A SERIES OF FIFTY CONSECUTIVE OPERATIONS 
FOR CATARACT. / 
By Robert L. Randolph^M. D., 
Assistant Ophthalmic and Aural Surgeon to the Johns Hopkins Hospital and Dispensary 
and to the Presbyterian Eye, Ear and Throat Hospital, Baltimore, 
Ophthalmologist to the Baltimore and Ohio Railroad. 
[From The Johns Hopkins Hospital Bulletin, No. 20, March, 1892.] [From The Johns Hopkins Hospital Bulletin, No. 20, March, 1892.] 
A SERIES OF FIFTY CONSECUTIVE OPERATIONS 
FOR CATARACT. 
By Robert L. Randolph, M. D., 
Assistant Ophthalmic and Aural Surgeon to the Johns Hopkins Hospital and Dispensary 
and to the Presbyterian Eye, Ear and Throat Hospital, Baltimore, 
Ophthalmologist to the Baltimore and Ohio Railroad. 
Statistics of operations for cataract are so numerous nowa- 
days that little is left to be said beyond the mere tabular 
report. Nearly every surgeon, though, learns from his own 
particular experience something which is new and which is 
worth adding to the history of this operation. 
As regards the operation with and without iridectomy, thus 
far I have seen no reason to abandon the iridectomy, though 
I confess that had the surroundings of my patients been such 
as the majority of cataract patients enjoy I would have 
practiced simple extraction more frequently. Few operators 
are in a position to put about their patients the comforts and 
safeguards that may be had in a hospital like this one or the 
Presbyterian Eye and Ear Hospital of this city. Out of the 
fifty operations here recorded six were performed in a hospital, 
namely, three in the Johns Hopkins Hospital and three in the 
Presbyterian Eye and Ear Hospital, and all did well. With 
the exception of eighteen, the remaining twenty-six were 
among the poorer classes of a country population of Virginia 
and in a mining region in the western part of this State. 
The first case reported here was operated upon in a log cabin 
near Warrenton, Virginia, and the old man was nursed by his 
daughter, who only saw him at mealtimes and at night. He 
was compelled, then, to help himself the greater part of the 
time, and as a consequence exposed himself to risks every 
hour of the day. He went through the same experience a 
year later, and, as in the first instance, he obtained excellent 
vision. Case 8 was a colored man 87 years old and blind for 
three years. He lived on the extreme end of my father's plan- 
tation in Virginia and was nursed by his wife. His cabin 
was too dark to perform an operation in with safety, and I 
put him on a cot and operated out in the yard. He was very timid, and jumped when I performed the iridectomy, causing 
some loss of vitreous. He counted my fingers after the opera- 
tion, and I assisted him upstairs to a room next to the roof, 
as the only other room in the house opened out into the yard. 
He remained there for a week, and at the end of that time 
was allowed to come downstairs. He made an uneventful re- 
covery, and subsequently obtained perfect vision with the 
proper glasses. Case 39 was operated upon in a cabin full of 
negro children and his daughter looked after him. The 
result wras most satisfactory. 
Home nursing at best is rarely comparable to good hospital 
nursing. The majority of these fifty cases were subjected to 
indifferent care and attention at the hands of, for the most 
part, ignorant persons, and among these twenty-six cases 
there were eighteen whom I did not see the second time till 
two weeks after the operation. Eight out of these eighteen 
had three visits a week from the family physician, and 
the remaining ten had absolutely no medical attention 
beyond what members of the family could give until I saw 
the patient two weeks after the operation. It is true, under 
these circumstances, I gave the most explicit directions to 
that member of the family to whose special care I would 
entrust my patient, but at best the after-treatment of this 
class of patients differed radically from what we see 
even in a general hospital where there are no special pro- 
visions for cataract patients. Among these fifty cases only 
two failed to recover sight, and as the circumstances peculiar 
to these two were rather unusual, and as such would prob- 
ably explain the failure, I shall give the histories. 
