marked by patches of atrophy, some of them 
surrounded by a zone of pigment. A four per cent, solution of 
cocaine was instilled several times, and the eyeball was strongly 
adducted by means of a pair of forceps grasping the conjunc- 
tiva over the insertion of the internal rectus muscle. A kera- 
tonyxis needle was then plunged through the sclera just in front 
of the equator and below the external rectus muscle, and the 
membrane lacerated freely in several directions. The needle 
was then withdrawn, and an ophthalmoscopic examination was 
at once made, the pupil being under the influence of atropia. 
This showed that the membrane had been completely divided 
in two places and incompletely in one place. Atropia was in- 
stilled and the eye at once bandaged. The bandage was re- 
moved on the third day, and there being no sign of reaction, 
vision was tested on the fifth day and found to have risen to 
without a glass, and with sph.- D 2 Q cyl- D 1 ax 9°°> to 
The patient was then permitted to go out, and on the eighth 
day left for her home. Three months later, V= + with the 
above glasses, and an ophthalmoscopic examination showed that 
the divided ends of the membrane had retracted, leaving the 
optic disc and region of the macula exposed to view. 
II. Miss Emma W., aged twenty-six, first seen Oct. 19, 
1885. Ten months before the patient had been attacked by a 
serious inflammation in both eyes, only slightly painful in char- 
acter, but attended by marked loss of vision. There was no ex- 
ternal evidence of any ocular inflammation. The disease sub- 
sided in about two month's, and the vision slightly improved in 
R. E., but there has been no change in the latter for at least 
six months. The patient gives a distinct syphilitic history. 
Present condition. R. E. N - cornea and aqueous humor 
clear, iris normal in color and reaction, lens transparent. A 
mass of filaments and membranes running like a mesh work 
across the vitreous, the fundus appearing indistinctly through 
the meshes. L. E. V = -j$ - unimproved. Media clear, ex- 
cept for some small floating opacities in the vitreous. Iris nor- 
mal. Small patches of old choroidal inflammation, mainly in 
equatorial region. This was considered an unfavorable case, 
but the operation was done on the right eye in the same posi- Membranous Opacities in the Vitreous. 
7 
tion as the first case, but with a broad needle with a double 
cutting edge. The ophthalmoscope showed that the membra- 
nous mesh-work had been incompletely divided in two places. 
Atropia and a bandage. Latter removed on third day ; no re- 
action. V = Ophthalmoscope showed that the cut on the 
temporal side had gaped considerably. The vision was tested 
at the end of two weeks and found to have risen to 2Vo» beyond 
which it did not improve. Patient seen at the end of two 
months and the same condition existed. 
III. Mrs. Mary R., aged thirty-five, first seen Oct. 26, 1885. 
Patient has been myopic since childhood, and four years ago 
had serious trouble with both eyes, particularly the left eye, ac- 
companied by partial loss of vision and great intolerance of 
light, brought on probably by long-continued abuse of her eyes 
in doing fine embroidery. Since the attack subsided she has 
been careful in the use of her eyes, and there has been consid- 
erable improvement in the vision of the right eye, but the left 
eye has remained very defective in vision. No history of syph- 
ilis or rheumatism. There is no external evidence of disease 
in either eye, except a tendency to divergence of the left eye. 
Present condition. R. E. N = with sph.- D6=|$. 
Some floating opacities in vitreous - general choroidal atrophy, 
most marked on temporal side of disc and downwards in infero- 
temporal quadrant. L. E. N- with sph. - D 6 = 2Vo- 
Numerous floating opacities in vitreous, and one band of thin 
membrane running from near the nasal margin of disc forwards 
and outwards'to the ciliary region. Patches of choroidal atro- 
phy all over fundus. Here the two-edged cutting needle was 
introduced on the nasal side of left eyeball in a corresponding 
position and the membranous band thoroughly divided as the 
ophthalmoscopic examination showed. There was no reaction 
and on fifth day V= with sph.- D 6. Two weeks later vision 
was the same, and remained unchanged for four months, since 
which time the patient has not been seen. 
