Frederic Francis Burghard

OPHTHALMIC OPERATIONS
BY
M. S. MAYOU, F.R.C.S. (Eng.)
Assistant Surgeon, Central London Ophthalmic Hospital; Surgeon, The Children’s Hospital, Paddington Green

CHAPTER I
GENERAL CONSIDERATIONS APPLICABLE TO
OPERATIONS UPON THE EYE

Operations upon the eye differ so widely from general surgical operations that it is necessary to say something of the preparations for them before passing on to their actual performance. Although not formidable in themselves, they require great accuracy and presence of mind; slight mistakes, such as too small an incision, may cost the patient his sight, which sometimes may be almost more important than life itself.

Most intra-ocular operations are performed without general anÆsthesia; it is therefore important that the patient should be given confidence by talking to him during the operation, so that he may follow the instructions of the surgeon during its performance; loss of self-control on the part of the patient, movement of the head, screwing up of the eyes, &c., may lead to disastrous results, however well performed the operation itself may be.

GENERAL PRELIMINARIES TO AN OPERATION

The urine should always be examined, especially in cases of cataract, as not infrequently this disease is associated with diabetes, and it is often advisable to treat the general condition before operation.

The bowels should be opened by an aperient the night before the operation, as it is desirable to keep them confined for the first two days afterwards, so as to avoid straining. During the first week after a major operation, when the patient is confined to bed, they should be evacuated in the supine position.

The best time for operating, if possible, is the morning, as the patient has had a night’s rest and is less likely to lose self-control. Usually there is some pain after the cocaine has gone off, and the patient is better able to stand it during the daytime.

AnÆsthetics. General anÆsthesia should be induced in all patients with congested eyes, in small children, patients who are deaf, and those who show a want of self-control. Chloroform should be used for all intra-ocular operations, and should be given to the full surgical degree. It should be given on a towel or an inverted mask specially made for the purpose, a Junker’s inhaler being used during the time the actual operation is being performed. As the surgeon usually stands at the head of the patient, the anÆsthetist should stand on the side away from the eye being operated on. The local use of cocaine in addition to general anÆsthesia is indicated when operating on patients to whom it is advisable to give as little anÆsthetic as possible.

Local anÆsthesia is obtained by the use of a 4% solution of cocaine instilled four or five times before the operation at intervals of three minutes; a drop of the solution should also be instilled into the eye which is not being operated on, to prevent an accidental reflex stimulation of the conjunctiva and screwing up of the eyes. Adrenalin (1–1,000) may be used in conjunction with the cocaine; it is especially useful in squint operations, as it lessens the hÆmorrhage. Eucaine and stovaine have been used, but are not nearly so satisfactory. Under ordinary circumstances the only pain felt during an intra-ocular operation is during removal of the iris; this is obviated to a great extent by instilling the cocaine at least 15 minutes before the operation is performed, so as to allow time for its diffusion into the anterior chamber. The patient should be warned when to expect the pain, so that he may not move; his self-control may be tested beforehand by pricking the nose with a pin.

The theatre. The theatre should possess, as far as possible, all the modern improvements found in an up-to-date general surgical operating-room. The light should proceed from a single large window, which, if possible, should face the north. The window should consist of a single pane of glass or of two panes forming the angle of the theatre; it should begin about 5 feet from the floor and should extend to the ceiling (Fig. 74). The advantage of an angular window is that it allows the operator to stand with his back to the light in the angle, and so enables onlookers to see. No top light should be allowed, as it produces a corneal reflection which may prevent the operator from seeing the position of his knife in the anterior chamber. Beneath the window there should be a recess for the end of the operating table, so that the patient’s face can be brought close to the window if necessary (Fig. 74). This recess is formed by building the main wall of the theatre further out than the window, which has to be supported by a transverse girder.

The window should be fitted with outside blinds so that the theatre can be easily darkened for the operations, such as capsulotomy, which require the use of artificial light. The best artificial light is a small enclosed electric hand-lamp fitted with a bull’s-eye, by means of which the operation field can be brilliantly illuminated while the surrounding area is left in comparative darkness (Fig. 75). Failing this, a single powerful lamp with a ground-glass globe, placed in front of the patient, will serve, the rays of light being brought to a focus on the eye by means of a large convex lens of about + 10 D.

For squint operations it is desirable to have a light fixed to the ceiling, directly over the head of the operating table, for testing the position of the eyes either by the reflection of the light from the surface of the cornea or by the Maddox rod test.

The operating table should be provided with a means of adjusting its height and the position of the head-piece, so that the patient’s head can be brought to about the level of the operator’s elbows when the latter is standing upright with his arms at his side.

After operation the patient should be warned to lie still and not to strain in any way; he should be carried to bed and should lie on his back if possible. If a patient cannot sleep on his back it is better that he should lie on the sound side than be without rest. A length of bandage should be fastened round the wrist of the hand on the same side as the eye which has been operated upon, and should be attached to the bed so as to prevent the hand being put up to the eye during sleep. After major operations, such as those for cataract and glaucoma, the patient is confined to bed for ten days, during the first four of which the head should not be raised from the pillow, the bowels being evacuated while the patient is in the supine position; but old patients with a tendency to bronchitis or hypostatic pneumonia must be propped up in bed and allowed to get up earlier: in these patients it is better to perform the operation in the summer if possible. In old people and patients with a tendency to melancholia the mental condition must be carefully watched, as frequently they cannot stand the confinement to bed and darkness.

