Being the Hunterian Lectures delivered before the
Royal College of Surgeons of England on
February 19 and 21, 1917

The material at our disposal consists of 54 globes, the great majority of which were removed in the Madras Ophthalmic Hospital in the period from 1911 to 1915, though some are of much older date. They were placed in 5 per cent. formalin immediately on removal, and were subsequently frozen and bisected. In a number of instances one half of the eye was submitted to microscopic examination after suitable sectioning. Each of the half-globes and a number of microscopic specimens have been photographed for purposes of illustration. It will be convenient to classify our observations under a number of separate headings.

The Various Directions in which Dislocation of the Lens is
found to have taken place.

Before considering this subject in the light of the pathological specimens before us, it is necessary to make certain preliminary statements:

1. Inasmuch as all our material is derived from blinded eyes, it is obvious that we are dealing with the coucher’s failures alone, and are excluding his successes. In a very large percentage of the latter the lens is seen, during life, to be floating freely in the vitreous, apparently untrammelled by adhesions.

2. The position in which we find the lens on bisection of the eyeball is not necessarily that into which it was thrust at the time of operation, for the changes which occur in the eye as a result of inflammatory action may profoundly alter the position into which the lens was originally forced by the coucher. Nor must we forget that in those globes, in which the cataract is not tightly tethered by adhesions, gravity plays a part.

Having thus cleared the ground, we may start with the statement that, though the lens may be displaced in any direction within the sclero-corneal coat, backward dislocations are by far the most common, whilst forward ones were only found 4 times in the whole series of 54 globes. None the less, each of these latter cases possesses considerable interest.

Forward Dislocations.—(1) In No. 81 the couching instrument passed through the limbus, and the track of the wound can be plainly followed in microscopic sections. The ciliary body was pushed bodily away from the sclera, and the lens nucleus was forcibly thrust into the space formed by this cyclodialysis (Pl. II., Fig. 10); it is to be seen imbedded in a mass of inflammatory exudate, whilst its capsule, with some of the cortex, lies in the normal situation.

(2) In No. 44 the capsule and the nucleus of a Morgagnian cataract are seen floating in the vitreous chamber (Pl. II., Fig. 11). During life the nucleus frequently passed backwards and forwards between the aqueous and vitreous cavities. The same phenomenon, though rare, has been observed in other couched eyes.

(3) No. 61 is probably an instance of the same kind of thing having happened at an earlier period (Pl. II., Fig. 12). Now, however, the small dark Morgagnian nucleus is seen fixed in the lower part of the anterior chamber, into which it doubtless gravitated by its own weight, and there set up inflammatory mischief, which led to its adhesion to the surrounding parts, and to its becoming fixed in situ by the formation of organising exudate.

(4) In No. 108 the only evidence of lens material present was the capsule of a Morgagnian cataract, which lay impacted in the lower part of the anterior chamber (Pl. II., Fig. 13). On section, Morgagnian fluid escaped, and no trace of a nucleus could be detected. It is of interest to record that the writer has, on a number of occasions, operated on Morgagnian cataracts in which the lens nucleus had been reduced to the thickness of a lamellar disc, or in which no trace of a nucleus could be detected. In this case no adhesions had formed, and during the transit of the specimen to England the capsule fell from its position to the bottom of the bottle.

Those in which the lenses, or their nuclei, have been completely dislocated into the vitreous, and there lie floating more or less freely (Pl. II., Fig. 14), are 9 in number. In 7 of them the cataracts were Morgagnian, and in the 2 others there was a bulky nucleus with a thin covering of stiff cortex. In 7 the tension of the globe was high; in 6 the retina was completely or nearly completely detached, and in 2 of them it was so much folded as to limit the movements of the lens.

