Cheselden,[3] a renowned surgeon, and oculist to Her Majesty, Queen
Caroline of England, first announced, in 1728, his success in making
an artificial pupil by means of his knife-needle. He made his puncture
back of the corneoscleral junction on the temporal side, passing the
knife across the posterior chamber, and making a counter-puncture
in the iris-membrane near the nasal margin. He then cut through the
iris from behind forward as he withdrew the knife, the incision being
carried through two-thirds of its extent. The pupillary opening
thus made was a long oval slit, horizontally placed. He has reported
two successful cases[4] (Figs. 1 and 2), occurring in patients who
had previously undergone couching of the lens. His instrument,
strange to say, was practically of the same general shape as the Hays
knife-needle, but was larger, and judging from the description more
clumsily constructed, as there was danger of leakage of the aqueous
and sometimes of the vitreous when it was used. Its form resembled a
combination of a bistoury and a sickle-shaped knife, having a sharp
edge on one side, a rounded back, and an acute point. We possess two
good illustrations of this knife-needle, one by Cheselden himself (Fig.
3), and the other by his pupil, Sharpe[5] (Fig. 4).
[3] Cheselden, William: Philosophical Transactions, London, 1728, xxxv,
p. 451.
[4] Ibid, abridged, vii, pl. v, Figures 2, 3 and 5.
[5] Sharpe, Samuel: A Treatise on the Operations of Surgery, London,
1739, p. 169.
[Illustration: Fig. 1.--Original case of iridotomy. Iris incised above
(Cheselden).]
[Illustration: Fig. 2.--Second case of iridotomy. Iris incised below
(Cheselden).]
[Illustration: Fig. 3.--Original knife-needle in situ, behind the iris
(Cheselden).]
For more than a century the method of Cheselden seems to have been the
storm center of controversy. Some doubted his veracity, others essayed
his operation but failed, while a few had a moderate degree of success.
Many attributed to him statements which do not appear in his published
report. He says clearly that in each of his cases couching had
previously been performed, and yet some have insisted that the lens was
present, and must have been wounded. He also states that his incision
was made from behind forward, and yet his followers, Sharpe[4]
and Adams,[6] both describe the incision as being made from before
backward. As Sharpe was his pupil, and presumably had seen him operate,
Guthrie[7] suggests the possibility of his having made his incision
both ways, the technic being practically the same.
[6] Adams, Sir William: Practical Observations on Ectropium, Artificial
Pupil and Cataract, London, 1812, p. 37 et seq.
[7] Guthrie, G. J.: Operative Surgery of the Eye, London, 1830, p. 428.
Morand,[8] in his “Eulogy of Cheselden,” claims to have personally seen
him operate “on an eye in which the iris was closed by an accident,”
and gives a more detailed description which closely follows the
original method. He states that Cheselden presented him with one of
his knife-needles as a souvenir of the occasion. Although Morand does
not record the exact date of his visit to London, he does state that
it occurred during the year 1729. Huguier,[9] in his exhaustive thesis
on artificial pupil, also places the date of this visit in the year
1729. This fact is important, as some writers have declared that Morand
neither made the visit to London nor saw Cheselden operate, but only
quoted the original account given in the Philosophical Transactions.
The publication of Morand’s high encomiums in 1757 attracted renewed
interest to the subject of Cheselden’s operation among men of
scientific and medical attainments.
[8] Histoire et Mémoires de l’Académie Royale de Chirurgie, Paris,
1757, iii, p. 115.
[9] Huguier, Pierre Charles: Des Opérations de Pupille Artificielle,
Paris, 1841.
Sharpe,[4] in 1739, performed this operation in the same manner as
Cheselden, except that after he had entered the knife-needle through
the sclerotic he passed it through the iris and across the anterior
chamber, and then incised the iris-membrane from before backward.
