Al Mckay recalls his experiences with early cataract surgery.
My first surgical encounter with ophthalmology was in 1959; I was a medical officer at a tiny hospital in southern Tasmania, actually I had been born in that very hospital 26 years previous. On Tuesday afternoons I travelled to the Royal Hobart Hospital to attend a lunchtime meeting of most of the doctors servicing the South. After lunch I went to watch Dr Jim Rogers, a local ophthalmologist, performed an intracapsular lens extraction in the hospital’s theatres. Jim was to become a mentor to me and it was his inspiration that fueled my subsequent career path. He was an Honorary Surgeon at the hospital and honorary then meant just that, honorary, no recompense. Most specialists donated some of their time to provide for the medical and surgical care to non-paying patients at public hospitals. This service involved the giving of two or three sessions a week, spread between the outpatients department, the wards and the operating theatres.
All "honoraries” were listed on a roster for consultation and/or surgery of emergency medical cases and, in the case of Royal Hobart Hospital, this would involve an on-call period of every fourth week, day and night. There was no ophthalmic registrar as an intern covered Eye, ENT, Skin and psychiatry, such was the status of ophthalmology at the time. In actual fact the hospital had four registrars only, they represented surgery, anaesthetics, medicine and obstetrics/gynaecology. There were senior residents in paediatrics and orthopaedics.
The staffing of all hospitals in the 50s was basic, even the general superintendent in many hospitals including the “Royal” was a practicing surgeon. The changes in prestige of visiting medical staff over this last sixty years have been noticeable. When I was a student at Sydney Hospital, the honoraries were served tea by the ward sister with the full silver service regime. Gradually this was replaced by afternoon tea with chipped cups in the Presidents’ dining room until modern days when one goes to the cafeteria and buys an ersatz coffee slopped into a plastic mug. It is indeed a shame that the communal chitchat of doctors over a cup of tea is no longer a feature in most hospitals. The interdisciplinary nature of such informal consultation and discussion denies many a patient of what could be helpful suggestions on management.
Now back to the theatre. The patient had entered hospital the day previous, he was listed for an intracapsular cataract extraction. The pre-operative regime was for full assessment the evening before surgery as well as having the upper and lower lid lashes cut short. He was sedated overnight with Nembutal and Chloramphenicol drops instilled an hour pre-op.The operation was performed under local anaesthesia (xylocaine and adrenalin) administered by Jim, the operating surgeon, in the theatre annex prior to his scrubbing up. He achieved akinesia of the facial nerve prior to administering the retrobulbar injection. The pupil had been dilated with homatropine and cocaine and the retrobulbar block
enhanced these medications. In some other cases the operation was performed under general anaesthesia if a suitably trained anaesthetist was available. His scrubbing procedure was meticulous; it was the custom not to wear gloves then.
This may appear peculiar in modern times but in the ‘50s gloves were thicker than modern ones, they were always reused having been washed, checked for holes and powdered with talc by the nursing staff prior to autoclave sterilisation. The presence of talc was liable to cause wound reactions and the thickness of the gloves was thought to decrease the dexterity of the surgeon. Having scrubbed he soaked his hands in a basin of methylated spirits. Jim was assisted by one of his colleagues in a shared operating list. He wore no magnifying glasses and did not use a microscope; this was the common practice of the time.
In an associated publication I have pictured the instruments used and techniques employed at this operation. I took the liberty of reproducing some images published in “Eye Surgery” by H. B. Stallard then a surgeon at Moorfields Eye Hospital and later to become one of my surgical teachers. This eye surgeon was made more famous in the film “Chariots of Fire” detailing his early life, not as a surgeon, but as an athlete at Caius College, Cambridge.
Jim did not use a metal speculum for lid retraction but employed lid sutures of 6/0 blacksilk, two in the upper lid and one in the lower lid, the sutures were threaded on cutting needles by the sister as the more modern eyeless type of sutures had not yet made their appearance in the South. These sutures were fixed to a drape comprised of a full head bandage and a towel positioned so as to leave to operated eye exposed. Next he immobilized the eye with a stay suture (traditionally white to avoid confusion) passed under the insertion of the superior rectus muscle, This suture was clipped to the drape: the needle holder used was a “Silcocks”, the fixation forceps were Jayle’s.
A limbal based flap was raised in preparation for the corneal section, a small groove was made with a Tooke’s knife and pre-placed sutures inserted. At this operation a section was made using a Graefe knife. This knife was always housed in a special container as they were, unlike modern knives, designed for multiple use and sharpness was imperative.
Honorary surgeons at public hospitals often carried their own surgical knives. All knives were tested for tip integrity using kid-glove leather stretched and drawn tight over a purpose-designed drum. Use of the Graefe knife required considerable skill as the section made was almost 180º and performed in one manoeuvre on either eye commencing at the temporal quadrant. This entailed equal dexterity with either the right or left hand.
Some surgeons favoured dissection with a Tooke’s knife or a keratome. If these methods were used the wound would be enlarged with corneal scissors, right and left hand. All surgical instruments were expensive. These were often blunted and in need of sharpening giving employment to specialist instrument technicians, an industry no longer in existence. Speed was considered to be essential in open eye procedures; the possibility of a disastrous expulsive haemorrhage increased with length of time that the eye remained open, it was thought that to dally was to welcome complications.