From a consideration of the lenses found floating in the vitreous, we turn to that of those which were entangled in a more or less consistent inflammatory exudate occupying the vitreous chamber (Pl. II., Fig. 15). During life such lenses were reported to be fixed, or nearly so. In the specimens they are seen to be nested in a mass of exudate, which holds them imprisoned against the ciliary body and the back of the iris. Usually this exudate is limited in quantity and is confined to the anterior portion of the eye, and principally to the neighbourhood of the dislocated lens. More rarely it is very abundant, and occupies a large part or even the whole of the vitreous chamber (Pl. III., Fig. 16). We shall deal with this exudate more fully at a later stage; for the present it suffices to state that it is inflammatory in origin, and that it contains a large number of cells. Of the 6 cases which form this group, 3 were Morgagnian cataracts; 5 were certainly dislocated in their capsule, the sixth is hidden in such dense exudate that it cannot be clearly seen. It is desirable to make it clear that intermediate forms are found between this group and the previous one. In other words, there is no hard-and-fast line between the cases in which the lenses float freely in the vitreous and those in which they are, to a greater or less degree, tethered by the pathological thickening of the hyaloid body.

We have next to consider a group of 10 eyeballs, in each of which the dislocated cataract was firmly fixed to the ciliary body and to the back of the iris by definitely organised fibrous tissue (Pl. III., Fig. 17). These globes present certain well-marked features of some interest: (1) The percentage of Morgagnian cataract is much lower than that in the preceding groups, and corresponds closely with the normal frequency of this form of cataract in Indian practice. (2) The cataract was dislocated in its capsule in no less than 8 of the 10 cases. (3) The retina was totally detached in 2 and very extensively so in one; in every one of the remaining 7 this membrane showed the presence of white dots, apparently on its surface. (4) The time which had elapsed since operation in the cases falling under this group is remarkable. In one it is given as seven months; in 2 others there is no history; in the remaining 7 the duration was from two to twenty years, with an average of well over seven years. The association of the presence of white dots with these long histories is remarkable, and will be taken up in a later section.

No. 99 (Pl. III., Fig. 18) is a specimen of special interest for two reasons—viz., (1) the cataract is fixed to the globe unusually far back, being attached to the retina a little behind the equator of the eye; (2) the dislocation has taken place in an upward direction, and therefore against the action of gravity. From time to time we meet clinically with a couched lens whose suspensory ligament, though torn through over a wide circumference, has been spared at one part, which acts as a hinge. The loosened lens flaps backwards and forwards with the movements of the eye, at times obstructing the pupil, and at others being lost to sight. If the hinge is above, the cataract usually blocks the pupil when the head is erect; but one meets with cases in which the lens floats up out of the way unless the face is thrown forward into the horizontal plane; this is apparently due to a check-ligament action of the remaining suspensory fibres of the lens, acting on a lens which is very nearly of the same specific gravity as the vitreous in which it lies. Should inflammation be set up in such an eye and the lens become involved in the exudate, it may become fixed, as in this case, in the upper segment of the globe.

PLATE III

In 11 globes, dislocated cataracts were found matted between the iris and ciliary body in front and the completely detached retina behind. It is very difficult to say what the nature of the original cataracts was, since all that one can now find is a nucleus, usually rather dark-coloured, imbedded in a mass of inflammatory tissue (Pl. III., Fig. 19). These nuclei are undergoing steady reduction in bulk as the result of phagocytic action. In 7 of the 11, the lens remnants lie either within the complete capsule or in its near neighbourhood. The interior of the capsule is usually found to have been invaded by the mass of inflammatory and organising tissue which mats together all the structures (i.e., the iris, the ciliary body, the remains of the lens, and the detached retina), and which occludes the angle of the anterior chamber. The completeness of the dislocation varies greatly. In some cases the lens is hardly moved from its usual position, and lies in front of the anterior hyaloid membrane, whilst in others it is displaced into the vitreous cavity. In one instance the detachment of the retina and the inflammatory changes are sharply limited to the lateral half of the eye towards which the cataract was dislocated, but this case belongs more to the next group than to the one we are now discussing.

There are three outstanding and very important features common to these cases: (1) In the great majority of them there is evidence that the operation was followed by severe iridocyclitis; (2) 9 of the 11 were shrinking eyes with low tension; and (3) the time which had intervened between the couching and the enucleation was between one and two years in every case save one, in which it is probable that the furnished statement of three months was inaccurate. It will be noticed that the histories are much shorter than those in the previous group. This, together with the other two points mentioned, indicates that we have to deal with a condition widely different from that in any of the previous groups. Here the inflammatory process had been induced by a septic infection of the eyes of a decidedly more virulent character, though it fell short of that acme of infectivity, which leads in so many cases of the Indian operation to panophthalmitis and destruction of the globe within a few weeks.