Case 49, woman 78 years old, had been troubled many years 
with dacryocystitis, more marked in the left eye than in the 
right. She had been blind from cataract for three years. 
Refused treatment for the lachrymal trouble, saying she was 
too weak and old to stand the pain incident upon the probing. 
She was made acquainted with the additional risk of a cataract 
operation performed on an eye when there was disease of the 
lachrymal sac. She was willing, however, to run the risk of 
infection from this source, so I operated on the least affected 
eye. The result was a perfect success. A year later she pre- 
sented herself for operation upon the second eye. The opera- 
tion was smooth and she counted fingers with ease immediately 
afterward. I left the city that evening, not expecting to see her again for two weeks. She was entrusted to the care of 
the physician who assisted me in the operation. It is well to 
state here that she belonged to a most ignorant class of white 
people, and though nearly eighty years of age, was accustomed 
to going barefooted in warm weather. The first time I oper- 
ated she had shown herself unmanageable and walked around 
the house three days after the operation. That was in the 
winter time. The second operation was in June last, and 
when I saw the patient two weeks after the operation her 
physician told me that she got up out of bed the next 
day, tore the plaster off her good eye and came downstairs 
and sat in the yard and smoked her pipe. The second day 
after the operation she walked nearly a mile barefooted to see 
her daughter. Whatever were the causes which produced it, 
when I saw her the second time the eye was lost. It is impos- 
sible, then, to say whether to attribute the loss of the eye to 
infection from the mucocele or to carelessness and exposure 
after the operation. Before each operation the contents of 
the lachrymal sac were pressed out, and, as far as possible, the 
conjunctival sac was rendered aseptic by irrigating it with a 
solution of corrosive sublimate 
The second case (Case No. 47) is that of a man sixty-one 
years old. He had been subject for many years to rheuma- 
tism, and had suffered also for a long time with varicose veins 
on both legs, and as a result of the latter condition his right 
leg was covered with an eczema. The blood-vessels at his 
wrists and temples were tortuous and hard. Left eye, total 
cataract and good field of vision for light. The operation was 
as smooth as any I ever performed, and after the delivery of 
the lens the patient could see my face and count fingers 
readily. I removed the speculum and closed the eye, putting 
on the usual bandage. Ten minutes later, and just before I 
was about to leave the house, he complained of violent pain 
in the eye. I suspected hemorrhage and immediately removed 
the bandage to investigate. I found the latter soaked with 
blood. The mass of blood and protruding vitreous were 
cleaned away and strong pressure applied. On returning six 
hours later it was found that the oozing had continued and 
he was still suffering pain. The lids were opened and a clot 
of vitreous was discovered between the edges of the wound. 
This was removed, and after first irrigating the conjunctival 
sac with a very weak sublimate solution, a pressure bandage was applied. At my visit the next day 1 found the bandage 
quite moist and there was every evidence that the oozing was 
persisting. I cleaned out the sac again and renewed the 
bandage. On the afternoon of the second day I saw him 
again and there were still signs of hemorrhage. The same 
course of treatment was pursued and on the third day I 
found the bandage clean. Of course he was told that vision 
was irrevocably gone from the onset of the hemorrhage. In 
nearly all cases of this class the cornea sloughs, but this 
termination I fortunately escaped. Hemorrhage after cata- 
ract extraction is rare. Dr. Knapp reports in a recent num- 
ber of the Archives of Ophthalmology his only case. In my 
own case I can account for the hemorrhage only by the con- 
dition of the blood-vessels throughout his body. No doubt 
the vessels of the retina were tortuous and their walls 
atheromatous, and when the lens was removed and intra- 
ocular tension thereby lowered, the blood-vessel walls could 
not withstand the pressure from the increased volume of blood 
pouring into them, so they ruptured. The whole condition of 
the patient pointed to a diseased state of the circulatory 
apparatus. It is impossible to guard against such a termina- 
tion, though I should regard it as a contra-indication for 
operation upon the other eye, for no matter how smooth the 
operation might be, the chances are that hemorrhage would 
follow the delivery of the lens. 