Although he was Cheselden’s pupil, and dedicated his small volume on
surgery to him, he probably did his master more harm than good, as
all the objections to Cheselden’s method seemed to be based on the
deprecatory remarks of Sharpe. He says, “I once performed it with
tolerable success, and a few months after, the very orifice I had made
contracted and brought on blindness again.” He mentions the danger
of wounding the lens, the lack of success in paralytic iris with
affection of the retina, the danger of iridodialysis from traction of
the knife, and the possibility of failure because the incision would
not enlarge sufficiently. Thirty years later (1769) he published the
ninth edition of his book without recording a single additional case,
but added the thought that, since extraction of the crystalline lens
showed the cornea was not so vulnerable as had been believed, he would
“imagine” that a larger knife might be introduced perpendicularly
through the cornea and iris and a similar incision made. In his first
eight editions he pictures Cheselden’s iris-knife (Fig. 4, vide p.
25), but in his ninth edition he substitutes a broad lance-knife with
two edges which closely resembled the one Wenzel (vide Fig. 17) had
just introduced (1767), and which Sharpe suggests “can also be used for
the extraction of the cataract.” He evidently did not have a very clear
idea of the subject, and only succeeded in casting doubt and discredit
on the method of Cheselden, which, judging by his own statement, he had
tried but once.
Heuermann,[10] in 1756, had already antedated these thoughts of Sharpe
by practising a similar method. He passed a double edged lance-knife
through the cornea instead of through the sclera, and then made a
sweeping incision through the iris-membrane without enlarging the
corneal wound. He was probably the first to puncture the cornea with
the iris-knife.
[10] Heuermann, Georg: Abhandlung der Vornemsten Chirurgischen
Operationen, Copenhagen and Leipzig, 1756, ii, p. 493.
Janin,[11] about 1766, performed Cheselden’s operation several times
with but little success owing to reclosure of the wound by plastic
exudate. He adopted Sharpe’s modification, but later on changed the
incision from a horizontal to a vertical one with better results. He,
however, afterward abandoned this procedure and became the originator
of the other school, composed of those who preferred to use the
scissors.
[11] Janin, Jean: Mémoires et Observations sur L’Oeil, Lyon 1772, p.
191.
Guérin,[12] in 1769, made a free corneal incision with a large
cataract knife, and then introduced a small iris-knife, with which
he made a crucial incision from before backward in the center of the
iris-membrane. Although Guthrie[6] distinctly states that Guérin
afterwards removed the four angles of the cross with a pair of scissors
in order to prevent reclosure of the incision, no direct confirmation
of this statement can be found in his writings.
[12] Guérin, M.: Maladies des Yeux, Lyon 1769, p. 235.
Beer,[13] in 1792, first published his method, which he designated
as “an improvement on Cheselden’s method.” Although the technic is
somewhat different, the procedure is practically the same as that
originated by Heuermann in 1756. Beer selected certain cases in which
a prolapsed iris had followed the lower incision for cataract, causing
adherent leucoma with a tensely drawn iris-membrane. He plunged his
double-edged lance-knife (Fig. 5) through the cornea and stretched out
iris, from above downward and a little obliquely (Fig. 6), so as to
incise the center of the tense iris fibers crosswise, at right angles
to the line of traction; cutting horizontally when the traction was
vertical, and vertically when this was horizontal. In his monograph on
artificial pupil,[14] 1805, he substitutes for the lance-knife his new
broad iris-knife, which is practically the same as that later shown
by Walton (vide Fig. 12), as, indeed, Walton’s procedure (vide Fig.
13) was almost identical with that of Beer. For other conditions he
usually employed Wenzel’s operation until by chance he encountered a
puzzling case which led him to perform the operation we now know as
iridectomy (1797) and which thereafter became his favorite procedure
for artificial pupil.
[13] Beer, Georg Joseph: Lehre der Augenkrankheiten, Wien, 1792, ii, p.
12.
[14] Beer, Georg Joseph: Ansicht der Künstlichen Pupillen-Bildung,
Wien, 1805, p. 105.
[Illustration: Fig. 6.--Beer’s iridotomy with broad iris-knife (after
Mackenzie).]
