THE ACTUAL CAUTERY NEEDLE IN THE TREATMENT

OF CONICAL CORNEA.

BY JULIAN J. CHISOLM, M.D.,

MARYLAND.

KERATOCONUS, when diagnosed, does not produce the satisfaction which usually accompanies the finding out of a diseased condition. The statement that a disease is half cured when the diagnosis has been surely made does not apply, unfortunately, to the pathological changes under discussion. The finding of it produces rather an indescribable feeling of discomfort, as the curative treatment so far practised is of a very unsatisfactory character, because it gives results far from perfect. It is very fortunate that the curious bulging of the clear cornea is so rare, that many cases are not likely to come under the observation of any one surgeon, and, therefore, an opportunity for experimental treatment on a larger scale is not likely to be offered.

Such a yielding of the anterior surface of the cornea as to form a positive cone, with prominent apex in the visual axis, is usually well advanced before the unfortunate patient seeks professional aid. He has been aware for some time that his eyesight was undergoing a change. He had suffered no pain, nor. had any injection of blood vessels attracted the attention of friends to his failing eyesight. He is well aware that, at a period not very remote, his distant vision was good. Now his horizon is very foggy, and even his near vision is by no means satisfactory. It has occurred to him that he was growing very near-sighted, and some months since he supplied himself with concave glasses. They answered his purpose for a time, but they had to be changed for stronger ones. Now, even the strongest do not aid him. He has become so very near-sighted that he has lost confidence in his movements, and fears to go on the street alone, as he really cannot see approaching vehicles, and is in constant fear of being knocked down or run over.

He

finally seeks aid from a specialist, and these bold operators, who never lose an opportunity of adding to their lists of brilliant surgical works, shrink from the prospect of attacking a condition of the eye for which so little is to be secured by operative procedures.

Surgeons have found that the use of glasses, however ground, are not of material benefit. Extending the pupil by iridectomy, or displacing the pupil towards the margin of the cornea, is not a satisfactory treatment as long as the prominent cone is allowed to remain. The question to be considered is, how to shrink the cornea back to its normal curvatures, even at the cost of rendering opaque its pupilary surface. The rubbing on of nitrate of silver is rather a painful and doubtful means of creating a superficial ulcer, which by its healing process is to induce the much needed flattening of the surface. The shaving of the corneal apex preparatory to the cauterization is not so easily or safely carried out. The suggestion has been made of cutting out a plug of corneal thickness, including the conical prominence, and sewing up the wound, as with any other gaping surface. I know of no statistics concerning this method of treatment. The successful treatment of conical cornea is a problem yet to be solved.

One year since I accidentally fell upon a title in the Repertoire Bibliographique of the Annales d'Oculistique for November and December, 1879. It was as follows: Traitment du Keratocone par la Cauterisation ignée, par Gayet. The idea struck me at the time as a good one, and I determined to put it in practice upon the first opportunity. As to the method of application nothing was said, it was simply the title to an article, and I have never seen any other reference to it. As I had no precedent for guidance, I conceived, therefore, the idea of perforating the apex of the cone with a needle heated to whiteness, depending upon the contraction induced by the burn for the good results which I hoped would follow the procedure. Soon after reading the title of the article referred to, a most unprepossessing case for operation returned to the Presbyterian Eye and Ear Charity Hospital of Baltimore-one upon whom I had previously declined to operate by any of the then to me known methods, for the reasons which a description of the case will clearly exhibit.

Mary G., aged twenty-seven, had been suffering for many

years from a complication of eye troubles. Her general health has been very bad, and she is miserably nervous with heart palpitations and stomach disturbances. For the last five years she had been aware that her throat was larger than natural, and she has often been told that her eyeballs are very prominent. The case could be recognized at a glance as a most aggravated form of exophthalmic goitre. Conjunctival irritation had been slowly added to the stretching of the lids over the protruding eyeballs, and a very decided injection of the margins, with a liberal supply of crusts among the scattering eyelashes, indicated a marginal blepharitis of long standing as a disease superadded to the exophthalmia. As an addition to her bodily affliction she had been slowly but steadily growing near sighted. For some months her vision had been so very defective that she found difficulty in walking the streets. Upon close inspection both cornea showed so pointed a condition as to give the appearance of a thick drop of molten glass deposited upon each corneal centre.

After a long course of tonics, belladonna, iron, and quinine, to improve her general condition, the patient was transferred from the out-door department to the hospital wards, as she could no longer walk to the dispensary with safety. An inspection at the time of admission showed that, although the cornea and media of the eye were perfectly clear, the conicity had so distorted the shape of the surface, and had caused such irregular and defective vision that she could not count fingers at a greater distance than one foot with either eye. On account of the exophthalmic and blepharitie complication to the conical cornea, to which was to be added her miserable physical condition, I did not feel justified in yielding to her solicitation to have her sight made better by using any of the usually referred to methods of excising a portion of the cornea, or rubbing on a point of nitrate of silver. I had just read that the actual cautery had been applied to the cure of the keratoconus, and I thought this case peculiarly fitted for an application of a needle cautery, as offering the fewest objections in the face of so many ugly complications. Her consent being willingly given I determined first to operate upon one eye, and I selected the left. Although both were equally defective in vision, the left lids were not quite so irritable, hence my selection.

An apparatus needful for my conception of the operation was

readily improvised. A fine sewing needle, held in a needle. holder, and an alcoholic lamp completed the apparatus, and were used as follows: The patient, lying upon the operating table, had the lids separated by a stop speculum. The eyeball was held firmly by fixation forceps. The needle, heated to whiteness in the flame held near the face of the patient, was thrust through the cornea a little above its centre. It perforated the tissues without apparent impediment, and entered the very capacious anterior chamber, its point stopping at some distance in front of the lens, so as not to involve this important structure. As the needle was rotated to free it from the burnt. tissue and then withdrawn, the aqueous escaped in a jet d'eau at least one foot in height. The anterior chamber was soon emptied of its fluid contents, and became collapsed. No anæsthetic was used, and the patient did not complain of pain from the puncture. With the escape of the aqueous, sight became much more defective, as was to be expected. An atropia drop was applied to keep the iris from the corneal wound, and cold water dressings were continuously used.

When next seen, twenty-four hours after the operation, I found, to my surprise, very little inflammatory reaction. She had slept well, and had not suffered at all. The eye was but slightly injected, not more than accompanies the needle puncture for capsular secondary cataracts. When the lids were separated the white cauterized spot could be clearly seen. As soon as the eye was opened the patient expressed her delight at the improvement in her vision. Upon measurement it was found that she could count fingers at six feet instead of at one foot, her best vision of the previous day.

The burn

From this

For two weeks the patient was inspected daily. As the sight remained improved, with no inflammation from the presence of the burn, it was determined to try the same operation upon the right eye, from which she still saw the fingers at one foot distant. For this operation a larger needle was used. made by it was much more extensive and painful. wound the inflammatory reaction was very decided. weeks she had a very red and painful eye, and I was fearful of supervening injury from iritic inflammation. In time all irritation subsided, the pupil remaining black, and free from adhesions. When the patient left the hospital, six weeks after the second operation, the eyes were free from injection. The apex

For three