In case No. 7, an old gentleman of 75 years, I allowed the 
patient, as is my custom, to get up out of bed the day after 
the operation. That afternoon I went to see him and found 
him fast asleep in a chair by an open window with only the 
shutters closed. A storm was coming up and it had been 
blowing violently for nearly an hour, and on entering the 
room I observed that the wind was blowing directly on his 
bald head, as the curtains were fluttering about his shoulders. 
He awoke as I entered and commenced to sneeze. I predicted 
trouble then and there, and sure enough iritis set in a 
few hours later. He was treated vigorously with sodium 
salicylate and instillations of atropia, and the inflammation 
subsided in three weeks, leaving him with almost a closed 
pupil and with very poor vision. Discission a year later gave 
him vision; in other words, the ultimate result was 
satisfactory. 
This case was of special interest to me, inasmuch as it pre- sented the rather unusual effect of large doses of salicylate of 
soda. About midnight, after taking during the day nearly 
180 grains of the drug, he became delirious and imagined that 
some one was pursuing him. He tore up the sheets on his 
bed and took the bandage off his eye, and was found by the 
gentleman of the house sitting on the bare floor, raving in the 
wildest manner, and it was with the utmost difficulty that he 
could be induced to return to bed. I gave him a hypodermatic 
injection of morphia and discontinued the use of the salicy- 
late of soda, and the mental trouble disappeared. I have since 
given even larger doses in the same length of time and have 
not seen this effect. 
With regard to the method of operating. The instruments 
were allowed to remain twenty minutes in absolute alcohol, 
and I have found that this agent answered my purposes on 
the whole more satisfactorily than either carbolic acid, cor- 
rosive sublimate or hot water. I am, of course, aware that 
alcohol is inferior to either of the three above-named agents 
as a germicide, but, from the point of view of convenience, 
among the greater number of these fifty cases it has been 
found capable of a wider application. I should prefer boiling 
water as a sterilizing agent for routine hospital work, but 
frequently when it was asked for among several of my patients 
I would be brought boiling water, it is true, and no doubt free 
from micro-organisms, but full of sediment of all kinds and 
deposit from the sides of a dirty kettle. It is hard to prevent 
a drop or more of a carbolic acid solution from coming in 
contact with the eyeball when using this agent as a disin- 
fectant for the instruments, and such a result is always 
followed by a decided hyperaemia, a condition always to be 
avoided. 1 have a tin box ten inches long and three inches 
wide and one inch deep, and within this a rack for all instru- 
ments needful for the occasion. The instruments are placed 
in the box and the latter is filled with alcohol. The instru- 
ments are taken out a couple of minutes before they are used, 
to allow any excess of the solution to evaporate from their 
sides, keeping the conjunctiva free from contact with an 
agent which in any way might irritate, and this is manifestly 
not possible to the same degree with any aqueous solution. I 
use a solution of corrosive sublimate to wash the lids, 
but unless there be some good reason for it, as in troubles of 
the lachrymal sac, I never irrigate the conjunctiva with anti- septic agents of any kind whatever. Irrigations of corrosive 
sublimate, according to Knapp, have been known to stain 
the cornea indelibly, and I find that such irrigations, indeed 
irrigations of all kinds, produce more or less hyperaemia of 
the conjunctiva and so increase the liability of hemorrhage 
into the section. Beyond a two per cent solution of cocaine, 
to every ounce of which I have added ten grains of boric acid, 
I introduce nothing foreign between the eyelids. As regards 
the dressing, I still think the bandage the safer mode of pro- 
cedure, and while it is far more uncomfortable than the 
plaster strip, it seems wiser to sacrifice comfort, indeed any- 
thing within reason, to increased security. 
