|Year : 1965 | Volume
| Issue : 3 | Page : 100-104
Couching and its hazards - a review of 62 cases
King George's Medical College, Lucknow (U.P.), India
|Date of Web Publication||22-Feb-2008|
R C Saxena
King George's Medical College, Lucknow (U.P.)
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Saxena R C. Couching and its hazards - a review of 62 cases. Indian J Ophthalmol 1965;13:100-4
The operation of couching for cataract is one of the most ancient procedures known to surgery, the earliest description being that given by Celsus, A contemporary of Christ. Sprengel (1815) is of the opinion that couching was not only known long before the time of Celsus, but also that the technique of operation, even in that distant era, varied widely in the hands of its different exponents.
In the East the operation was probably invented even centuries earlier.
Dutt (1938) and Bidyadhar (1939) attributed to Susruta the discovery of the operation which they said was entirely unknown to the Greeks, Egyptians or any other people of that time.
With the performance of the first cataract extraction by the French surgeon Daviel ended this procedure which had been practised in Europe for over 17 centuries. In India although couching has been widely replaced by scientific and modern techniques of extraction, one still comes across cases, with or without troublesome complications, where couching has been practised. The practice of couching is mainly prevalent in the villages of India where the poor and the ignorant, for want of expert ophthalmic relief submit their eyes to "Satia" (Quacks) for this obsolete procedure in the quest for restoration of sight.
In this paper an effort has been made to present detailed clinical data regarding cases of couching with its complications studied from August 1963 to July 1964, from the cases attending the Ophthalmic Section of Gandhi Memorial and Associated Hospitals, Lucknow.
Sixty-two cases have been recorded during the above period which constitute 0.22% of the total number of patients attending the out-patients department. The patients came either with some painful complication in the 'couched' eye or for treatment of the other eye. Out of these 62 cases 53 cases were villagers whereas 9 were from the slum areas of Lucknow. Nearly all of them were extremely poor and illiterate. Out of 62 cases 37 cases came for the treatment of the 'couched' eye whereas the rest came for the treatment of the other eye which invariably showed senile cataract in a hyper- mature stage except for two cases where couching was done in both the eyes.
As far as age incidence is concerned, all the cases were between 40 and 70 years of age, the majority (28 cases) being between 56 and 60 years.
As regards sex incidence, out of 62 cases 34 were males and 28 females. The difference is not significant.
It was surprising to see that out of the whole series only 2 cases had couching done on both the sides. In the remaining 60 cases only one eye was operated. Unilateral operation was frequent because either the "satia" never returned to the village of his exploit or the patient learned the bitter lessons of this operation.
In the present study the couched eye was examined as early as 3 days after couching and as late as 10 years. [Table - 1] shows that most of the cases came to the hospital two to three years after couching.
Position of Lens
The positions in which the lenses remained dislocated in these 64 eyes were different and are shown in [Table - 2].
In the majority of eyes (49 i.e. 76.6%) the luxation of lens was into the vitreous chamber, out of which 11 showed limited mobility of lens perhaps because the suspensory ligaments inspite of luxation remained attached at the lower pole of the lens, whereas in the remaining 38 eyes the lens was freely floating. There were 4 eyes, where it appeared that the "Satia" could not push the lens behind successfully because of hyphaema (2 eyes) and non-co-operation (2 eyes). In 4 eyes one could notice the presence of a fine capsule in the pupillary area (after cataract) with the nucleus in the vitreous chamber. It appeared that during the operation the capsule must have got ruptured.
It was most interesting to come across two eyes (couching done 20 to 30 days back) where the lens got caught in the pupil half lying in front and half behind the pupil. (Cases of inverse glaucoma).
Clinically the position of lens could not be ascertained in the case of panophthalmitis (after couching) but during evisceration it could be located in the posterior segment.
| Complications|| |
Out of 64 eyes 25 eyes appeared white and free from any inflammation, whereas the other 39 eyes showed untoward effects, signs of inflammatory reaction which caused a lot of discomfort and pain to the eyes.
Out of the 25 normal looking eyes 11 showed no untoward effect at all, whereas in the other 14 eyes, on examination with an ophthalmoscope, vitreous opacities were seen in all, macular degeneration in 2 and glaucomatous optic atrophy in 2 eyes (a case of chronic simple glaucoma).
In the group of 39 eyes with inflammatory reactions of various degrees, secondary glaucoma in 16 eyes was most prominent. Out of these 16 eyes, presence of the lens in pupillary area was responsible for rise of tension in two eyes. They demonstrated typically the so-called inverse type of glaucoma, where the tension increased with miotics and got decreased with mydriatics.
Four eyes showed anterior dislocation of the lens in which one case was interesting because his lens was originally, in the vitreous but one day it slipped into the anterior chamber through the pupil causing slight irritation to the iris and rise of tension. One eye had subluxation which was causing partial blockage of the angle in the temporal quadrant. The remaining 9 eyes had posterior dislocation with intractable glaucoma in 7 eyes. The tension in these 16 eyes was between 28 and 80 mm. Hg. Schiotz.
The tension was on the higher side in 8 other eyes but there the rise of tension was secondary to conditions like Iridocyclitis without hypopyon (3 eyes), and hyphaema (2 eyes). Here the tension varied from 28 to 35 mm. of Hg. Schiotz.