Prior to the lens extraction a small peripheral iridectomy was performed at the 12 o’clock position using iris forceps and de Wecker’s scissors. Next pressure was applied to the lower limbus with an Arruga’s expressor and the lens capsule grasped with Castroviejo’s cross-action capsule forceps. The lens was wriggled from side to side to break the zonule and then tumbling was commenced. This technique was used in the hope that little damage would be done to the endothelium as the lens was delivered into the corneal wound but great care was exercised to avoid any instrument contact with that endothelium. In the event that the lens was resistant to these manoeuvres or if capsular rupture occurred a vectis may be inserted behind the lens and used somewhat like a scoop or spoon to facilitate removal.
After removal of the lens the pre-placed sutures were drawn tight and the conjunctival flap closed. The pupil was carefully examined to determine if any vitreous strands or traction bands were present tenting the margin and, if necessary, the iris was stroked into position using an iris repositor. Having closed the wound an air bubble was injected to reconstitute the anterior chamber. This air injection also helped to determine if the vitreous face was now in the correct position. Some Chloromycetin ointment was applied and both eyes were padded and bandaged.
Subconjunctival injections of steroids or antibiotics were not in use at this time. The complications of I-C Lens extraction were numerous but the most important of these were haemorrhage, capsular rupture, vitreous loss and infection. It is worthy of note that within a year or so Alpha-Chymotrypsin, a proteolytic enzyme, became popular for intra-capsular lens extraction. This substance was injected into the posterior chamber and left for three minutes before being washed out. The enzyme helped to weaken the zonule and facilitate extraction. The widespread use of this agent along with first the erisophake and later the cryo-pencil further increased the popularity of I-C lens extraction. Healon, sodium hyaluronate, made its appearance in eye surgery in 1980. This visco-elastic substance was use as an endothelial protecting agent and also was useful in the restoration of the a-c in the event of vitreous prolapse ( as a viscous retractor). Its development heralded in a plethora of viscoelastic procedures. What of these operative complications?
Most surgeons feared the catastrophic event of expulsive haemorrhage. This complication was, fortunately, exceedingly rare, I experienced it only on one occasion and it is indelibly printed in my mind. I had barely completed the corneal section when the iris bulged, stretched open and, within a second or so, the lens followed by the vitreous and the retinal prolapsed through the wound. You may read of all the ways to avert such a disaster but, well, it all happened in a blink of an eye; one may say too fast for intervention.
his complication may cause a severe iritis and associated occlusion of the pupil with fibroblastic membranes that may be associated with dense pigmentation. Initial treatment was to remove all remnants of lens material by vectis and the wash out of soft lens material. After a month the anterior uveitis may settle leaving an opaque posterior membrane with or without Elschnig’s pearls. An operation to cut a hole in this membrane was performed using a Zeigler or Bowman’s knife. In some cases repeat of the procedure may be necessary but each operation increased the risk of subsequent uveitis and retinal detachment.
In my early surgical days congenital cataract and some traumatic cataracts in the young were treated with discission (needling). Again repeat operations were often necessary and it was not uncommon for fragments of lens material to remain encapsulated beneath the iris.
Chloramphenicol eye drops were the mainstay of treatment. This antibiotic had been marketed since 1949 and was widely used as Chloramphenicol palmitate suspension in the treatment of infants, its liver complications not widely known at the time. The use of subconjunctival penicillin was the most common (mixed in the hospital pharmacy) although much reliance was placed on systemic use as well. I recall that a fledgling company called Allergan first produced cortisone eye drops in 1953. The use of steroids in the treatment of uveitis was a major advance.
Pupil block and glaucoma;
Another sight-threatening complication sometimes related to choroidal detachments. Some cases responded to simple methods with medication but others required more invasive surgery.
Iris prolapse occurred in some cases as a result of secondary glaucoma associated with wound dehiscence or pupil block. This could be a troublesome complication as the wound may require resection and resuturing. This became far less common with the advent of multiple virgin-silk sutures. This material made its appearance about the time of my residency but again the eyeless needle had not prevailed and threading of Grieshaber needles in theatre required patience with inexperienced scrub nurses. Contributing to less wound complications was the improvement in technique and better wound closure accompanied by more and finer suturing.
Leaking wounds could give rise to a flat anterior chamber, anterior synechiae, subconjunctival drainage bleb, choroidal detachments, subsequent secondary glaucoma and epithelialization of the anterior chamber. Of note is the management of simple iris prolapse which would require reposition and/or iridectomy. As retrobulbar anaesthesia was likely to increase pressure to the globe and thus cause further prolapse simple topical anaesthesia was employed in the form of cocaine crystals. These were kept in the theatre in a small bottle. One would simply apply a crystal to the exposed iris and conjunctiva for several minutes to achieve the desired loss of pain sensation. I do not know if any records were kept on this cocaine stash and I do not know of any incidents of in appropriate use.
Of course there were many other complications not all that different to modern day open eye surgery. The advent of small section surgery has been a godsend.