LOCAL PREPARATION OF THE PATIENT

When operating upon the eye, a surgeon has to face the great difficulty that he is operating in an area which is not always aseptic, since it is practically impossible to render the conjunctival sac sterile. At the same time, the conjunctiva has been shown to be sterile in health in 25% of cases, pyogenic organisms (principally the staphylococcus albus) being found only in 15%; but, although these are usually not of a very virulent character, they are by far the most frequent cause of sepsis; ten cases of suppuration after operation which the author has examined were all due to this organism. After the methods of purification given below, this percentage is considerably reduced, so that, if due precautions are taken, the risk of sepsis is comparatively small. On the other hand, if conjunctivitis or lachrymal obstruction be present, the risks are enormously increased, especially in the latter condition owing to the frequent presence of the pneumococcus in the discharge, unless special precautions are taken. It is, therefore, of the utmost importance that every case should be examined for lachrymal obstruction before operation. Care should be taken also to see that there is no purulent discharge from the nose or any septic sores about the face.

Sepsis after intra-ocular operations manifests itself in one of two forms: either by suppuration, which usually ends in a rapid and complete destruction of the eye (panophthalmitis), or more rarely in less virulent cases by recurrent attacks of hypopyon associated with acute irido-cyclitis; or by a plastic irido-cyclitis, which may lead to slow disorganization of the eye, with always the possibility of destruction of the other eye by sympathetic cyclitis (sympathetic ophthalmia). Although these conditions are comparatively rare, owing to the improvement in modern aseptic and antiseptic methods, every surgeon of experience will meet with these disastrous complications; indeed it has been suggested that immunization with staphylococcus vaccine should be carried out before major intra-ocular operations, since infection is generally due to this organism.

The methods of purifying the eye before operation. On the second night previous to the operation the eye should be bandaged and examined the following morning for conjunctival discharge. If any be present, an examination for organisms should be made, and the operation postponed until the conjunctival condition has improved. In the event of the case being extremely urgent, the conjunctiva should be swabbed over with nitrate of silver (10 gr. to the oz.) immediately before the operation; some surgeons prefer 1–2,000 perchloride of mercury. If lachrymal obstruction be present, the sac should be thoroughly washed out with boric lotion and protargol (10%) injected. The canaliculi may be temporarily occluded subsequently (see p. 294). If the lashes be very long they should be cut short. Epilation is performed by some Continental surgeons, but is not practised in this country. Various forms of specula are made to keep the lashes out of the field of operation; of these, a modification of Lang’s is perhaps the best (Fig. 76).

On the morning of the operation the lids should be thoroughly cleansed with soap and water, followed by 1–2,000 solution of perchloride of mercury, special attention being paid to the lid margins and lashes. The conjunctival sac should be washed out with boric lotion and a pad of cyanide gauze applied over the closed lid.

GENERAL CONSIDERATIONS AS TO MAKING AND HEALING OF WOUNDS IN THE GLOBE

It has already been pointed out that the great danger in intra-ocular operations is sepsis. It is the aim and object of every ophthalmic surgeon to make such wounds into the globe as will become rapidly shut off from the conjunctival sac. Delay in the healing tends to the formation of a fistulous opening into the globe. This aperture in the continuity of the globe may lead either directly on to the surface or beneath the conjunctiva, subsequent inflammation in which may spread to the interior of the eye.

Cocaine and other solutions used at the time and subsequently to operation should be sterilized. To ensure this the solutions should either be boiled immediately before use, or put up in drop bottles made in one piece with a long tapering neck, which is sealed off, and can be broken immediately before use. These bottles can be kept in an aseptic solution so as not to soil the hands of the surgeon.

The hands of the surgeon are purified. After the dressings have been removed, the patient’s head and the area surrounding the operation are covered with sterilized towels. In operations such as advancement, where sutures are used, it is desirable that the face should be covered with sterile muslin, with a hole cut in it for the eye, so as to prevent the sutures being contaminated from the skin of the face. The eyelids are again washed in 1–2,000 perchloride of mercury lotion, and the conjunctival sac is washed out with a strong stream of boric lotion or normal saline by means of a sterilized irrigator or an undine (Fig. 77) which has been kept in a bowl of lotion.

Instruments. Non-cutting instruments are boiled for 15 minutes in distilled water and placed in a tray of 1–80 carbolic lotion. Some surgeons prefer to place the instruments in the tray without lotion on sterile wet lint, as this excludes infection from the surgeon’s hands due to the lotion running off them on to the instrument. Failing distilled water, a small quantity of soda may be added to the water used for boiling, but this has the disadvantage that a deposit is liable to form on the instruments. This may be obviated to a certain extent by not placing them in the solution until it is boiling. Cutting instruments should be sterilized by dipping them in liquefied carbolic acid (crystals dissolved by heating with 10% of water) for half a minute immediately prior to use and then into absolute alcohol to remove the acid; they are then placed in the tray. The greatest care should be taken to see that cutting instruments and needles do not touch the side of the dish. The edges and points should always be carefully tested immediately before sterilization on a drum covered with fine kid specially made for the purpose. The points should pass through the drum by the weight of the instrument held flat on the open palm; the cutting edge should also be tested. Scissors are best tested by cutting wet cigarette paper, special care being taken to see that the edges are good near the points. Immediately after operation the instruments should be boiled, and dried whilst hot in order to prevent rust.

