ACTA OPHTHALMOLOGICA VOL. 44 1966

From the departmen1 of ophthalmology, Komrnzrnehospitalet, Copenhagen

(Head: professor P. Brcendstrup, M . D.)

CAUSES OF DEATH AMONG PATIENTS ADMITTED T O A N OPHTHALMOLOGICAL WARD‘))

BY

Preben Kristensen

The mortality in the population from proper ophthalmic diseases is low - according to ]oRZ (1949) 1-2; annually per million inhabitants, a figure arrived at on the basis of different statistics. However, almost any disease of or operation on an eye may indirectly cause or contribute towards the patient’s death. Deaths are not so very rare in ophthalmological wards.

An account will be given below of an analysis made of the deaths among the patients admitted to the Ophthalmological Ward, Kommunehospitalet (Municipal Hospital, Copenhagen) between 1931 and 1964. The patients are not selected and represent a group of population comprising about 700,000. Within this period 27,108 patients were admitted, of whom 78, or 2.9 per mille, died in the ward. The age distribution of these is shown in table 1. It is seen that about 50 per cent were over 70 and about 23 per cent under 7 years old. Of these 18 children, 12 were six months old or younger. Clinico- ophthalmologically these patients may be classed in eight groups.

Group I : 11 patients died of malignant tumours manifesting themselves in the eye and/or orbit. The age distribution of these patients is seen in table 2, and the nature of the primary tumour (verified microscopically) in table 3. All these patients were beyond therapeutic reach owing to the great extension of the tumour. 45 per cent were infants under 7 years of age. Three patients, whose primary tumour was not situated in the eye, had been admitted to the ophthalmological ward owing to ophthalmic symptoms. In two of these the symptoms were due to metastases from breast cancer, for which the patient had been operated on six months and three years previously. The third patient had choked disks owing to metastases from an unknown primary tumour. Of the remaining patients, one died during his first stay in the ward.

’*) Received September 1st 1965.

169 Acta Ophthalmol. 44, I1 12

Table I . Age distribution of 78 patients dead during stay in ophthalmological ward 1931-1964.

years 0 s 0- 7

30-39 40-49 50-59 60-69 70-79 80-89

Total

8 10 1 2 1 2 2 9 5

18 4 12 4

52 26

Table 2. Age distribution of 1 1 patients dead of malignant tumours.

years 0 6

0- 7 2 3 30-59 1 40-49 1 50-59 1 1 60-69 1 70-79 1

Total 7 4

Table 5. Type of primary tumour (cf. table 2).

Orbital sarcoma 4 Retinoblastoma 2 Breast cancer metastasis 2 Melanosarcoma 1 Malignant rhinopharyngeal tumour 1 Unknown primary site 1

Total 11

The others had been admitted twice or more and gical treatment and radiotherapy. The group by

had been subjected to sur- no means gives a reliable

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picture of the over-all mortality from malignant tumours with ocular mani- festations among the ophthalmologic patients of the hospital, some having presumably died at centers for radiational therapy and some - perhaps in particular formerly - at home.

Group 2: 23 patients died in the ward after admission with infections (bacteria or virus) localized in the eye and/or orbit. The age distribution of these patients is seen in table 4, while the nature of the ocular affection is shown in table 5. The causes of death have been set out in table 6. In this group there were ten infants dead within the first months of life. Nine of these died before 1942. The infants had suffered from ophthalmoblenorrhoea (gonorrhoeic and non-gonorrhoeic), xerophthalmia, or abscess in the orbital region. Several of these infants were in a miserable state, displaying mal- nutrition and a poor general condition. One was a premature, and two had congenital deformities. Seven died of pneumonia and three from sepsis - in one case developed after lacrimal probing three days before death. In the

Table 4. Age distribution of 23 patients dead in ophthalmological ward after admission as cases

of infection with orbital manifestation.

0-1 4 6 50-59 1 60-69 2 70-79 5 1 80-89 4

Total 16 7

Table 5. Type of ocular infection (cf. table 4).

Corneal ulcer, keratitis Ophthalmonoblenorrhoea Herpes zoster ophth. Xerophthalmia Abscess in orbital reg. Phlegmonous dacryocystitis Adenitis of lacrimal gland Metastatic panophthalmia

Total

8 5 3 2 2 1 1 1

23

171 IS'

Table 6. Causes of 23 patients’ death (cf. tables 4 and 5).

Pneumonia Thrombosis of coronary artery

13 (of whom 10 before 1942)

(heart disease) 4 Cerebral apoplexy 3 Sepsis 3

Total 23

other two cases of sepsis this had developed in relation to orbital abscess and ophthalmoblenorrhoea respectively. Death occurred on an average 20 days after admission. The remaining patients of this group were 50 years of age and older. The majority had cardiopulmonary and hypertensive disorders, and many had decubital ulcers. Three patients with zoster ophthalmicus, aged 75, 77, and 87, died of pneumonia, coronary thrombosis, and cerebral haemor- rhage respectively.