Adams,[15] in 1812, revived the operation of Cheselden with certain
modifications. While his puncture was made in the same location,
his technic was different. He entered the sclera with a small
iris-scalpel[5] of his own special design (Fig. 7), which, like
Sharpe, he passed through the iris-membrane into the anterior chamber,
carrying it across to the nasal side (Fig. 8). From entrance to exit
he always kept the edge of the knife turned back toward the iris, so
as to cut from before backward. He was thus able by the most delicate
pressure of his instrument, to make a long horizontal incision, without
causing iridodialysis (Fig. 9). If the first incision appeared to be
too short, he did not withdraw the knife entirely, but again carried it
forward and partially withdrew it, always cutting in the same plane.
To quote his own words, “by repeating the efforts to divide the iris
(taking care in so doing to make as slight a degree of pressure as
possible upon the instrument, instead of withdrawing it out of the eye
at once, as recommended by Cheselden), a division of that membrane may,
in almost all cases be effected, of a requisite size to establish a
permanent artificial pupil” (Figs. 10 and 11).
[15] Adams, Sir William: A Treatise on Artificial Pupil, London, 1819,
p. 34, et seq.
[Illustration: Fig. 8.--Adams’ iris scalpel in situ, showing location
of scleral puncture (after Lawrence).]
[Illustration: Fig. 9.--Iridotomy by Adams’ method (after Lawrence).]
[Illustration: Fig. 10.--Occlusion of pupil (Adams).]
[Illustration: Fig. 11.--The resulting pupil after iridotomy (Adams).]
Here were three elements of success, a sharp knife, a gentle sawing
movement, and the most delicate pressure of the instrument. His method
was a decided advance, and he reported success in nearly one hundred
cases. Others, less skilful, however, failed of success, and the
severe criticisms of Scarpa,[16] though evidently unjust and tinged by
personal animosity,[17] cast a shadow of doubt on the method.
[16] Scarpa, Antonio: Trattato Delle Principali Malattie Degli Occhi,
Ed. quinta, l’avia, 1816, translated by James Briggs, London, 1818, p.
373.
[17] Edin. Med. and Surg. Jour., No. 58.
[Illustration: Fig. 13.--Iris-knife in position to make central pupil
(Walton, after Beer).]
From that time on for nearly half a century this form of iridotomy
was practically abandoned, the pendulum swinging toward the use of
scissors, which Maunoir had popularized and Scarpa had indorsed.
Walton,[18] however, about 1852, proposed a method closely resembling
that of Heuermann and almost identical with that of Beer (vide Fig.
6). His iris-knife (Fig. 12) was practically the same as the broad
iris-knife of Beer. He incised the cornea near the limbus, and
passed the knife across the anterior chamber to the middle of the
iris-membrane which he punctured with a sweeping vertical incision
(Fig. 13). If the tissue still retained its elasticity there appeared
a long pupillary aperture, elliptical and vertical (Figs. 14 and 15).
This incision, however, like all those made through a single set of the
iris fibers, was only successful when there was sufficient resiliency
remaining in the iris tissue to draw the slit open, and thus keep the
edges from uniting. While this method never became very popular, there
were some who later practiced it by substituting a very narrow Graefe
knife for the iris-knife of Heuermann, Beer and Walton. In fact, this
latter procedure still has considerable vogue, both for iridotomy and
capsulotomy.
[18] Walton, H. Haynes: The Surgical Diseases of the Eye, London, 1861,
p. 604.
[Illustration: Fig. 14.--Occlusion of pupil (Walton).]
[Illustration: Fig. 15. New pupil after incision with iris-knife
(Walton).]
During the following seventeen years no notable advance was made, the
scissors method still retaining its hold on the profession, until
in 1869, von Graefe, after long reflection, became convinced of the
dangers of that method, and communicated to one of his pupils, M.
Meyer, his method of simple iridotomy performed with the knife-needle.
Meyer[19] quotes his views as follows:
[19] Meyer, Edouard: Traité Pratique des Maladies des Yeux, Paris,
1880, translated by Freeland Fergus, Philadelphia, 1887, p. 396.