The direction of an incision into the globe should be as oblique as is consistent with the object of the operation, so as to allow larger healing surfaces to come into apposition. With this object in view it is desirable that a conjunctival flap should be formed to all wounds wherever possible (Fig. 78). Further, owing to the extreme vascularity of the conjunctiva, as has been shown elsewhere,3 wounds in it become firmly united after 48 hours. As a rule sutures are best avoided and are seldom required.

Position of the incisions. Corneal incisions are to be avoided, if possible, for the following reasons: firstly, the cornea being free from blood-vessels heals comparatively slowly; secondly, the wound is liable to become fistulous owing to the rapidity with which the epithelium grows down the side of the wound. On the other hand, incisions situated from 3 to 6 millimetres behind the limbus are liable to injure the ciliary body, and, in addition to irido-cyclitis being set up by the trauma, the iris or ciliary body will prolapse into the wound and prevent the union of its edges, with the result that sepsis may spread into the globe along the prolapsed portion of the uveal tract and set up an irido-cyclitis which may not only ruin the eye affected but may also cause a sympathetic irido-cyclitis in the other eye (Fig. 79).

The site of election of an incision into the anterior part of the globe is therefore about 1 millimetre behind the limbus; that is to say, as near the cornea as is consistent with obtaining a good conjunctival flap to cover the wound in the globe (Fig. 78). When possible it is advisable to make all incisions in an upward direction for the following reasons: They are more easily performed; any deformities, such as an iridectomy, are hidden by the upper lid; more perfect rest is obtained, as the wound is not exposed in the palpebral aperture, the eye being turned upwards when the lids are closed.

The immediate danger of the passage of a knife into the anterior chamber of the eye is the wounding of the lens. To avoid this the point of the knife should be always kept superficial to the iris if a clear lens be present in the eye. After operation the chief danger is prolapse of the iris into the wound. This is best avoided at the time of operation by carefully replacing the iris with the spatula at the end of the operation, but unfortunately prolapse not infrequently occurs during the first few days owing to the reaccumulation of the aqueous in the anterior chamber and its sudden escape through the imperfectly healed wound as the result of straining or of some movement on the part of the patient; the iris may be carried into the wound with the escaping aqueous, and a fistulous opening or a scar may form subsequently (Fig. 80).

The less manipulation used consistent with the object of the operation the less likelihood is there of cyclitis following it. All instruments should be held lightly in the fingers, which should be as far as possible responsible for the fine manipulation required. The part of the hand not actually holding the instrument should be steadied on the face before the instrument is brought in contact with the eye.

When more than one operation has to be performed on the same eye it is desirable that all ciliary injection after the first operation should have disappeared before the second is undertaken.

Dressings. A pad of sterilized wool, with a few layers of cyanide gauze moistened with 1–6,000 perchloride of mercury lotion next the closed eyelid, held in position by a bandage, is all that is necessary.

Bandaging. The bandage is started on the forehead over the affected eye and is carried in a direction away from the eye to be covered. A complete turn is made to encircle the head and is fixed with a pin. The bandage is then brought up beneath the ear and over the eye and fixed with pins on the forehead (Fig. 81). When absolute rest is desired, it is necessary to bandage both eyes. After intra-ocular operations this is desirable for the first three days. When pressure is desired, a figure-of-eight bandage should be used (Fig. 82). A useful bandage (Moorfield’s bandage) for occlusion of both eyes is made from stockinette, which fits closely over the eyes and nose and is fastened with tapes.

The dressings should not be disturbed for at least 24 hours. The lids are then cleansed with 1–6,000 perchloride of mercury lotion, and the lower one is pulled down so as to allow the escape of tears and to see if any discharge be present. The upper lid should not be touched. If no discharge be present the eye is re-dressed. If discharge be present the conjunctival sac should be washed out carefully with boric lotion. Most wounds with conjunctival flaps are shut off in 48 hours, after which time it is advisable to wash out the conjunctival sac twice a day with boric lotion. Great care should be taken to see that no undue pressure is made on the globe. The patient should be warned not to screw up the eyes or strain whilst the dressing is being performed.

CHAPTER II
OPERATIONS UPON THE LENS

Surgical anatomy. The lens consists of fibres which are developed from cells originating in an inclusion of the foetal epiblast. A normal lens is surrounded by a capsule, the anterior half of which is lined with a single layer of epithelial cells on its inner surface. In foetal life the cells which line the posterior half of the capsule go to form the lens fibres, so that after birth the lens capsule is lined by cells only on its anterior surface. The lens capsule, which is deposited from the epithelial cells lining it, consists of a highly elastic membrane; small wounds in its continuity, therefore, gape widely. Throughout life the cells lining the capsule continue to become new lens fibres, but at the same time the bulk of the lens does not increase markedly. This is due to the fact that the lens fibres become more closely packed together and lose some of their watery constituents (sclerosis). The older central part of the lens is the first to undergo this process, with the result that a definite hard nucleus is found in the lenses of people about the age of thirty to thirty-five and upwards.