IV. Miss Emma F., aged twenty-two, first seen Nov. 30, 
1885. Patient has always been myopic and has worn glasses 
for several years. Nine years before she had received a violent 
blow on the left eye, with immediate loss of vision, which was 8 
Bull : Surgical Treatment of 
followed by severe inflammation, swelling of the lids, and great 
pain in eye and head. As the inflammatory symptoms sub- 
sided, the vision began to be restored, but there has been no 
change for a number of years. Present condition. R. E. 
V=22o°o: with sph. - D 2.5o = The fundus presents the 
usual appearances of a myopic eye. L. E. V = unimproved. 
Pupil dilated and immovable. Lens slightly opaque at peri- 
phery. Floating opacities in the vitreous of varying size and 
shape, and a large, thick, vascularized membrane attached an- 
teriorly to the outer ciliary region and posteriorly to the retina 
on the nasal side of the disc, and entirely concealing the latter 
and the region of the macula from observation. Here the 
membrane was so dense that the slender cataract knife was em- 
ployed, being introduced on the temporal side of the left eye 
through the sclera, and the membrane divided in the vertical 
direction. It was felt to give under the knife, and the ophthal- 
moscope showed a small hemorrhage, probably from the divided 
vessels of the membrane, lying on the membrane and floating 
in the vitreous. Some reaction followed this operation, but on 
the tenth day the eye was quiet, and V = The ophthalmo- 
scope showed a retraction of the nasal end of the membrane, 
while both ends moved freely as the eye moved. There was no 
further improvement in the vision, though the case was watched 
for nearly a year. 
V. Mrs. M. N., aged sixty-three, first seen Nov. 30, 1885. 
Patient has been excessively myopic from childhood, but has 
never worn glasses. Has had repeated attacks of some form 
of deep inflammation in the eyes, accompanied by deterioration 
of vision, from which she recovered each time with a steady 
loss of vision. Present condition. R. E. V=-2 unim- 
proved. Iris sluggish in its movements. Periphery of lens 
cloudy. Several broad, fine membranes stretching across the 
vitreous apparently from side to side, floating with the move- 
ments of the eye, but fixed at either end, and permitting a very 
indistinct view of the fundus through their cobweb-like sub- 
stance, where are signs of most extensive choroidal atrophy. 
Myopia of about D 16 with the ophthalmoscope. L. E. V = 
2 $-j, and the vitreous and fundus are in about the same condi- Membranous Opacities in the Vitreous. 
9 
tion as the right eye. As both eyes were about alike, the ope- 
ration was done on temporal side of right eye with the discission 
needle, and the membrane extensively lacerated as the ophthal- 
moscope showed. No reaction. On the fifth day V=^^-?r, but 
with sph.- D 14 it rose to 2V0' continued slowly to improve 
until at the end of the second month it was the membrane 
having retracted on both sides, leaving a free vent. 
VI. Mr. James C. R., aged forty-two, first seen Jan. 25, 1886. 
Four years ago he had a violent fall, striking on the right side 
of the forehead and supra-orbital region. There was extensive 
laceration of the soft parts and the bone was fractured. The 
vision of the right eye was affected at once and grew steadily 
worse, so that in the course of a few weeks it was reduced to 
perception of light. Since then it has somewhat improved. 
Present condition. R. E. N- cornea clear, iris flutter- 
ing, and pupil immovable. Lens in place and transparent. 
Vitreous crossed by a dense, broad membrane, running from 
the outer margin of disc downwards, forwards, and outwards. 