In simple extraction it seems to me that one would be 
more apt to get a round pupil by employing the bandage. 
My section is made in the clear cornea, with possibly a slight 
tendency to the conjunctiva. In the five simple extractions 
reported I have made the apex of the section well out into 
the clear cornea. Such a section, I think, lessens the proba- 
bility of prolapse of the iris. In opening the capsule I split 
the latter horizontally and above, near the border of the lens. 
In the operations with iridectomy it has been my custom to 
instil a solution of atropia (4 grs. to 3 i) into the eye on the 
evening of the second day. In simple extraction a couple of 
drops of eserine (2 grs. to i i) are instilled immediately after the 
operation, and no further drops are used during the treatment 
unless specially demanded. The unoperated eye is always 
kept closed by a strip of adhesive plaster, which is removed 
on the evening of the second day. This is done simply to 
keep the eyeballs still as far as possible until the corneal 
wound has united. The patients are required to remain 
quiet in bed (or at least lying down) for twelve hours after 
the operation. It is my object to keep the patients guarded 
against direct rays of light, so the room is simply shaded with 
that view, but is never so dark that one would be unable to 
see to read. As regards diet there is absolutely no restriction. 
The bandage is removed on the sixth day, and after this 
atropia is instilled regularly (in the iridectomy cases) twice 
daily till the fourteenth day. 
If we arrange the visual results in three categories, good, 
moderate, and failure, we have-perfect, 41 cases; moderate, 
1 case; failure, 2 cases; vision not tested, 8 cases. In other 
words, out of these fifty cases only two failed to obtain sight. The main essential in this operation is absolute smoothness 
and exactness in the steps of the operation. Freedom from 
any hitch whatever is after all the best guarantee for sight 
restored. This, I think, is especially true in the simple 
extraction. 
I think it is apparent that had simple extraction been gen- 
erally adopted in this series of cases there would have been 
numerous prolapses of the iris; and while I am not disposed 
to lay as much stress on the gravity of a prolapsed iris as 
many seem to do, it is too early in the day to pass judgment, 
for an incarcerated portion of the iris, even if it does not give 
rise to immediate trouble, may do so many years later. And 
the very imperfect after-treatment which was the lot of the 
majority, while it shows that it is possible to get good vision 
with virtually no treatment after the operation, it ought not 
to prove that our hospital methods are attended with needless re- 
strictions and that more freedom to the patient is quite as safe. 
When a patient tears off the bandage and releases himself 
from all restraint on the third day after the operation, it is a 
very rare exception that any sight is restored, though there 
are few of us who have not had one or two just such 
cases and where most excellent vision was gotten. But such 
occurrences prove nothing, and they should not induce us to 
relax our care in the after-treatment of cataract patients, nor 
lead us to think that we can afford to allow our patients all 
sorts of liberties as soon as the operation is done. 
I append herewith a tabular statement of each operation: No. 
Sex. Age. Health. 
Cataract. 
Operation. Healing Process. 
Duration of Treatment. 
Primary 
Vision. 
Secondary Operation after Ex- 
traction. Duration of 
Treatment. 
Ultimate 
Vision. 
Remarks. 
1 
( Male. 
( 65. Good. 
Hard. Ripe. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
2 0 
11 
With iridectomy. 
2 
( Male. 
| 77. Good. 
Hard. Ripe. 
Left Eye. 
Patient jumped and dis- 
located lens into anterior 
chamber. Removed with 
difficulty. Mild iritis fol- 
lowed. Recovery in four 
weeks. 
20 
Til 
Discission one year later. 
Three days. 
20 
With iridectomy. 
3 
j Female. 
| 66. Rheumatic. 
Hard. Ripe. 
Right Eye,. 
Smooth. Uncomplicated. 
Two weeks. 
20 
T 6 
With iridectomy. 
4 
( Female. 