Chemically the lens fibres are composed of crystallin, which is closely allied to a serum globulin and is therefore soluble in salt solution. When the lens capsule has been opened, by operation or accident, the saline aqueous is admitted to the lens, which becomes opaque, swells up, and is gradually absorbed (Fig. 83). In those under the age of thirty, therefore, a simple incision into the capsule is all that is required to cause it to be absorbed. But, as has already been pointed out, the lens develops a hard nucleus after that age and will not then be absorbed satisfactorily by simply opening its capsule; to remove it, as is done in senile cataract, the hard nucleus must be extracted from the eye.

The lens is held in position by the suspensory ligament, which consists of interlacing fibres attached on the one hand to the ciliary process and on the other to the capsule at the lenticular margins (Fig. 84). Prolapse of the vitreous after cataract extraction is prevented by the integrity of this ligament and the posterior capsule of the lens, together with the hyaloid membrane of the vitreous. The tension on the fibres of the suspensory ligament, in addition to keeping the lens in its place, also exercises traction on the lens capsule. In dislocated lenses there is a gap in the suspensory ligament either as the result of injury or of congenital malformation; when such cases require operation there is some difficulty in producing a sufficient gap in the capsule to promote their absorption, owing to the mobility of the lens and the want of traction on the incision in the capsule.

DISCISSION OR NEEDLING

Discission of the lens has for its object the tearing open of the anterior capsule, so that the lens substance may be broken up and absorbed.

Indications. This operation will be required:

(i) For cataract in patients under the age of about thirty. The forms of cataract for which these operations are usually performed are: (i) complete congenital cataract, in which the whole lens is opaque and consists of little more than a shrunken capsule which may have to be extracted if discission is unsuccessful; (ii) lamellar cataract, of sufficient density to interfere seriously with vision; (iii) posterior polar cataract in rare instances; (iv) traumatic cataract, to complete the absorption of the lens by breaking up its fibres.

Before operating on any form of cataract the following facts must be ascertained as far as possible:—

(a) Vision. It must be remembered that in children a defective eye retaining the power of accommodation is often more useful than an eye which sees better but has to wear different glasses for different distances. Vision must be reduced to less than 6/18 in both eyes after correction with glasses before the operation should be undertaken. In rare cases, in children, and in traumatic cataract where the cataract is very dense and confined to one eye, it may be removed partly to improve the personal appearance and partly to enable the patient to see large objects.

An eye without a lens (aphakia) will not work with an eye with a lens even if the former be corrected with glasses.

If the patient be unable to see letters, he should have a ready and quick perception of light, no cataract, however dense, being sufficient to prevent this.

(b) A patient should have a good projection of light; that is to say, he should be able to locate the light when thrown into the eye with a mirror whatever direction it comes from. Children generally turn the head towards the light, provided that they can see it and that the eye is not defective from other causes.

(c) Note whether the pupils are equal and active. In children most useful information can often be obtained as to the condition of the fundus by means of the pupil, which often will not react when the patient is unable to appreciate light.

(d) The condition of the fundus of the other eye, if observable, should be taken into account, as many diseases of the fundus, such as choroiditis and myopia, are bilateral, and would influence the prognosis considerably.

(e) The lachrymal sac and conjunctiva should be free from all signs of inflammation (see p. 181).

(ii) For the removal of a lens for high myopia. In selected cases operation gives very satisfactory results with great improvement of vision; indeed full normal distance vision has been obtained without glasses. The operation, however, is only justifiable under certain circumstances, the chief of which are:—

In emmetropia, if the lens be removed, a glass of + 11 D. has to be placed before the eye for distance vision and + 14 D. for near vision. It is impossible to predict the exact amount of correction of myopia which will be produced by the removal of the lens, owing to the surgeon’s inability to estimate the refractive power of the lens associated with the distortion of the posterior pole of the globe. Usually a patient with about 22 D. of myopia is rendered emmetropic by the operation.

There are two main objections which have been raised to the operation: first, that there is a slight risk of septic infection, sympathetic ophthalmia even having been known to occur; secondly, that retinal detachment seems rather more common after operation than in ordinary myopia of the same degree. As a rule it is only advisable to perform the operation on one eye, the patient using the other for reading purposes, but under certain circumstances, as when the operation has been successful for a considerable period of time, it would be justifiable to perform it on the other eye. The operation should never be performed on patients having only one eye.

Instruments. Speculum (Fig. 85), fixation forceps (Fig. 86), discission needle.

Operation. First step. The operation is best performed by artificial light. The pupil having been dilated with atropine and the eye anÆsthetized with cocaine (a general anÆsthetic being necessary, however, for young children), the speculum is inserted by first drawing up the upper lid, making the patient look down, and inserting the top blade, and then drawing down the lower lid, making the patient look up, and inserting the lower blade. The speculum is opened to its full width without undue strain on the canthus and is kept in position by tightening the screw. The eye is steadied by fixation forceps held in the left hand, which grasp the conjunctiva as close to the cornea as possible directly opposite to the spot at which the puncture is to be made; the puncture is made directly behind the limbus and the needle is passed into the anterior chamber.