Projection good in every direction. Pupil easily dilated by 
atropia. L. E. V = -|$, media clear and fundus normal. Here 
the slender cataract-knife was plunged through the sclera on 
the nasal side below the internal rectus muscle, and a long cut 
made through the membrane, but the ophthalmoscope showed 
no gaping of the edges. Absolutely no reaction. On the 
sixth day there was a decided gape in the membrane and V = 
22o°o> h°le being oval in shape. There was no further im- 
provement. This patient was seen in May, 1888, and the con- 
dition of the eye remained the same. 
VII. Mr. Wm. B., aged forty-five, first seen May 3, 1886. 
Patient syphilitic. Has had repeated attacks of iritis in both 
eyes, and for more than a year the vision in the right eye has 
been steadily failing, and for several months has been useless. 
Present condition. R. E. V - perception of light. Field want- 
ing in supero-nasal quadrant. Cornea clear. Iris discolored 
and adherent to capsule of lens. Pupil irregular and immova- 
ble, and only partially dilated by repeated instillations of atropia. 
Lens apparently transparent. Filamentous membrane stretch- 
ing across vitreous nearly in horizontal plane. Tension- 1. 10 
Bull : Surgical Treatment of 
L. E. V = Cornea clear, iris discolored and adherent to 
lens. Lens and vitreous apparently clear. A detachment of 
the retina was supposed to exist in the infero-temporal region, 
probably directly connected with the membrane. This gentle- 
man was told of the bad outlook and that the chances of im- 
provement were slight, while serious inflammation might follow 
the operation. He decided to risk it, and the small discission 
needle was plunged through the outer aspect of the sclera, and 
a single sweep from above downwards given to it, and it was 
then withdrawn. Somewhat violent reaction followed, which 
yielded to atropia, hot water, and bandage, but no ophthalmos- 
copic examination was made for three weeks. No change was 
discoverable in the membrane, owing to the adherent condition 
of the pupil, but the patient could distinguish the movements 
of the hand, and claimed that he noticed considerable improve- 
ment in the vision. He urged another attempt, but the danger 
of reaction was considered too great. The defect in the field 
continued the same. 
VIII. Mrs. E. H., aged sixty-four, first seen May io, 1886. 
Patient had never had any trouble with her eyes till about 
eighteen months ago, since which time the vision in both eyes 
had gradually failed, and she now complains of seeing every- 
thing through a mesh-work or veil. Present condition. R. E. 
V = -|J} unimproved. Ht. =D I. Cornea and lens normal, ex- 
cept at periphery of latter, where there are numerous peripheral 
opacities. Delicate cobweb-membrane extending across the 
vitreous from the nasal side downwards and outwards. L. E. 
V -unimproved - Ht. about D 1.75. Cornea and iris nor- 
mal. Peripheral opacities in lens. Delicate cobweb-membrane 
in vitreous, not quite so extensive as in light eye. In this case 
an attempt was made to lacerate the membrane with the discis- 
sion-needle in each eye separately, but although it was readily 
torn, there was no gaping of the holes in the right eye. In the 
left eye one of the lacerations gaped wide, but there was no im- 
provement in the vision. The needle was introduced through 
the sclera on the temporal side in each eye. There was abso- 
lutely no reaction in either eye following the operation. 
IX. D. C., aged fifty, first seen Nov. 28, 1887. Twenty-five Membranous Opacities in the Vitreous. 
11 
years ago this patient contracted syphilis, and had, among other 
constitutional symptoms, an inflammation in both eyes, begin- 
ning in the left eye, which ended in total blindness. The right 
eye was much less seriously affected. Both eyes remained 
quiet until six years ago, when the left became inflamed again. 
This attack subsided, and there was no further trouble till Sept., 
1887, when the left eye became again inflamed and still re- 
mains so. Present condition. R. E. V = - cornea clear. 
Iris discolored but freely movable. Lens clear. Large mem- 
bran iform opacity in the vitreous, attached by a broad base to 
the nasal margin of the optic disc. L. E. V = 0. Tension+2. 