We come next to a group of 5 cases, which have one feature in common—viz., that the cataract, though dislocated backwards, lies distinctly in front of the anterior hyaloid membrane, and therefore outside the vitreous cavity (Pl. III., Figs. 20 and 21). In 3 of them the solid parts of the lenses have been pushed back from their original position in such a way that they act like wedges, forcibly keeping the anterior hyaloid membrane in a plane posterior to that which it would normally occupy. Out of these 5 cataracts 4 were cortico-nuclear; the fifth was too much altered for it to be possible to state what its nature was. In certainly 4 out of the 5 moderately severe iridocyclitis had followed the couching, but the exudative process was a much less severe one than that which characterised the specimens of the previous group. The consequence was that there was no such matting of all the parts concerned as is there seen. In every case the detachment of the retina was complete or nearly so, but in not one was the lens enwrapped in its folds. This we may attribute to two causes: (1) a merely contributory one, that the vitreous cavity was not invaded; and (2) that the infection was less virulent, and the inflammation consequently less severe, than in the members of the previous group.

There is a small group of 3 cases in which the remains of the lens lie in situ in the periphery of the capsule, whilst the central portion has disappeared. These resemble the peripheral after-cataracts not infrequently seen following the extraction of a not fully mature lens.

In conclusion we have to mention 2 specimens in which the condition found was so unusual that it would scarcely have been possible to have anticipated its occurrence.

The first of these was one of the earliest globes sectioned. A Morgagnian lens, entire in its capsule, was found thrust behind the retina. It lay against the scleral coat close to the ciliary body; it had detached the retina over a large area in the neighbourhood of the ora serrata, and had led to a complete separation of it on that (the nasal) half of the eye. The edge of the detached retina had contracted adhesions to the front of the lens capsule, and was much puckered in that neighbourhood, doubtless as the result of cicatrisation.

The second specimen (Pl. IV., Fig. 22) shows many features in common with the last. The lens is entire in its capsule, and is almost certainly Morgagnian; the tear in the retina through which it was thrust has now cicatrised up, leaving a puckered scar. The retina is totally detached, and on section the cataract lay as far forward as the separation of that membrane would permit. The pupil was blocked by exudate, and atrophic scars in the iris showed that there had been extensive laceration of that membrane. The globe was removed a year after operation.

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 secondary 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

In No. 116 it is the retina which is impacted in the corneal wound (Pl. IV., Fig. 25). It seems likely that in this instance the sequence of events was as follows: A severe plastic inflammation resulted from the couching, and involved among other structures a capsular synechia, which had formed at the time of operation or soon after. The vitreous became heavily infected, and the consequent exudate became adherent on the one hand to the retina, which thereby underwent total detachment, and on the other to the capsule and its synechia. The progressive contraction of the scar-tissue then drew the retina into the wound. This would appear to be the most likely explanation, but it is not impossible, in dealing with such an operation as couching, that the retinal detachment was very extensive, and that the injury inflicted provided a path along which a direct prolapse of the retina may have occurred.

The Sclera.—A very large number of Indian cataract couchers perform the posterior operation, and therefore make their preliminary incision in the sclera outside the limbus. Dr. Ekambaram, who has watched these men at work, believes that they deliberately endeavour to avoid the ciliary body, and it also looks as if some of them purposely place their incision below the external rectus muscle. Like his Western confrère, the Indian surgeon does not always succeed in placing his incision just where he wishes to; this is not surprising, as many of these men work without any local anæsthetic, and not a few of their patients are nervous and unruly to the last degree. Moreover, it is more than probable that there are different opinions amongst couchers as to the best site for the preliminary cut. These considerations will serve to explain the variety of location of the scars, as found in the specimens before us; indeed, some such explanation is called for, since the cicatrices may be found as far forward as the limbus, and as far back as the equator of the globe; what is more, they may be seen in the present collection, not only in their common situation, on or near the horizontal meridian, but in any of the quadrants of the eye.

As a rule, the evidence of injury to the sclera is to be inferred from the interference with the parts beneath that coat, and such instances will be taken up when we come to consider the lesions of the ciliary body and choroid; but occasionally we have been fortunate enough to hit off the scleral scar either in the original division of the globe or during the course of sectioning of part of it for the purpose of microscopic examination.

