The Indian operation of couching for cataractElliot, Robert Henry
History
The Indian operation of couching for cataract
Elliot, Robert Henry
Cataract -- Surgery -- India; Ophthalmology -- India -- History
The sequence of events in these two cases was possibly as follows:
The posterior operation may have been adopted and the incision placed
far back; a wide tear in the retina resulted; the lens, completely
separated from its attachments, was kept entire by the toughness of
the Morgagnian capsule, whilst the fluidity of its contents made its
insinuation through the retinal tear an easy matter. The fact that a
case has recently been recorded in which, in a boy of seventeen, the
lens spontaneously escaped through a 2 mm. trephine hole throws a
sidelight on such cases as these.
=Accidental Injuries to Other Structures than the Lens during Couching.=
Though the primary object of the Indian cataract coucher is to depress
the lens, he may accidentally injure any or all of the other structures
of the eye. Evidence of such damage is obtained both clinically and
pathologically.
=The Cornea.=--Opaque scars on the cornea are quite frequently seen in
the out-patient room in eyes which have been subjected to the anterior
operation, but are rendered invisible in formalin-mounted specimens
owing to the opacification of the membrane. Other evidence of corneal
injury is, however, available.
In No. 9 a corneal fistula is present, lying to the inner side of
the centre of the eye (Pl. IV., Fig. 23). The lamellæ immediately
surrounding it are largely replaced by connective tissue; the whole
thickness of the membrane is markedly reduced, and the lining
epithelium is irregular and vacuolated. The iris is very closely
adherent to the back of the cornea near the fistula, but more loosely
attached farther out. There has evidently been some ulceration of the
cornea and the formation of a limited staphyloma, which burst at a
later date, leaving the fistula now seen. It is probable that the point
of fistulisation was determined by the use of a septic instrument at
the time of operation, and that septic keratitis followed, leading to
early perforation with entanglement of the iris. On the other hand,
it is possible that the _enclavement_ of the iris occurred as the
instrument was withdrawn. In either case, the later sequence of events
included a dsecondary rise in tension, the formation of a staphyloma,
and a fresh perforation at the weakest point, resulting in the
production of a permanent fistula.
In No. 45 the lens capsule is adherent to the back of the cornea,
the iris being widely torn, and being probably also involved in the
synechia (Pl. IV., Fig. 24). All that remains of the lens is a brown
nucleus; the cataract was evidently Morgagnian. It is probable that,
after the escape of the fluid it contained, the lax capsule prolapsed
into the wound, either with the gush of fluid which accompanied the
withdrawal of the instrument or at a later date.
PLATE IV
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