As it frequently happens that lens matter is left behind, a number of opera tors practice its removal by suction syringes of special construction. The procedure, however, has never obtained general favor.
The operation for the removal of a hard cataract consists essentially of three steps: the corneal incision of sufficient size to permit of the passage of the lens; an incision, or a series of them, into the anterior capsule of the lens (cystotomy) in order to allow the egress of the lens matter through it; and the delivery of the lens-substance from the eyeball it self. Before the actual operation is made, certain preliminary details should be carefully attended to. A general warm bath should be given to the pa tient the night before the operation. Care should be exercised to make his head clean with Castile soap and water. The bowels should be relieved by a gen tle laxative, in order that they may not be disturbed for the first few days after the operative procedure.
The instruments, with the exception of the knives, which should be immersed in alcohol for at least twenty minutes prior to their use, should be boiled. After the cleansing has been completed, they should be kept in a tray of alcohol during the entire operation, being dipped for a few moments in a tray of sterile water just as they are being picked up for use.
The patient having been carefully prepared and the field of operation having been excluded from external con tamination for a couple of hours previ ously by a few turns of a roller bandage, his eyelids, eyebrows, eyelashes, and adjacent parts should be thoroughly washed with a saturated solution of boric acid. The lids should be gently everted and the upper and lower cul-de-sacs flushed with the same character of solu tion. Several drops of a solution of hydrochlorate of cocaine are then introduced into the eyes at five minute intervals, for about fifteen min utes before the operation, care being taken that the eyelids are kept closed and that a clean towel is thrown over the field of operation. If possible, the patient should lie flat on his back in the bed that he is to occupy. If circum stances do not permit this he should be placed upon some form of operating chair or table. The source of light should be situated so that tbere shall be a field of uniform illumination upon the exact points to be operated upon. If the surgeon be ambidextrous, he may place himself in front of the patient or behind him in accordance witb comfort and existing circumstances. A trained assistant should be present and assume such a position that be may be able to hand the instruments to the surgeon or receive them from him with such skill and rapidity that the operator may be able to keep his vision fixed upon the field of operation during the successive stages. Prior to any procedure it is well for the surgeon to speak kindly and quietly to the patient for a few moments to gain his confidence and at the same time inform him of certain movements of the eyes that may be necessary during the operation. He should be cautioned against holding his breath and strain ing and told to resist all desire to close his eyes forcibly. By these few injunc tions quietly and authoritatively given, the most intractable patients may be rendered obedient, the soothing words thus given often bearing fruit to the surgeon a hundredfold.
All these minor, but most essential, preliminaries being satisfied, the eyelids are to be separated by an elevator held in the hands of a skilled assistant, who is capable, if necessary, to momentarily re move the instrument without any dam age to the organ. The patient is asked
to look down. The globe is firmly held in any desired position by gently taking a fold of bulbar conjunctiva about two or three millimetres' distance from the corneal Embus within the grasp of a fixation-forceps held with one hand, while with the other the corneal section is to be made. The knife most generally employed is one introduced by von Graefe, which consists of a long, straight, narrow blade converging at its far ex tremity into a sharp point. TJnless contra-indicated, the primary puncture should be made just within the margin of the clear cornea at the outer ex tremity of a horizontal line, which, as a rule, would pass three millimetres be low the summit of the membrane. The cutting-edge of the knife should be situated upward and its point directed toward the centre of the cornea. After the tip of the knife has been made to enter the anterior chamber, it should be carried directly across and re-entered into the corneal tissue at the point de sired. The section should then be com pleted by an -upward movement so regu lated that the corneal section is kept true and smooth throughout its entire extent. At this stage the elevator, in uncomplicated cases, is removed and not used again. The first stage of the opera tion being completed, the surgeon next addresses himself to the performance of the second stage, or that of capsulotomy-, or so-called cystotomy. Directing the patient to look down and without any fixation-instrument in position, if. pos sible, he introduces a cystotome, with the heel of the cutting-point first, between the lips of the corneal wound, and inserts the point of the instrument into the anterior capsule, without dislocating the lens, in such a manner as to be able to make a series of as free incisions as he may believe desirable and in such po sitions as he may deem the best. These having been obtained, the cystotome is withdrawn in such a way that the iris is not wounded during the procedure. The avenue of escape for the lens having been made, it remains to practically com plete the operation by the performance of the third stage, or that of the deliv ery of the lens. The surgeon should, with the ball of the finger-tip of one hand upon the sclera just below the lower edge of the cornea, and a spatula held in the other hand and placed upon the sclera just above the corneal sec tion, make a series of delicate, yet steady, upward and forward pressures and coun ter-pressures until just one-laalf of the lens has engaged in the corneal wound, when, by a dextrous and slightly tilting and upward motion from side to side, the lens will emerge without any com plication whatever, and the corneal flap will fall smoothly into place. Should the pupil not be round and should any lens debris be seen, the eyelids are to be closed and a slight gentle rotary motion be made upon tbe globe through the upper lid by the fingers. If there be anv cortex remnants, the stump of the flap is to be slightly depressed and the masses gently, though as completely as possible, washed out of the anterior and posterior chambers by free irrigation from varying positions with warm sterile water or boric-acid solution without the introduction of any instrument whatso ever into the chambers.