“For such cases von Graefe has suggested another method of operation,
the principle and execution of which are contained in the following
note written for us by that illustrious savant in 1869:
“When, in consequence of a cataract operation, the lens is absent,
and when there is highly developed retro-iritic exudation, with
disorganization of the iris tissue, flattening of the cornea and
the other sequelæ of a destructive iridocyclitis, I substitute
simple iridotomy for iridectomy, which is the operation hitherto
performed, generally without success. The operation consists in
inserting a double-edged knife, resembling in shape a very sharp
pointed lance-knife, through the cornea and newly formed tissues till
it pierces the vitreous body, and immediately withdrawing it; and,
while withdrawing it, enlarging the wound in the membranes without
increasing the size of the corneal wound. Experience shows that such
plastic membranes attached to the atrophied iris and to the capsule
of the lens have a tendency to contract sufficient to maintain, to a
certain extent, the opening which has been made.
“If, in the ordinary method of iridectomy, combined with laceration
or extraction of the false membranes, we find that the artificial
pupil usually becomes closed, we must attribute this to an
excessive vulnerability, which immediately sets up proliferation
in those tissues which have been touched, and which are endowed,
in consequence on their structure, with an irritability altogether
peculiar. We know that even the transitory reduction of the
intraocular pressure, which follows the evacuation of the aqueous
humor, is sufficient to give rise to hemorrhage in the anterior
chamber, which interferes with the perfect success of the intended
operation; but most of our failures in the ordinary methods are
due to the irritation caused by the forceps and the traction on
the surrounding structures. Simple iridotomy is free from such
inconveniences; it is, so to speak, a sub-corneal act, and enjoys the
immunity which belongs to subcutaneous operations.
“I have also reduced the corneal wound to a minimum, by using small
falciform knives. These are passed through the false membranes, which
are then cut from behind forward.”
Von Graefe thus proposed two methods, (1) by cutting from before
backward with a double-edged lance-knife, according to the method of
Heuermann, and (2) by cutting from behind forward with a sickle-shaped
knife, after the original suggestion of Cheselden. Later in the same
year, as he lay on his last bed of illness, he became so absorbed in
the study of this subject that he sent a telegram to the Heidelberg
Congress[20] (September, 1869), in which he advocated the method by
the sickle-shaped knife-needle as the best procedure. His last message
to his colleagues showed, therefore, that through mature conviction
he strongly favored the use of the knife-needle, and the making of
a sub-corneal incision in the iris-membrane without evacuating the
aqueous humor. His untimely death, however, prevented him from further
perfecting this procedure and presenting it to the profession.
[20] Klinische Monatsblätter für Augenheilkunde, 1869, p. 431.
Galezowski,[21] in 1875, published a somewhat similar method in which
he used his falciform knife, _aiguille-a-serpette_ (Fig. 16), which
he introduced through the cornea and iris-membrane, making either
a horizontal or a vertical incision, with a “go-and-come” (sawing)
movement, after the suggestion of Adams. If this single cut was not
sufficient, he made a linear incision of the cornea with a Graefe
knife, drew out the iris and cut it off with scissors. By a process of
evolution, however, he perfected the former procedure and eliminated
the scissors. This latter method was published in the third edition of
his book in 1888. He punctured the cornea and iris-membrane with the
sickle-shaped knife, making first a horizontal incision by the sawing
movement of Adams, and finishing with a second cut in the vertical
direction, thus forming a T-shaped incision. In actual practice,
however, he almost always prolonged this second cut, thus making a
crucial incision after the manner of Guérin.[11]
[21] Galezowski, Xavier: Maladies des Yeux, 2d. ed., Paris, 1875, p.
401, and 3rd. ed., Paris, 1888, p. 384.
The writer,[22] in 1888, was led to devise an operation with a modified
Hays knife-needle, in which through a corneal puncture he made a
converging incision in the iris-membrane which resembled an inverted
V. The resulting pupil opened up and formed either a triangular or an
oval-shaped pupil depending on the degree of stiffness or resiliency of
the iris-membrane. This method will be described in detail later on.
[22] A brief description of the author’s method, written by him, was
first published in de Schweinitz on Diseases of the Eye, Philadelphia,
2nd. ed., 1896, p. 607.