60. Good. 
((Colored.) 
Hard. Ripe. 
Right Eye. 
Smooth. Slight hernia of 
iris, which was clipped off 
on third day. Recovery in 
sixteen days. 
20 
11 
Simple extraction. 
5 
j Female. 
( 66. Good. 
Hard. Ripe. 
Right Eye. 
Smooth. Uncomplicated. 
Two weeks. 
18 
• • 
Simple extraction. 
6 
j Female. 
( 68. Diabetic. 
Hard. Ripe. 
Right Eye. 
Smooth. Uncomplicated. 
Two weeks. 
20 
71 
Discission one year later. 
Three days. 
With iridectomy. 
7 
J Male. 
( 75. Good. 
Hard. Ripe. 
Right Eye. 
Exposure brought on 
iritis on third day, and 
almost closed pupil was 
result. Three weeks. 
1 5 
111 
Two years later, a trian- 
gular piece of iris removed 
over site of old iridectomy 
and iridotomy performed. 
Two weeks. 
20 
71 
With iridectomy. 
8 
i Male. 
■< 87. Asthmatic. 
((Colored.) 
Hard. Ripe. 
Right Eye. 
Some loss vitreous. Un- 
complicated. Two weeks. 
20 
TH 
One month 
later. 
With iridectomy. 
9 
j Female. 
( 55. Good. 
Hard. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
20 
Tol 
Discission six months 
later. Three days. 
20 
41 
With iridectomy. 
10 
j Male. 
( 64. Good. 
Hard. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
20 
10 
•• 
Simple extraction. 
11 
J Male. 
( 57. Rheumatic. 
Hard. 
Left Eye. 
Smooth. Slight prolapse 
of iris. Clipped off fourth 
day. 
T?0H 
Discission four months 
later. Four days. 
L8 
Simple extraction. 
12 
j Female. 
( 58. Good. 
Hard. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
n 
With iridectomy. 
13 
( Female. 
( 75. Good. 
Hard. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
With iridectomy. 
14 
j Female. 
( 60. Good. 
Hard. 
Right Eye. 
Smooth. Uncomplicated. 
Two weeks. 
2 0 
11 
With iridectomy. 
15 
j Female. 
( 68. Good. 
Hard. 
Right Eye. 
Smooth. Uncomplicated. 
Two weeks. 
20 
3 0 
With iridectomy. 
16 
( Female. 
( 71. Good. 
Hard. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
2 0 
Too 
Discission eight months 
later. Three days. 
H 
With iridectomy. 
17 
j Female. 
( 71. Good. 
Hard. 
Right Eye. 
Smooth. Uncomplicated. 
Two weeks. 
2 0 
71 
Discission three months 
later. Three days. 
18 
With iridectomy. 
18 
j Female. 
( 54. Good. 
Hard. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
Patient had atrophy of 
optic nerve. 
19 
j Male. 
( 70. Good. 
Hard. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
20 
TOO 
Discission two months 
later. Three days. 
<8 
With iridectomy. 
20 
( Female. 
/ 77. Rheumatic. 
Hard. 
Right Eye. 
Smooth. Uncomplicated. 
Twro weeks. 
18 
With iridectomy. 
21 
j Female. 
( 78. Good. 
Hard. 
Right Eye. 
Smooth. Uncomplicated. 
Two weeks. 
20 
Four weeks 
later. 
With iridectomy. 
22 
j Female. 
1 78. Good. 
Hard. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
20 
311 
Four weeks 
later. 
With iridectomy. 
23 
j Female. 
] 67. Asthmatic. 
Hard. 
Right Eye. 
Attack of asthma, and 
escape of vitreous. Five 
weeks. 
20 
TOH 
With iridectomy. 
24 
5 Male. 
( 78. Good. 
Hard. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
^8 
With iridectomy. No. 
Sex. Age. Health. 
Cataract. 
Operation. Healing Process. 
Duration of Treatment. 