Iridocyclitis. Cornea cloudy. Lens opaque and lying in the 
anterior chamber. Iris dilated ad maximum and adherent to 
the lens. The left eye was enucleated as a necessary prelimi- 
nary to the operation on the right eye. Two weeks later the 
needle with double cutting edge was introduced through the 
temporal side of the sclera, and an attempt was made to cut 
across the entire membrane, which, however, was only partially 
successful, as the membrane seemed to bend before the instru- 
ment. Some reaction followed and it was feared that the vision 
might suffer, but on the sixth day the eye had become entirely 
quiet and a laceration was discovered in the membrane which 
had already gaped a little. On the twelfth day V = and even 
improved a little beyond this in the course of the next few 
weeks. 
X. Miss A. L., aged thirty-two, first seen Dec. 5, 1887. 
Two years ago the patient suddenly noticed a large black spot 
before the left eye, which rapidly obscured her vision. This has 
remained ever since, with alternate conditions of improved and 
deteriorated vision. Her sight is always worse at the menstrual 
epoch. Present condition. R. E. V -Media clear and 
fundus perfectly normal. L. E. V=|$. Cornea, iris, and 
lens normal. At posterior pole there are spots of choroidal ex- 
udation, and stretching across the vitreous in every direction 
are numerous fine filamentous opacities, fixed at the ends but 
waving with the motions of the eye.' The keratonyxis needle 
was plunged through the sclera at the point above indicated on 
the outer aspect of the eye, and the fine filamentous opacities 12 
Bull : Surgical Treatment of 
swept in every direction by the needle. An ophthalmoscopic 
examination immediately afterwards showed that apparently 
nothing had been accomplished, the filaments bending before 
the needle, instead of being torn. There was no reaction, and 
no improvement in vision. 
XI. Mr. Geo. G., aged thirty-five, first seen Dec. 5, 1887. 
The patient has had defective vision in the left eye for several 
years, which came suddenly without any known cause, but 
which was probably a hemorrhage into the vitreous. Thinks 
the vision of the right eye has failed of late. Had a chancre 
nine years ago. Present condition. R. E. V = 
proved. Cornea, iris, and lens clear. Refraction hypermetro- 
pic. Faint dust-like opacities in the vitreous. Fundus appar- 
ently normal. L. E. V = -21oOo unimproved. Cornea, iris, and 
lens normal. Broad but very delicate membrane in the'vitre- 
ous, fixed but wavy, obscuring slightly the entire fundus. Re- 
mains of an old chorio-retinitis. The double-edged broad 
needle was introduced in the position of choice on the outer 
aspect of the eyeball, and a single sweep of the needle made 
from above downwards. There was no reaction from the opera- 
tion, and on the eighth day the ophthalmoscope showed that the 
membrane had been entirely divided, and the ends had retracted 
on either side almost out of sight. V = |J and has remained 
so, the patient having been seen within the month, and the vit- 
reous found almost clear. 
XII. Mr. A. E., aged forty-four, first seen Jan. 16, 1888. 
Patient has had defective vision in left eye for five years, dating 
from a sudden attack of almost complete loss of sight. Three 
weeks ago he again had a sudden obscuration of vision in the 
left eye, which during the past week has begun to improve. 
Present condition. R. E. V = |$. Media and fundus perfectly 
normal. L. E. V = 2Cornea, iris, and lens normal. A 
membrane, pierced by numerous holes, stretches across the pos- 
terior part of the vitreous, adherent posteriorly to the margin 
of the optic disk; and, floating in the vitreous, and at times 
obscuring nearly the entire fundus, are several blood clots. 
This patient has grave cardiac disease, both hypertrophic and 
valvular. It was thought best to wait until the recent hemor- Membranous Opacities in. the Vitreous. 