Second step. Using the shaft of the needle lying in the cornea as a fulcrum on which to rotate the needle, an incision is made in the anterior capsule of the lens, and the lens fibres are broken up by a stirring movement. The needle is then rapidly withdrawn in the same plane in which it was inserted so as to avoid making a crucial incision in the cornea with the spear-like end and thereby losing the aqueous. The best way to make sure of this is to mark one side of the handle so that it may be inserted and withdrawn in the same position. A pad and bandage are then applied.

After-treatment. The pupil should be kept dilated subsequently by the use of atropine twice a day until the lens has become absorbed. The bandage may be removed about the fourth day and dark glasses worn.

The effect of the operation on the lens varies considerably. It may swell up so rapidly that the tension of the eye becomes increased, in which case an evacuation may have to be performed; in other cases, especially in the cases of a patient with high myopia, several needlings may be required before absorption is complete.

CAPSULOTOMY

Capsulotomy is the division of the opaque capsular membrane left after a cataract has been removed.

Indications. After a cataract has been removed, either by discission or extraction, an opaque membrane is usually left. This is due to the proliferation of the cells in the anterior capsule of the lens while attempting to lay down new lens fibres. Although the posterior capsule is clear and free from cells, those from the anterior capsule may spread to it and so render it opaque. A fibrinous exudate may also organize and help to thicken the membrane (Fig. 87). For these reasons and also because the soft matter may not have absorbed entirely, it is not advisable to operate too soon after a cataract has been removed. There should be at least six weeks’ interval after an extraction has been performed. A few surgeons operate earlier than this, the idea being that the membrane is then softer and more easily divided.

Although the operation of discission for after-cataract (capsulotomy) is simple it is not to be undertaken lightly. The patient’s vision should be less than 6/18. In former days the operation was looked upon as attended with as much risk as the extraction, owing to the frequency with which it was followed by inflammation. The reasons for this seem to have been want of proper antiseptic precautions, the passage of the needle through the non-vascular corneal tissue instead of through the conjunctiva, and also the use of a badly made needle, often resulting in prolapse of the vitreous into the wound. A proper discission needle should have sufficient width in its spear-like point to cut a hole large enough to admit the shaft freely; hence needles which have been sharpened several times should be discarded. It need hardly be said that there should be no signs of cyclitis (keratitis punctata) present when the operation is undertaken.

Instruments. These are the same as for discission, with the addition of a needle with a long cutting edge.

Operation. Capsulotomy is best performed by artificial light under cocaine. The cutting needle is inserted into the anterior chamber as in the previous operation. The point is then thrust through the membrane below (but it should not penetrate deeply, otherwise the vitreous will be torn) and an incision is made in an upward direction. This incision usually gapes sufficiently to give a clear pupil (Fig. 88). Those surgeons who operate early try to cut out a triangular portion of the membrane. When a dense band is present which gives before the needle and cannot be divided, a second or ordinary discission needle should be passed into the anterior chamber from the limbus opposite to the cutting needle. The discission needle is made to pass behind the band whilst the cutting needle lies in front of it. By a rotary movement of the discission needle around the cutting needle the band is carried against the edge of the latter and so divided. The needles are then withdrawn (Fig. 89).

Results. These are good as a rule, but the operation may have to be performed again owing to an insufficient or non-central opening being obtained in the membrane, or to a fresh membrane forming; this is liable to take place if any irido-cyclitis follow the operation.

After-treatment. This should be carried out as described for needling.

EVACUATION

Indications. (i) In cases of increased tension associated with soft lens substance in the anterior chamber.

(ii) To accelerate the absorption of soft lens matter from the anterior chamber. As a rule it is only undertaken for the former condition.

Instruments. Speculum, fixation forceps, bent broad needle, curette.

Operation. Under cocaine.

First step. An incision is made behind the limbus, usually in an upper segment of the cornea, by means of a bent broad needle. The point of the instrument is passed into the anterior chamber immediately behind the limbus with the handle at right angles to the cornea; directly the anterior chamber has been entered the handle is depressed so that the point of the instrument shall turn forwards and avoid injuring the iris. The blade is passed on into the anterior chamber until the point reaches about the centre of the pupil. It is then either withdrawn directly, or, if a larger incision be desired, lateral pressure is made so that in withdrawing the blade the wound is enlarged.

Second step. Evacuation. With the rush of aqueous which follows the incision some soft matter is usually evacuated; then a curette may be introduced, if necessary, and the lens fragments removed by gentle manipulation. Occasionally the iris may prolapse into the wound; if this happens it should be replaced, but if it occur more than once the prolapsed portion should be removed. Suction apparatus has been used for removing the soft lens matter, but it is not to be recommended in most cases, owing to the difficulty of sterilization and the trauma which it may cause. After-treatment as for needling should be carried out.

EVULSION OF THE CAPSULE

Indications. (i) In congenital cataract when the lens consists of little more than a dense capsular mass.

(ii) In dense capsular membranes following removal of a lens by discission in which a cutting needle cannot make a hole.

Instruments. Speculum, fixation forceps, keratome, capsule forceps, discission needle.

Operation. A general anÆsthetic is usually desirable.