Primary 
Vision. 
Secondary Operation after Ex- 
traction. Duration of 
Treatment. 
Ultimate 
Vision. 
Remarks. 
25 ■ 
26 ■ 
27 ■ 
28 
29 
30 
31 
32 
33 
34 
35 
36 
Female. 
71. Good. 
Female. 
75. Good. 
Female. 
72. Good. 
Male. 
: 52. Good. 
। Male. 
! 53. Good. 
। Female. 
! 69. Good. 
j Male. 
! 76. Good. 
। Male. 
I 66. Good. 
। Male. 
! 79. Good. 
। Female. 
! 72. Good. 
। Female. 
! 73. Good. 
Female. 
! 65. Good. 
Hard. 
Left Eye. 
Hard. 
Left Eye. 
Hard. 
Right Eye. 
Hard. 
Right Eye. 
Hard. 
Left Eye. 
Hard. 
Left Eye. 
Hard. 
Left Eye. 
Hard. 
Right Eye. 
Hard. 
Right Eye. 
Hard. 
Left Eye. 
Hard. 
Right Eye. 
Hard. 
Right Eye. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
555 
n 
iS 
2 0 
7(7 
55 
n 
55 
Discission three months 
later. Four days. 
Eighteen months later. 
Three days. 
One year later. Three 
days. 
Three months later. Four 
days. 
Six months later. Three 
days. 
One year later. Three 
days. 
18 
18 
H 
18 
88 
With iridectomy. 
With iridectomy. 
With iridectomy. 
The cataract was secon- 
dary to old iritis and 
the pupillary margin 
was bound down at 
one point. 
Remains of several old 
adhesions. 
With iridectomy. 
Preliminary operation 
(Forster) was here 
performed. 
With iridectomy. 
With iridectomy. 
With iridectomy. 
With iridectomy. 
With iridectomy. 
37 
38 
39 
40 
41 
42 
43 
44 
45 
46 
47 
48 
49 
50 
( Male. 
( 72. Good. 
J Female. 
1 71. Good. 
( Male. 
( 91. Good. 
( Male. 
( 57. Good. 
( Male. 
( 37. Good. 
j Male. 
( 30. Good. 
j Male. 
( 77. Feeble. 
j Male. 
( 12. 
| 61. 
J Male. 
( 21. Good. 
i Male. 
■x 61. Rheumatic, 
( Varicose veins. 
( Male. 
1 74. Good. 
j Female. 
( 78. Good. 
J Male. 
1 91. Good. 
Hard. 
Right Eye. 
Hard. 
Right Eye. 
Hard. 
Right Eye. 
Hard. 
Right Eye. 
Hard. 
Left Eye. 
Hard. 
Left Eye. 
Hard. 
Right Eye. 
Traumatic. 
Left Eye. 
Hard. 
Left Eye. 
Hard. 
Left Eye. 
Hard. 
Left Eye. 
Hard. 
Right Eye. 
Hard. 
Left Eye. 
Hard. 
Left Eye. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Ten days. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Twenty minutes 
later. Hemorrhage from 
within eye. 
Smooth. Uncomplicated. 
Two weeks. 
Smooth. Lachrymal ab- 
scess gave rise to suppura- 
tion and eye was lost. 
75 
Not 
taken. 
Vision 
not 
taken. 
Vision 
not 
taken. 
Not 
taken. 
2 0 
2 55 
Not 
taken. 
Not 
taken. 
2 0 
255 
Not 
taken. 
Not 
taken. 
• • 
With iridectomy. 
With iridectomy. 
With iridectomy. 
Simple extraction. 
With iridectomy. 
With iridectomy. 
With iridectomy. In- 
cipient atrophy. 
The cataract was a result 
of concussion. The 
lens was extracted 
without iridectomy. 
Discission. 
With iridectomy. 
With iridectomy. 
With iridectomy. 
With iridectomy.