Iridocyclitis was the next group involving 12 (30.8%) eyes out of which 6 were with hypopyon and 6 without hypopyon. One of the hypopyon cases definitely showed phacoanaphylactic reaction due to the tear in lens capsule whereas the rest were due to irritation of the ciliary body. Two cases in this group developed hypotony with loss of light perception due to long standing inflammation.
Four cases came with hyphaema, mild in 2 and severe (filling more than 1/2 anterior chamber) in 2 with secondary rise of tension. They were all cases that were recently operated. After absorption of the blood, irregular tears in the iris could be seen in some of them.
Leucoma adherans at the site of entrance of the couching needle was seen only in 2 eyes with no other associated complication.
The most dreaded complication of panophthalmitis was seen only in one eye, operated 15 days previously in a village.
After-cataract was present in 3 cases where the nucleus had settled down in the vitreous.
One old case of couching showed massive retinal detachment with no light perception. In [Table - 3] the complications and their incidence seen after couching are tabulated.
In the 25 eyes with no reaction, besides dimness of vision there were no symptoms. The eyes looked externally as if a perfect extraction had been done with a round pupil. The dislocated lens could be seen resting over the lower chorio retina.
In those 39 cases that had inflammatory reactions, the symptoms were diminution of vision, both gradual and rapid, pain in the operated eye, blepharospasm, headache and vomiting.
Narrow palpebral fissure, circumcorneal congestion, shallow anterior chamber in a few and deep in the majority, with lens, blood or pus in the chamber in a few of them, were the principal signs. The pupils were irregularly dilated or constricted the light reaction being sluggish or absent depending on the retinal involvement. Abnormal situation of the lens was the main feature, which was associated with tears in the iris in some cases. Fundus in one case showed retinal detachment and in another glaucomatous atrophy.
Cases which showed no obvious untoward effect were only prescribed suitable glasses. All these cases improved well except cases with macular degeneration and glaucomatous optic atrophy. Both medical and surgical treatment were given to relieve the secondary complications. Cases of secondary glaucoma were put on miotics (mydriatics in cases of inverse glaucoma) and intravenous fluid therapy. Where there was subluxation or dislocation of the lens into the anterior chamber or in the pupillary area, it was extracted. Inspite of all possible treatment, glaucoma could not be controlled in 7 eyes which ultimately ended in complete blindness. Seven cases, where the lens could be extracted showed satisfactory results. In the other 2 cases glaucoma could be relieved temporarily by cyclodiathermy.
The cases of iridocyclitis were put on mydriatics, Hydrocortisone locally and subconjunctivally, antibiotics parentrally and diamox orally. Out of 12, 4 developed blindness, 2 due to hypotony and 2 due to secondary rise of tension. Rest of the cases did improve clinically but visual acuity on the whole remained low due to heavy vitreous opacities.
Two cases of mild hyphaema were put on rest and coagulants. Paracentesis was done in addition in the other two cases having hyphaema when the blood was filling more than half the anterior chamber, with secondary rise of tension. This was followed by extraction of the subluxated lens. All the four improved considerably.
Evisceration was the only treatment left for the case of Panophthalmitis.
Cases of leucoma adherans and after cataract were provided with suitable glasses. Needling had to be done in two of the after-cataracts to achieve good visual acuity.
Since there was no perception of light in the case of retinal detachment no effort was made for any surgical interference.
[Table - 4] shows attainment of visual acuity after proper management and refraction in present series of 62 cases having 64 couched eyes.
| Discussion|| |
It was surprising that in our part of the country in the twentieth century almost 1 in 850 of all hospital attendances had a couching operation done on him before he visited us. There may be many more who may not be visiting an eye hospital, being content with sufficient vision to enable them to move about in their own homes. This shows that even today couching is being practised by quacks on a large scale.
When we analyse the data, we find that majority of the cases are above 50 years of age. There is no significant difference in sex and except for two patients all were unilaterally operated for couching.
As regards the analysis of visual results, the present study clearly shows that the incidence of complications is too high in this technique. Out of 64 eyes, 53 eyes definitely showed associated complications in which 39 eyes had pain and congestion due to inflammation of various degrees. The complications can partly be attributed to the absence of pre-operative and postoperative measures, lack of asepsis and modern techniques of anaesthesia and akinesia, but in the majority the presence of a displaced cataractous lens inside the eye-ball, which behaves like a foreign body, causing ciliary irritation and mechanical obstruction in the drainage of aqueous humour, leads to hazardous complications like iridocyclitis, secondary glaucoma and vitreous degeneration.
In view of above incidence of complications, and poor visual attainments the operation of couching should be completely discouraged by all efforts. Expert Ophthalmic relief may be made available deep in all villages.
| Summary|| |
The results of 62 cases of couching observed at Gandhi Memorial and Associated Hospitals, Lucknow, are analysed.
Couching is an operation which is still widely practised in the village population of India where modern type of Ophthalmic relief is yet not possible. The hazardous complications have been discussed in detail.
In view of high incidence of complications and poor attainment of visual acuity it has been emphasised to make all efforts to discourage this technique and make modern ophthalmic relief possible in villages.
| References|| |
Bidyadhar, N. K. (1939), Arch. of Ophthal. 22, 550.
Celsus A. Cornelius: Medicine (1956), trans by James Grieve, printed by Dr. Wilson and T. Durham, Strand, London.
Daviel, Jacques: Quoted from Hubbell, A: (1902), J.A.M.A. July 26.
Dutt K. C. (1938). Arch. of Ophth. 20, 1.
Sprengel K., Histoire de la Medicine, Trans. by A. J. L. Jourden (1815), Paris.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]