In No. 306 the track of the original wound can be seen as a pigmented scar in the sclera immediately behind the line of the ciliary processes (Pl. IV., Fig. 26). Microscopic sections show—(1) that the pigmentation of the deeper part of the scar is due to the impaction of uveal tissue in its depth; (2) that there is a fistulous scar running right through the thickness of the sclera; and (3) that the subconjunctival tissue in the neighbourhood of the wound is permeated by large open spaces lined with endothelium (Pl. IV., Fig. 27). It is clear that a limited measure of filtration had been established, but this apparently proved insufficient to keep the tension of the eye from rising, as is shown by the deep glaucomatous cupping and by the obliteration of the anterior chamber.

No. 43 shows a scar a little farther back, in the neighbourhood of the ora serrata; but in this case the wound appears to have healed solidly. The pigment of the underlying uveal tissue shows a marked disturbance, whilst before the specimen was cut it was observed that the sclera was pigmented in the neighbourhood of the cicatrix.

In No. 8 the wound lay in the limbus, and the solidifying scar can be traced right through the thickness of the ocular tunic and down to the mass of inflammatory exudate which surrounds the dislocated lens, and fills the angle of the anterior chamber. Here, again, the pigment can be traced some distance up into the scar, in which the uveal tissue is distinctly entangled.

The Uveal Tract.—In quite a large number of couched eyes one can see, during life, evidence of past injury to the iris in the form of more or less extensive scars, many of which probably also involve the ciliary body. Moreover, in other cases, one can infer the presence of injury to the ciliary body and the choroid from the existence of pigmented cicatrices in the sclera. Anatomically, the present series of eyeballs affords additional information on this head. Iris scars are fairly common. In one case, already referred to, the coucher had effected a cyclodialysis; in 3 more the wounds lie across the front parts of the ciliary processes; in 6 they involved the region of the orbiculus ciliaris, and in one of these the scar lies as much on the choroid as it does on the ciliary body (Pl. II., Fig. 15); lastly, in 4 the wounds lie well behind the ciliary body, being placed in 2 of them just in front of the equator, and in 2 more well behind it. Taking them as a whole, the wounds tend to be grouped in the outer quadrant of the eye, above or below the horizontal meridian. It has already been pointed out that this is in accordance with Ekambaram’s evidence as to the site of selection for the incision in the posterior operation. Far the best method of examining these scars is by transillumination with a bright light from behind. Some points of interest remain for consideration.

In No. 44 the wound lay behind the ciliary processes (Pl. II., Fig. 11), the instrument, most probably at its point, tore off a tongue-shaped process from the posterior surface of the iris, thus thinning that membrane over this area; the torn portion contracted an adhesion to the subjacent hyaloid membrane, which was itself infiltrated with inflammatory exudate; the appearance presented is curious and interesting.

In several of the globes scar-tissue radiates from the wound area into the surrounding tissues, and is then a strong contributory factor in the production of retinal detachment. In one globe (No. 130) two scars are to be seen, one of which was evidently placed too far back by mistake (Pl. V., Fig. 28); the eye also furnishes contributory evidence that things did not go well during the operation, for the iris is very widely lacerated. It seems probable that the patient was refractory or the surgeon unskilful. In any case, it is clear that the instrument was introduced a second time.

In No. 148 a caseating mass in the eyeball (Pl. V., Fig. 29), lying behind the equator, was found to contain a fragment of metal; the latter was most unfortunately lost at the time the section was cut, but it was presumably the tip of the couching instrument, and its presence, taken with the facts that the wound was placed very far back and that dislocation of the lens was not effected by the operation, would seem to indicate that the patient moved violently and that the operator failed in his purpose. The strong but strictly localised inflammation excited suggests that the metallic fragment was of copper, and this is in accordance with the known facts of the case, since the probes used by these men to displace the lens are made of that metal.

No. 72 is also a specimen of special interest. Here, too, the puncture lay behind the equator, and there seems to have been some difficulty in penetrating the choroidal and retinal coats, which were carried in front of the instrument, the result being a wide separation of these two tunics from their scleral bed (Pl. V., Fig. 30).

