Eduard Konrad Zirm: Notes to Self

Eduard Konrad Zirm (1863-1944)[1] “There is one thing stronger than all the armies in the world, and that is an idea whose time has come.” – Victor Hugo August 8, 1887* I think I will continue my education in Ophthalmology. Three years as a docent in the anatomy clinic in the University of Vienna have made me realize that my heart lies in surgery while my mind would want nothing less than precision and perfection. I also know that Vienna, my own country, is the place to be to train in the science and skills of Ophthalmology. February 24, 1889* Asepsis, that is the foremost for the success of any surgery. My mentor, Professor Carl Stellwag von Carion at my University, Vienna Univ-Augenklinik and Ignaz Semmelweis of Hungary, have convinced me to believe in this principle. July 5, 1896* I distinctly remember the day, five years ago, when they offered me the posts of Director and Professor at the eye clinic in Olmütz. It was a newly established clinic. And Olmütz, the small Moravian town, just seemed like a different world altogether from my city life at Vienna. While skeptical about my new life, I also knew that this was a big opportunity for me and I took the plunge. Today, the eye department has flourished to be one of the largest in the country unaffiliated to any University. August 30, 1904[1] It was an ordinary day. The work in the clinic was going as it always goes and I was most ready to get home tonight. It was around 4:00 in the afternoon when this gentleman walked in. He was holding his hands over both his eyes and was guided in by a young girl who was his daughter. Alois Glogar was his name, a 45-year-old day-laborer from Barnsdorff in Mähren [Fig. 1]. He had been cleaning a chicken coop when he was injured with unslaked lime burns to both his eyes. Lime—it’s the worst one of the lot! Both his corneas were completely milky, I could not see the iris. Visual acuity was counting fingers at half a meter in the right eye and counting fingers at one meter in the left eye. I irrigated both his eyes.[1] I have had to admit him, I intend to monitor him daily for now.Figure 1: Alois Glogar, Eduard Zirm’s patient on whom he performed the first successful keratoplasty[2]December 19, 1904* Mr. Glogar was discharged today, after more than 11 weeks. His vision was finger counting at 1 meter in left eye and ½ meter in right eye. What this man needs is a clear cornea to replace his scarred white one. Corneal transplant was the first organ transplant to have been done. The dreams and ideas have been there since Galen’s times. The French ophthalmologist, Guilluame Pellier de Quengsy, in 1789 described in his manuscript, the steps, instruments and even the perfect day for replacement of an opacified cornea using a glass disc set in a silver ring, the size of the cornea, stitched to the sclera with cotton threads. But I hesitate, for despite his detailed description, de Quengsy never did perform his surgery.[2] Franz Reisinger, who also has to his credit the introduction of hyoscine and atropine as mydriatics in ophthalmology, coined the term “keratoplasty”. He did extensive work with rabbits and chickens, trying to find a way to use animal tissue to replace a damaged human cornea.[2] Dieffenbach, the great surgeon from Berlin, even wrote about Reisinger’s ideas about keratoplasty as “certainly one of the most audacious fantasies, and it would be the highest reward of surgery if this operation succeeded” But I fear, for Reisinger was only met with skepticism and failure of his experiments with the grafts becoming cloudy or the eyes developing panophthalmitis.[2] Dr. Richard Kissam’s corneal graft on a one-eyed patient using a pig’s cornea failed. To be fair, this surgery was performed without any anesthesia in 1838, and for that it was a remarkable feat to begin with. If I ever do proceed with a corneal transplant, it has to be with a human cornea, not animal eyes. Anesthesia, proper handling of tissues, and principles of asepsis are other important factors that may improve chances of my success if ever I have the opportunity… and the courage. March 18, 1905* I complete 43 years on this Earth today. They have been fruitful and productive, except for this one case. Mr. Glogar was in again today with his daughter. Every time I see him, he puts me in the most conflicting state of mind. On one hand I feel helpless. Here is an otherwise healthy man, in his prime, put out of work. On the other hand, I always feel that I can do something for him. In my search for a solution, I came across an account by Dr. S. L. L. Bigger who reported what appears to be the first account of a successful keratoplasty, albeit in an animal. The story is most fascinating. In 1835 the doctor was travelling when he was captured by the Bedouins of Sahara near Cairo and while being held captive, he performed a penetrating graft of their pet gazelle, using the tissue of another gazelle.