GTOUP 9: is a mixed group comprising nine patients who had been admitted for further ophthalmologic examination or for operation, but who died before the time of surgical intervention. The age distribution of these patients is seen in table 7 . Two of the three infants had congenital cataract and other con- genital deformities, among which heart disease. These infants died of pneu- monia. The third was a premature, who had developed retrolental fibroplasia. Death was here due to meningitis. The ophthalmological diagnoses are seen in table 8 and the causes of death in table 9. A man, aged 43, had been admitted with bilateral retinal haemorrhage and died 12 days later of myo- carditis.

Group I: comprises 27 patients dead after cataract extraction. The age

Table 7. Age disti ibution of nine patients dead during stay in ophthalmological ward with

a view to operation or further ophthalmic examination.

yeais 0

0- 1 2 1 4 0 4 9 1 1 60-69 1 7 0-7 9 2 1

Total 6 3

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Table 8. Ophthalmologic diagnosis in the patients of table 7.

Congenital cataract 2 Senile cataract 2 Haemorrhagic glaucoma 1 Uveitis 2 Retinal haemorrhage 1 Retrolental fibroplasia 1

Total 9

Table 9. Causes of death of patients in table 7.

Pneumonia 2 Thrombosis of coronary artery (heart disease) 2 Embolism of pulmonary artery 1 Cerebral apoplexy 1 Ocult cancer 1 Sepsis 1 Meningitis 1

Total 9

Table 10. Age distribution of 27 patients dead after cataract extraction.

years 0 s 50-59 . 1 60-69 4 4 70-79 8 1 80-89 5 4

Total 17 10

0 76 Average ages: 8 73

distribution of these is shown in table 10. A total of 4691 extractions (senile and traumatic cataracts) were performed within the period. The mortality

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Table 11. Causes of death after cataract extraction.

Pneumonia 10") = 37 o/o

5 = 59 010

3 8 l Embolism of pulmonary artery Thrombosis of coronary artery Cerebral apoplexy Malignant gastro-intestinal disease 1

Total 27

") of whom 6 before 1942.

for these was thus 5.6 per mille. The causes of death are seen in table 1 1 . All the operations had been performed in local anaesthesia with cocaine, carbo- caine or lidocain (with noradrenaline). Scophedal (= scopolamine + eucodal + ephedrine) was generally used as premedicant. The course of the anaesthesia and operation had been uncomplicated. (One patient had, however, been operated on for prolapse of the iris three days after the cataract extraction. This patient died one month later of a malignant gastro-intestinal disease). 1 1 of the 27 patients had displayed no signs of cardiovascular diseases prior to the operation and had been in a good general condition. The remaining had had hypertensive, vascular, and cardiopulmonary disorders, from very mild to very severe degrees. Thus, one patient had had both legs amputated owing to gangrene. In no more than three cases, however, had the disorder given occasion to examination by a specialist from the medical ward during the patients' stay in the ophthalmological ward. Four of the patients were diabetics. Death occurred on an average 1 1 days after the operation. Only two patients died within 24 and 48 hours of operation. If we divide the group in two, we find that 1187 cataract extractions were performed between 1931 and 1942, with nine deaths (7.6 per mille), and 3504 extractions between 1943 and 1964, with 18 deaths (5.1 per mille).

The group constitutes 35 per cent of all the dead. Groufi 5: Four patients dead after glaucoma operations - one man, aged 68,

and three women, aged 64, 72, and 73 respectively, subjected to cyclodialysis, sclerotomy according to Scheie, iridencleisis, and antiglaucomatous iridectomy. A total of 2160 glaucoma operations were performed within the period con- cerned - with a mortality of 1.8 per mille. The operation and anaesthesia (local in all the cases) gave no complications of any kind. Death occurred from 6 to 21 days after the operation - in two cases due to pulmonary emboli and in the two others to coronary thrombosis. Only two of the patients had displayed signs of heart disease and hypertension prior to the operation. I

The group constitutes 5.2 per cent of all the dead.

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Group 6: Two women, aged 82 and 83, died after evisceration of the eye. The former had the operation performed in local anaesthesia. There were no complications, but the patient died the day after the operation from pul- monary embolism. The other patient, who was highly senile and very weak, was operated on in general anaesthesia. In this latter case death occurred six weeks later, to all appearances independently of the operation or the anaesthe- sia. A total of 308 eviscerations were performed within the stated period. Within the same space of time 707 patients were subjected to enucleation, of whom none died.