No. 297, removed six weeks after the operation, is an eyeball which had undergone panophthalmitis, and had burst through a point in the sclera on the horizontal meridian somewhere in front of the equator. It is probable that a septic wound of entrance determined the site of the bursting. The lecturer has seen suppurating globes in which the sclera at one point had completely sloughed, the intense inflammation present bearing witness to the violence of the infective process excited.

Uveitis.—The type of inflammation of the uvea found in these specimens was plastic, and was mostly confined to the iris and ciliary body. The intensity of the inflammation varied very greatly. In a number of specimens the evidence of inflammatory action was either absent or only to be detected on very careful examination. On the other hand, a large number of cases present themselves at Indian hospitals in which suppurative panophthalmitis has followed the operation of couching. In Madras such globes were eviscerated, as it was considered dangerous to enucleate them, and much interesting material has thus been lost. All the intermediate stages between the very slight and the very severe inflammations can be traced in the specimens before us. This is in accordance with what we should have expected in what was practically a series of inoculations of healthy globes with pathological materials, which varied enormously in their nature and in the quantity introduced. Nor must we forget the great differences in the ages and in the conditions of health of the patients. The plastic mass poured out from the ciliary body and iris had in many cases enveloped the remains of the lenses (Pl. V., Fig. 31; also Pl. III., Fig. 19), which can be seen in process of disintegration under the action of phagocytosis (Pl. V., Figs. 32 and 33) or of fluid absorption. Evidence of calcification of the lens was obtained in at least one specimen (Pl. VI., Fig. 35), and the same process was also found at work in the uveal coat of several others. The rupture of the lens capsule often provides a ready path of ingress for the inflammatory exudate, which can then be seen filling the cavity of the capsule as well as surrounding it. The curly remains, both of the anterior and of the posterior portions of the capsule, can be clearly traced in many of the specimens, imbedded in dense masses of organising inflammatory exudate. In several such, the absence of the capsule opposite or to one side of the pupillary area, and the curled-up ends of the elastic membrane, mark the spot where rupture was effected at the time of operation.

PLATE V

1. Scantiness of Contents.—One chamber was quite empty, due to the presence of a corneal fistula (Pl. IV., Fig. 23). In a number of cases the chamber was greatly shallowed, owing to the encroachment of the vitreous body upon it. In these the filtering angle was sealed by adhesion over a wide area. In a few cases l’iris bombé was responsible for the shallowing of the chamber (Pl. VI., Fig. 34). In yet others a severe plastic inflammation had involved the structures, lying in and posterior to the aqueous chamber, and had matted them to the posterior surface of the cornea, thus almost obliterating the cavity. This union had been so strong that in the process of hardening the membrane of Descemet remained adherent to the organised exudate beneath it, and a spurious chamber was thus formed lying in the substance of the cornea (Pl. VI., Figs. 35 and 36).

2. Hypopyon was present in 6 specimens, and in one the pus was mixed with blood. The length of histories in these cases varied from a matter of months up to twenty years.

3. Hyphæma.—Blood was present in the anterior chamber in 9 specimens. In some of them it was fresh, whilst in others it was altered and decolorised. The long histories given by a number of these cases suggest either that there had been some recent cause for hæmorrhage, or else that a leakage of blood had been constantly occurring. In 2 of the eyes the iris had been torn; in every one of the others there was evidence that severe iritis had been present.

4. Vitreous in the Anterior Chamber.—In 4 eyeballs the aqueous and vitreous cavities appear to have been in free communication with each other, and filaments of the vitreous body can be traced into the anterior chamber. In 2 of these the angle was widely open, and in the other 2 it was closed by irido-corneal adhesions.

5. Lens Matter in the Chamber (Pl. II., Figs. 10, 12, and 13).—In 4 eyes lens matter was found in the anterior chamber. In one the history showed that a nucleus had passed freely backwards and forwards between the two chambers (Pl. II., Fig. 11). In another a Morgagnian cataract was wedged in the angle of the chamber, but had contracted no adhesions; in the remaining 2 the nuclear masses were firmly fixed in position by an abundant quantity of exudate.

6. Albuminous Exudates in the Anterior Chamber.—These were found in 3 cases; few or no structural elements were present. During life the contents of the chamber were fluid, but they had coagulated under the influence of the formalin preparation of the specimens; they were probably derived from the iris and ciliary body.

PLATE VI