[2] This further reiterates my belief that it must be a homologous graft. I have the portraits of Arthur von Hippel and Henry Power hung on the wall of my office.[1] Von Hippel was convinced that the corneal endothelium and Descemet’s membrane are most important for corneal transparency and was the first to perform a successful lamellar corneal transplant in 1886, when he transplanted a full-thickness rabbit cornea on to the lamellar bed of a young girl.[2] He also invented the clockwork motorized circular trephine with a wind-up key. This evolved from the idea of Erasmus Darwin, grandfather of Charles Darwin. This is an invaluable tool, both for obtaining a donor cornea as well as for preparing the recipient bed. November 23, 1905 Mr. Glogar has been re-admitted. His vision has now decreased to hand motion in both eyes and there is symblepharon.[1] He needs a corneal transplant desperately, but where do I find another human eye in good shape, while rendering the donor blind? It will be another sleepless night… December 7, 1905 I have done it! Finally! Karl Bräur, an 11-year-old boy came in today. He had suffered from a penetrating wound to his right eye in July, leaving a fragment of iron lodged in his eye.[3] His vision was counting fingers at 2.5 meters. I took him in for surgery in an attempt to remove the piece of iron with a magnet. Halfway through the procedure, I realized that the effort was futile. He had lost a lot of vitreous and the globe was collapsed.[1] As I sat contemplating the next step, in my heart, I knew the answer. I stepped out of the operating room to speak to the father. I told him that the eye could not be saved, that it would be best to enucleate it. As I was walking back to the theater, I stopped short as I crossed the all-too-familiar face of Mr. Glogar. That was it, I had my donor! I went back to the father immediately and he was more than willing to consent for it. There was no more time to waste. I had been preparing for this surgery in my head for months. The eye, in spite of some changes, was in good condition.[4] Once I had completed the enucleation, I placed the cornea in saline till the recipient was prepared under general anesthesia with chloroform.[1] I decided to do the transplant of both the corneas today itself for I did not know when I would get this chance again. I used the von Hippel trephine and cut out two 5-mm buttons from the cornea of the young boy. One was from the center which was kept damp with two steam-moistened gauze pieces and was placed on the left recipient bed without using any other instrument.[4] The other from the periphery that I did not place between the moistened gauze pieces but used directly for the right eye. I used overlay sutures in a St. Andrew’s cross pattern.[1] I do not know what the outcome would be…but all three of us had nothing to lose today! December 14, 1905 I continue to observe Mr. Glogar’s recovery. Both corneas are thankfully clear. But the man has now developed intolerable pain in the right eye. The right corneal button was protruding forward and I partially excised it along with the surrounding tissue.[4] All our hope now rests on the left eye. March 11, 1906 I am happy, Mr Glogar was discharged today, after 4 months, with a vision of 3/50 for distance and Jäger no. 13 for near with a refraction of +7.00 sphere.[45] The right eye had a flat, scarred cornea. But the left corneal graft has remained clear with peripheral scarring and vascularization. The iris is attached to the posterior surface of the graft, the pupil is round. The host corneal vessels did not go beyond the surgical wound. The lens was clear and with an indirect ophthalmoscope, it was possible to make out the normal retinal details.[5] December 6, 1906* I am to go to Vienna Medical School soon to talk about Mr. Glogar’s case. How did I succeed with that left eye? I have thought about that as well. I am indebted to my ancestors, von Hippel, Sellerbabeck and many others. From reviewing the literature and from my personal experience, the basic requirements for a successful graft are[2]: Use of human tissue, preferably from a young and healthy donor. Use of von Hippel’s trephine and eserine. Good, adequate anesthesia. Strict asepsis. Taking care to avoid the cornea coming in contact with the antiseptic. Protecting the graft at body temperature with gauze moistened with sterile physiological saline. Using overlay sutures. Carefully selecting cases eligible for the transplant with no eye infection and normal iris, lens and anterior chamber. Mr. Glogar is still doing well and has returned to working in the fields. I have no doubt that there will be better techniques, more skilled surgeons, much improved instruments and overall, a better understanding of the corneal tissue and I hope to see these times. For now, I am at peace that I did what I could to the best of my abilities. “Each man should frame life so that at some future hour fact and his dreaming meet.” Victor Hugo *The years are accurate. The day and months have been adde

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