13 
rhage had at least been partly absorbed. On February 14th the 
slender knife was introduced in the position of choice and sev- 
eral attempts made to lacerate the membrane in various direc- 
tions. A somewhat violent reaction followed, and it was not 
until the fourteenth day that an ophthalmoscopic examination 
was made. There were still some blood-clots floating in the 
vitreous, but quite a large laceration was seen in the membrane 
and the vision was found to have risen to This slowly im- 
proved as absorption went on, and at the end of three months 
the vitreous was very much clearer and V = 
XIII. Mr. Wm. S., aged thirty, first seen Jan. 30, 1888. 
This patient had a chancre in July, 1886, and after numerous 
constitutional lesions, the left eye became affected in April, 
1887, the attack having evidently been a choroiditis. The vision 
was markedly affected, but, since the subsidence of the attack, 
it has slowly improved. Present condition. R. E. V=|$. 
Media and fundus perfectly normal. L. E. V = j Cornea, 
iris, and lens normal. Some minute floating opacities in the 
vitreous, and a single strand of rather dense tissue extends di- 
rectly from the temporal margin of the optic disc forwards and 
outwards towards the periphery. As the narrow membrane 
seemed to be rather thick and dense, it was deemed wise to 
employ the slender cataract-knife. This was introduced at the 
usual point in the outer side of the eyeball, and passed slightly 
upwards and then brought downwards and withdrawn with a 
single cut. The ophthalmoscope was immediately used and 
the membrane was seen to have been completely divided. No 
reaction followed, but the vision was not tested till the eighth day 
when it was found to have risen to An examination of the 
fundus showed that marked retraction had taken place in the 
membrane, especially in the peripheral fragment, which had al- 
most disappeared from view. Subsequently the vision im- 
proved slightly to 
XIV. Mrs. M. H., aged twenty-four, first seen Feb. 21, 1888. 
This patient has both cardiac and pulmonary disease. Was 
confined with her first child fourteen months ago, and almost 
immediately afterwards had a sudden attack of loss of vision in 
the left eye. From this she slowly recovered, but this eye 14 
Bull: Surgical Treatment of 
never quite regained its normal vision. Early in January, 1888, 
she had a similar attack in the right eye, while nursing her 
child, from which in a week or two she began to recover. On 
February 14th she again had an attack in the right eye. This 
patient has no sign of any renal disease. Present condition. 
R. E. V = fingers at four feet. Cornea, iris, and lens normal. 
Dense membranous opacities, with wide meshes, stretching all 
across the fundus and obscuring every detail, and numerous 
large blood-clots fixed on the membrane, or floating in the vit- 
reous. L. E. V = |$. Cornea, iris, and lens normal. Broad, 
cobweb-like membrane in the vitreous, fixed posteriorly some 
distance below the margin of the disc, and attached anteriorly 
by a much broader base to the equatorial region upward and 
outwards. I regarded the right eye as being in an almost hope- 
less condition, but decided to operate on it before attempting 
anything on the left eye. Owing to the density of the mem- 
brane, the slender knife'was used, introduced in the usual posi- 
tion through the sclera on the temporal side, and attempts were 
made to thoroughly divide the membrane in several places. 
The attempts were partially successful, but violent reaction fol- 
lowed the operation, accompanied by fresh hemorrhage into the 
vitreous, which reduced the vision to perception of light. This 
subsequently improved to about what it was before the opera- 
tion, and the ophthalmoscope showed several holes in the mem- 
brane. One month later the left eye was operated upon at a 
corresponding point in the sclera, the keratonyxis needle being 
used, and the cobweb membrane was thoroughly lacerated. 
Vision improved almost immediately to the central re- 
traction of the membrane being considerable. This patient is 
still under observation. 
XV. Mrs. W. L., aged sixty, first seen March 14, 1888. 
This patient has had gradually failing vision in both eyes, with- 
out any decided or sudden inflammatory attacks, for more than 
two years. There is irregularity of the heart's action but no 
very decided organic lesion. Present condition. R. E. V - o20°q. 
Well-marked arcus senilis. Faint opacities at periphery of lens. 
Delicate band of connective tissue extending across the vitreous 
from above and outwards, downwards, and inwards. Signs of Membranous Opacities in the Vitreous. 