First step. The pupil is previously dilated with atropine. In the case of congenital cataract a discission needle is first passed into the mass to estimate its consistency. If it consist of little more than capsule an incision is made at the limbus with the keratome as described for evacuation.

Second step. The blades of the capsule forceps are then inserted closed, opened, and the opaque capsule grasped and withdrawn from the eye. The speculum is then removed and a pad and bandage applied. The pupil should be kept dilated with atropine subsequently, as a certain amount of irido-cyclitis following the operation is not infrequent. Occasionally the iris may become entangled in the wound, and it should then be removed.

EXTRACTION OF THE LENS

Indications. (i) For all forms of cataract in patients over thirty years of age.

(ii) For cases of high myopia over the same age.

(iii) For lenses containing foreign bodies.

(iv) For displacement of the lens causing irritation.

Probably no operation in surgery has so many modifications, many of which possess advantages and disadvantages which counterbalance each other so nearly that the individual surgeon must decide for himself which is the most satisfactory to carry out. The opinion of many surgeons, including the author, is that the ideal operation is one which can obtain sight for the patient at one sitting. The operation described below is carried out with this object in view, the various modifications and the indications for their use being subsequently discussed.

Instruments. Speculum, two pairs of fixation forceps, a Graefe’s knife, iris forceps (Fig. 90), iris scissors (Fig. 91), capsule forceps, cystotome, curette or spoon, iris spatula, vectis (Fig. 92), or lens spoon (Fig. 93).

Operation. The operation is performed under cocaine and is divided into five steps:—

1. Incision.

2. Iridectomy.

3. Opening the lens capsule.

4. Delivery of the lens.

5. Toilet of the wound.

First step. The incision. The surgeon, standing behind the patient’s head and holding the knife with the edge directed upwards, in the right hand for the right eye and in the left hand for the left, fixes the eye with a pair of forceps held in the other hand, by grasping the conjunctiva below and to the inner side as close to the limbus as possible (Fig. 94). Most continental surgeons stand in front of the patient and cut upwards. The point of the knife is then passed on the flat into the anterior chamber from the outer side, 1.5 millimetres behind the corneo-sclerotic junction.

It is first directed downwards and inwards until the chamber is penetrated (Fig. 95). The knife-point is then directed horizontally and passed across the anterior chamber in a line parallel with an imaginary tangential line across the top of the cornea. The counter-puncture is then made, the knife emerging 1 millimetre behind the corneo-sclerotic junction (Fig. 96). In making the counter-puncture the beginner is apt to go too far back in the sclerotic owing to the angle of the chamber being placed behind the limbus; he should therefore aim for a point about 1 millimetre inwards from the limbus. The knife is next made to cut upwards by a sawing movement so that a flap is formed of corneal tissue about 3 millimetres in breadth (a breadth and a half of a new Graefe’s knife), the upper margin being at the corneo-sclerotic junction. When the corneal flap has been made, the knife should lie beneath the conjunctiva, from which a flap about 3 or 4 millimetres in length should be formed. The knife-edge is then turned forward and made to cut its way out. In making the section, care must be taken not to prick the patient’s nose or eyelid with the point of the knife, as it may cause him to move his head with disastrous results. This is more likely to happen with patients who have sunken eyes.

Second step. Iridectomy. The patient is made to look downwards. A pair of iris forceps are inserted, closed, into the anterior chamber, opened, and the iris grasped near its root, and withdrawn. The piece of iris is then removed with the iris scissors, dividing it parallel with the incision as close to the eye as possible (Fig. 97). If the conjunctival flap hinders the insertion of the iris forceps into the anterior chamber, it may be turned forward over the cornea with the point of the closed forceps.

Third step. The capsule of the lens is opened. This is done in order to allow the lens nucleus and soft matter to escape. Since the anterior capsule becomes opaque after the removal of the lens, owing to the multiplication of the cells in their attempt to lay down new lens fibres, it is desirable to remove a portion of the anterior capsule from the pupillary area. This may be performed (a) by means of capsule forceps which are inserted closed, and when in position over the lens are opened as widely as possible without entangling the iris, then pressed down on to the anterior capsule of the lens and closed; in this manner the portion of the capsule thus included is removed by a slight lateral movement (Fig. 98); (b) by means of a cystotome, the lens capsule being opened by a triangular or T-shaped incision over the pupillary area; (c) by the point of the knife as it passes across the anterior chamber; (d) by a discission needle before the section is made. When the capsule of the lens has been opened properly the lens nucleus is usually seen to come forward. The advantage of the capsule forceps over the other methods is that they remove a larger portion of the capsule and leave no tags which may become incarcerated in the wound. On the other hand they are somewhat more difficult to use; more pressure on the lens is required, and therefore dislocation of the lens in its capsule may result. It is, therefore, not advisable to use them in cases in which a fluid vitreous is suspected. If the teeth of the forceps are not well made they will not grasp the capsule; it is therefore always advisable to have the cystotome in readiness. The cystotome also should be used when the anterior chamber becomes filled with blood so that the margin of the iris cannot be seen and there is a risk of the iris being grasped by the forceps.

The method of opening the capsule with the point of the knife or needle is useful in cases of extraction without iridectomy; the pupil should be dilated before the operation.