Group 7: One woman, aged 80, died from pulmonary embolism three days after re-operation for retinal detachment in local anaesthesia. The anaesthesia and operation, undertaken 14 days after the former operation, were uncom- plicated. Prior to the operation the patient had been in a good general con- dition, and clinical examination had revealed no abnormalities, beyond minor varices. The patient had been confined to bed since her first operation. A total of 597 operations for retinal detachment were performed, with only this single death (1 .7 per mille).

Group 8: One man, aged 75, died from coronary infarction the day after un- complicated excision of a lacrimal sac in local anaesthesia. The patient was hypertensive and had previously had a cerebral haemorrhage. This was the only death among 381 patients subjected to this operation within the stated period.

Between 1931 and 1964 a total of 3327 general anaesthesias were given, without only a single death (cfr. group 6). A much greater number of local anaesthesias likewise had caused no deaths. Neither have oculovagal reflexes been observed as concurrent causes of death. Deaths and causes of death among the patients admitted within the periods of 1931-1942 and 1943-1964, as well as the total period of 1931-1964 have been set out in table 12.

DISCUSSION

To judge from the results of the analysis reported above, the mortality within ophthalmology is due to:

1) Malignant tumours, which in the present cases had reached such an exten- sion that all the patients were beyond therapeutic reach.

2) Infections, which have declined appreciably as causes of death since the introduction of antibiotics. Improvement of the hygienic and social con- ditions in the population has likewise contributed towards a decrease of the mortality within this group. Thus, for instance, such infants in a miserable state as those included in group 2 are no longer met with in the ophthal- mological wards.

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3) Cardiovascular disorders, which have increased both absolutely and rela- tively as causes of death. This is now the predominant group (table 12).

The over-all mortality arrived at on the basis of the present investigation was higher than that calculated by BCjat (1959) in a corresponding study. Among 15.786 patients admitted to ophthalmological wards between 1942 and 1958 he counted 15 deaths. This is a mortality of 1.52 per mille, against 2.5 per mille in the present series from the period of 1943-1964. BCjat found a mor- tality of allout 1 per mille among 5223 patients subjected to cataract extraction, against 5.6 per mille in the present series. On the other hand, the Danish study showed a lower mortality from operation for retinal detachment than the French ( 1 . 7 against 3.04 per mille). A direct comparison of the two series is, however, impossible on the basis of the data available. BCjat’s series seems in general to have been more purely surgical.

According to Gartner & Billet, Beecher & Todd, and BCjat, general anaesthe- sia within the first few years of life contribute essentially towards the over-all mortality among ophthalmological patients. In the present series neither ge- neral nor local anaesthesia was the direct cause of death in any case. The great majority of the 3327 general anaesthesias had been given to young infants. Nor were oculovagal reflexes a concurrent cause of death in a single case. The general anaesthesia had in no instance been supplemented by retrobulbar anaesthesia, which, according to Hirsch et al., among others, prevents such re- flexes. The deaths among the infants in our series were due to malignant tumours and infections, the latter especially before 1942. Since that year no more than three infants have died, if we except the group with malignant tumours. Only one of these was a normally developed infant (death was due to sepsis). Of the remaining two, one was a premature in a very bad condition, and the other had severe congenital deformities. The four patients who died

1931-1942 1943-1964 1931-1964

::) two cases with non-orbital manifestation.

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after operation for glaucoma all died from dramatic cardiovascular insults. The results of investigations by Bennett do not suggest, however, that cardio- vascular causes of death are more frequent among glaucoma patients than in a group of general population. One patient of the present series died from sepsis three days after probing of inflamed nasolacrimal ducts. Another patient died from coronary thrombosis after excision of the lacrimal sec. Leplat (1895) (quoted by Schick & Briickner) reported one case of meningitis after probing of the nasolacrimal duct, and Takashima (1913) one case of fatal septic thromphlebitis of the orbit following excision of a chronically in- flamed lacrimal sac. This and other similar reports (Bernstein 1913, among others) show that occasionally even simple eye operations may prove fatal.

As stated above, the cardiovascular disorders predominate nowadays as causes of death. Various apparently healthy, elderly individuals with no clinical signs of such disorders or with only slight manifestations of such, have been seen to die suddenly few days after an eye operation or admission to an ophthalmological ward. This observation is parallel to the sudden deaths seen in corresponding gerontological series of patients exposed to emotional stress of different kinds. A further decrease of the mortality in ophthalmological wards must be aimed at by an effort to combat cardiovascular disorders in general, and by moderating the emotional stress to which most patients are exposed on being admitted with an eye disease. Regarding the latter, it is not enough to administer suitable sedatives, but we must also take care that the admission to hospital interferes as little as possible with elderly patients’ habits of life. The patients ought probably to stay in the ward for one or two days prior to the operation in order to, so to speak, acclimatize themselves (Bernstein 19.13). The postoperative regime can doubtless also be further modified in many wards. Chisolm, as early as 1887, was opposed to confine- ment to bed following cataract extraction, and he recommended use of mono- culus only. Ching, j e rvey & Brown (1958), Strong (1961), and others have re- ported their results of studies on out-patient cataract extractions and dacryo- cystorhinostomies and pointed out that out-patients are not more exposed to complications than in-patients. Out-patient cgtaract extractions should, how- ever, probably be limited to special cases, e. g. to patients accommodated in social institutions, in particular such as have an ophthalmological consultant of their own. The studies showed, however, that the hospital regime main- tained in several wards may be rendered less rigoristic. Until five or six years ago the patients included in the analysis under review were confined to bed for five days after cataract extraction. Now they get up the first post- operative day, but not till after the first change of dressing of the eye in the morning. Nor is permission to go the lavatory given before this. I t probably involves a smaller risk for these most often elderly patients to be accompanied to the lavatory than to use a bed-pan. Defecation, however, is rarely actual