15 
old choroiditis. L. E. N - fingers at two feet. Same condi- 
tions in cornea and lens as in the other eye. Broad, rather 
thick, irregularly shaped membrane in the vitreous, extending 
from near the nasal margin of the optic disc upwards and" out- 
wards to the equator. In this patient the operation was done 
on both eyes at the same time, as her stay in the city was lim- 
ited. On the right eye the keratonyxis needle was used, while 
on the left eye the double-edged cutting needle was employed, 
the puncture being at a corresponding point on the outer aspect 
of each eye. There was some reaction following the operation 
on the left eye, which, howev.er, subsided within the first week. 
An ophthalmoscopic examination showed complete division of 
the delicate membrane in the right eye with marked retraction 
of the divided ends, and a large hole through the thicker mem- 
brane in the left eye. One month after the operation an ex- • 
amination showed in the R. E. N = |$, and in the L. E. V - 220°0. 
Of the seventeen operations done on fifteen patients, four- 
teen gave decided improvement in the vision and three proved 
failures. In no case was there any loss of vision from the op- 
eration. It seems proper to conclude that the operation is a 
suitable one in certain cases, and is justified by the results ob- 
tained. It would seem wise to wait in any case until all inflam- 
matory symptoms have long subsided, before attempting to 
divide the resulting obstructing membranes, no matter whether 
caused by hemorrhages into the vitreous, or by a hyalitis, the 
result of choroiditis. The eye should be absolutely free from 
all irritation before attempting any such surgical interference. 
DISCUSSION. 
Dr. George Strawbridge, Phila.-I understand that the 
operation was performed without the use of the ophthalmoscope 
during the operation. I think that the operator was right in 
not placing much reliance on the ophthalmoscope during the 
operation. It is also very satisfactory to know that the opera- 
tion is so free from risk. 
Dr. W. S. Dennett, N. Y.-Ten years ago I had an opera- 
tion to do near the fundus in which I used my ophthalmoscope 
as a head mirror with much satisfaction. The patient was not 
etherized and I had no difficulty in seeing. If I had another 
such operation to perform I should try the same plan. 16 
Bull : Surgical Treatment of 
Dr. Samuel Theobald, Baltimore.-I would ask whether 
or not, in these cases, antiseptic precautions were employed ? I 
should also like to know whether Dr. Bull found it possible to 
cut through the membranes by a sawing motion, or did he sim- 
ply break them with a wide sweep of the knife ? 
Dr. C. S. Bull, N. Y.-Modified antisepsis was used in all 
of these cases. The eye and face were carefully washed with a 
solution of the bichloride of mercury before the operation. In 
the eye, a r : 5,000 was employed, and on the face a 1 : 2,000 
was used. The instruments were thoroughly sterilized. I was 
afraid to attempt any sawing motion lest it would enlarge the 
external wound and permit escape of the vitreous or lead to 
hemorrhage. 
Dr. W. F. Mittendorf, N. Y.-I think that vascularity of the 
vitreous membrane should speak against operations of this 
kind. Vascularity, even if no signs of inflammation are pres- 
ent, would, I think, indicate a fatal prognosis. I have in mind 
several cases where membranes with great vascularity almost 
entirely disappeared in the course of one or two years, leaving 
useful vision. In these cases, the danger of hemorrhage which 
might interfere with the success of the operation, must speak 
against it. 
Dr. T. Y. Sutphen, Newark.-I might say in this connec- 
tion that during the past year I have performed three opera- 
tions for puncture of the retina, under antisepsis, the details of 
which I shall give later. In these operations there was no re- 
action whatever, and therefore would sustain the opinion that 
there was comparative safety in such a procedure as Dr. Bull 
advises. BulljC.S. A Contribution to the Surgical Treatment of Mem- 
branous Opacities in the Vitreous.Kart ford,Conn, 
1888, 1/-