Fourth step. Delivery of the lens is performed by a gentle pressure, combined with massage, on the extreme lower margin of the cornea with a curette or spoon, until the upper margin of the lens presents in the wound, when the pressure is gradually made upwards over the cornea until the lens is delivered. Delivery of the lens may be prevented by—

(a) Imperfect opening of the capsule, which is usually the result of using a blunt cystotome; if capsule forceps are used this difficulty hardly ever arises.

(b) Too small an incision. The margin of the nucleus may present and not be able to pass the wound. The wound must then be enlarged with the iris scissors and the lens delivered in the ordinary way. Only by experience can the amount of pressure required for the delivery of the lens be gauged.

(c) A sticky consistency of the cortex is not infrequently found in cases of immature cataract. When the lens presents and cannot be delivered readily it may be helped out by means of the cystotome plunged into its substance, pressure being used on the cornea at the same time.

If from these or any other causes the suspensory ligament rupture and the vitreous present in the wound, the lens should be removed with the vectis. The vectis, which should be made of stiff steel, is passed vertically into the incision and behind the lens nucleus by depressing the handle; with a steady gentle pressure forwards it is then withdrawn together with the nucleus. The forward pressure should be such as to prevent the instrument slipping on the nucleus, for if it does so the accident is nearly always followed by a rush of vitreous. A Pagenstecher’s spoon may be used instead of the vectis, and is to be preferred in cases where a small nucleus is suspected, since the latter may slip through the loop of the vectis and fail to be delivered.

Fifth step. Toilet of the wound. After the nucleus has been extracted, all the soft matter should be removed as far as possible by gentle expression with the spoon. The angles of the coloboma in the iris should be replaced by stroking it inwards on its anterior surface with the iris spatula, paying particular attention to the angles of the wound (Fig. 99). The spatula should also be passed throughout the extent of the wound so as to free it from any capsule which may have prolapsed into it. The conjunctival flap is then placed in position by stroking it upwards with the iris spatula.

After-treatment. Atropine is instilled either at the time of operation or at the first dressing, and continued until all signs of redness of the eye have disappeared. The patient should remain in bed for at least ten days, both eyes being bandaged during the first four days. The eye that has been operated on should be covered for at least two weeks; subsequently a shade or dark glasses should be worn.

Modifications. The operation may be modified in various ways.

The incision. The position of the incision has undergone many modifications. The one described above is now in general use.

The size of the incision should be increased when (a) a large nucleus is expected, as in old people; (b) an immature cataract is to be extracted; or (c) a fluid vitreous is suspected, so that the lens may be delivered with as little pressure as possible.

The iridectomy may be omitted. Extraction without iridectomy is undoubtedly the ideal operation; it leaves the pupil unbroken and the eye looking normal to external appearance. Further, the pupil reacts more strongly to light than if an iridectomy has been performed. The presence of the iris further prevents the prolapse of any capsule into the wound. At the same time it is attended with considerable risk of prolapse, which, as has been pointed out, is a very great danger to the eye. With proper care this probably only occurs in about 5% of the patients operated upon, but is so serious that the opinion of most surgeons is in favour of the combined method (iridectomy and extraction); but at the same time it is the practice of many surgeons to omit the iridectomy under the following circumstances: first, if the patient be young and the deformity will interfere with his getting employment; secondly, if extraction of the lens in its capsule be performed the unbroken circle of the iris will help to prevent the prolapse of the vitreous which is otherwise so liable to take place.

Eserine (gr. ii ad ?i) should be used to prevent prolapse of the iris after the extraction has been performed, and should be continued once a day until a good anterior chamber is present, which is usually in about twelve to twenty-four hours, when atropine should be substituted. If the iris betray any liability to prolapse after the operation, as shown by the drawing upwards of the pupil, an iridectomy should be performed before the patient leaves the table. In any case the eye should be examined on the evening of the operation, and, if prolapse has occurred, that portion of the iris should be removed. If a prolapse of the iris occurs and is not discovered until the wound has healed, the conjunctiva should be dissected off the surface in the form of a flap and the iris tissue drawn out of the wound and removed, the angles caught in the scar being freed if possible. The opening in the globe is subsequently closed by replacing the conjunctival flap in position, or, if it has not been possible to preserve the conjunctiva over the cicatrix, by raising a flap from the ocular conjunctiva in the neighbourhood and stitching it down over the opening in the globe. Not infrequently this operation is followed by an attack of acute iritis, which usually subsides under treatment.

Preliminary iridectomy. The iridectomy may be performed at a previous operation. It has the advantages that the surgeon learns how the patient will behave under operation, and how the eye will react to such an operation. There is an absence of bleeding at the second operation, which makes it easier, and there is less liability for the iris to become adherent to the capsule. The disadvantages, which seem to outweigh the advantages, are that there is a double chance of sepsis, and that the patient has to submit to two operations when one is sufficient. It is only performed by the author in cases in which there is a tendency to increased tension in the eye due to swelling of the lens in the early stages of the cataract. When a preliminary iridectomy is performed a keratome may be substituted for the Graefe’s knife in making the incision for the iridectomy, a much smaller one being necessary.