1 7 7

before the first or second postoperative day. Binoculus is still the routine the first 24 hours. This will cause many patients to become so confused, that the binoculus will have to be removed. (Acute mania, mentioned by Bernstein (1913), for instance, as a concurrent cause of death, was not met with in the series under review). To judge from the above-mentioned studies by Ching and Jervey, binoculus seems to play no part with regard to postoperative complications. After operation for retinal detachment we here employ binoculus for 14 days (and thereafter pinhole spectacles) and confinement to bed for 21 days after the operation. Such a long period of confinement to bed is dangerous to elderly patients and ought presumably to be reduced. At the same time pinhole spectacles ought to be prescribed from the second post- operative day ( jervey 1952). The sudden deaths due to cardiac arrest bring up the question of cardiac massage, of which the nursing staffs of the ophthal- mological wards must then be instructed in the same manner as those of medical wards (Balslev, Tolstrup & Winkler 1965).

I t is worth noting that the figure stated for deaths is a minimum figure, a few patients having died in other special wards of the hospital, to which they had been transferred from the ophthalmological owing to complications necessitating such transfer. Furthermore, the results of investigations by See- dorf f (1964) suggest a certain excess mortality after the discharge from hospi- tal among patients operated on for cataract as compared with a normal group of population. The over-all mortality among ophthalmological patients is thus probably higher than is generally supposed.

S U M M A R Y

An analysis is reported of 78 deaths among 27,108 patients admitted to an ophthalmological ward between 1931 and 1964. A distribution of the deaths over the various ophthalmological groups showed, for instance, that 27 deaths had occurred among 4691 patients subjected to cataract extraction, i.e. a mortality rate of 5.6 per mille. The mortality, which has declined since the introduction of antibiotics and improvement of the social and hygienic con- ditions in the population, is now dominated by deaths due to cardiovascular disorders. To obtain a further decline of the mortality an effort must be made to combat such disorders. In this connection a modification of the post- operative regime is discussed.

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Balslev, J. T . . Tolstrup, N . & Winkler, K.: Hjertestopbehandling. Ugeskr. Laeg. 1965. 121: 1213.

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Bkjat, M.: La mortalit; en Ophtalmologie. Ann. D’ocuI. 1959. 192: 919. BBjat, M.: A propos de la mortalit6 en Ophtalmologie. Thesis. 1959. Bennett, G.: Mortality rates in glaucomatous subjects. Arch. Ophth. 1955. 54: 637. Bernstein, E. J.: Death after cataract operation. Ann. of Ophth. 1913. 22: 260. Ching, R.: Operation for cataract as an office procedure. The Journ. of Intern. Col.

Surg. 1958. 292: 429. Chisolm. J. J.: The revolution in the aftertreatment of cataract operations. Am. Journ.

Opht. 1887. 4: 153. Gartner, S . & Billet, E.: A study on mortality rates during general anzsthesi for

ophthalmic surgery. Am. Journ. Ophth. 1958. 45: 847. Jervey, J. W. (jr .) & Brown, R. A.: Cataract surgery as an outpatient procedure.

Trans. of Am. Ophth. 1962. 60: 268. Jervey, J. W.: Postoperative care of major eye surgery. South. Med. Journ. 1952. 45:

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Schick, F. & Bruckner, A.: Kurzes Handbuch der Ophth. vol. 3. 413. Berlin, 1930. Seedorff, H. H.: A gerontological follow-up on patients operated upon for cataract.

Acta Ophth. 1964. 42. 2.: 550. Takashima, S.: Ein Fall von Thrombophlibitis orbitalis nach Tranensachexstirpation

unter Beriicksichtigung des pathologisch-anatomischen Befundes. Klin. Monatsbl. f . Augenh. 1913. 1 : 338.

Strong, J. D. E.: Dacryocystorhinostomy - an outpatient procedure. Brit. Journ. Ophth. 1961. 45: 724.

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