Delivery of the lens by irrigation. McKeown removes the soft lens matter by a process of irrigation into the anterior chamber, a practice not yet much adopted, but of considerable service in removing the soft matter after the extraction of the nucleus, especially in immature cataract. It is also probable that the thorough removal of the soft lens matter by this method reduces the number of cases of cyclitis following the operation, since the soft matter forms a suitable medium for the growth of organism. The apparatus used is shown in Fig. 100, nozzle No. 2 being the most useful; it is inserted into one angle of the wound and a stream of sterilized normal saline solution at 39°C. (in the flask) is allowed to flow into the anterior chamber; this stream is obtained by raising the flask until sufficient pressure is obtained. An undine may be substituted for the flask. Care should be taken that there is a free return of fluid from the anterior chamber; irrigation should be continued until as much as possible of the soft matter has been removed.

Extraction of the lens in its capsule. This operation is frequently performed in India, where patients will often not return for needling of secondary cataract (capsulotomy). Although the method undoubtedly yields good results, the percentage of eyes damaged by loss of the vitreous must be higher than when the posterior capsule of the lens is left intact. The operation may be performed with or without an iridectomy, the lens being removed by pressure on the cornea with a large strabismus hook. If the vitreous should present, the lens should be removed with the vectis.

Extraction of the lens in its capsule is also performed when the lens is dislocated and causing irritation. If the lens be in the anterior chamber immediate extraction is called for, as glaucoma is a usual complication. Eserine is first instilled in order to contract the pupil and prevent the lens passing back into the posterior chamber; an incision is then made as for a cataract extraction and the lens removed by means of the vectis. Complete dislocation of the lens into the vitreous rarely requires operation, as the patient is able to see. Partial dislocation (luxation) occasionally calls for extraction, the vectis usually being employed for delivering the lens, but before undertaking the operation an attempt should be made to get the lens into the anterior chamber by dilating the pupil and making the patient lie face downwards; if this is successful eserine should be instilled to contract the pupil behind the lens and so retain it in the anterior chamber, from whence it can more easily be extracted. Some surgeons prefer to fix the lens with a needle passed through the sclerotic behind the ciliary body before making the incision.

Subconjunctival extraction. In order to diminish the risks of sepsis, more especially in cases in which the conjunctiva is affected with trachoma, some continental surgeons deliver the lens into a pocket beneath the conjunctiva, whence it is subsequently removed. The operation has the additional advantage of a better blood-supply to the corneal flap, which is also held in better position after the operation.

Operation. A section upwards is made with a Graefe’s knife as in the ordinary method of extraction previously described, the lens capsule being opened with the point of the knife as it is passed across the anterior chamber. When the section through the sclerotic has been completed and the knife lies entirely beneath the conjunctiva it is withdrawn.

The wound in the conjunctiva on the outer side is then enlarged upwards with scissors, and an iris spatula is passed beneath the conjunctiva from the small wound on the inner side and the point made to appear in the wound on the outer side; by this means the conjunctiva is raised on the spatula, and by means of sharp-pointed scissors a pocket is made in an upward direction by undermining the conjunctiva (Fig. 101). Delivery of the lens is then performed into this pocket, from which it is subsequently removed, the conjunctival wound on the outer side being closed with a stitch. The advantage of this form of subconjunctival extraction over other forms which have been devised is that if difficulty is met with in delivering the lens, &c., the operation can be readily converted into an ordinary extraction by completing the division of the conjunctival flap.

Complications. These may be immediate or remote.

Immediate. 1. If the knife-point become entangled in the iris as it is passed across the anterior chamber it should be slightly withdrawn, if this can be done without loss of aqueous, the iris being thereby disengaged.4

2. Loss of the aqueous before the section is complete may result in the entanglement of the iris as before described, or the iris, owing to the presence of the aqueous in the posterior chamber, may bulge forward in front of the knife-blade. The latter complication is more likely to occur if the section be made too rapidly. The iris may sometimes be disengaged by depressing the handle of the knife towards the patient’s chin and raising the blade towards the cornea so as to allow the aqueous in the posterior chamber to escape. If this cannot be accomplished, the section should be completed and the iris, which may be divided by the knife, removed subsequently when doing the iridectomy.

3. Avulsion of the iris due to movement of the patient’s head. This is more liable to take place if the eye has not been properly cocainized some time before the operation. The grasping of the iris by the forceps is always felt by the patient to a certain extent, and he should be warned not to move. Avulsion is usually not complete and only results in a larger iridectomy than was intended.

4. Dislocation of the lens. (a) When opening the capsule, either from too great pressure of the capsule forceps, or from the patient moving his head. The lens must then be delivered by the vectis. (b) If, in delivering the nucleus, the upper edge is not made to present by pressure on the lower part of the cornea, the nucleus, especially if it be small, is liable to be dislocated upwards beyond the incision. It must then be removed with the vectis. In cases where a small nucleus is suspected, pressure should be made on the sclerotic above the incision with a curette, as well as on the lower part of the cornea, so as to make the nucleus present in the wound.

The lens may be dislocated backwards into the vitreous; if this should happen and the lens cannot be delivered, the flap must be replaced in position and the eye bandaged. Unfortunately this complication is usually followed by irido-cyclitis and loss of the eye.

5. Loss of the vitreous. There are two chief phenomena which may indicate that loss of vitreous is about to take place after the extraction of the lens.

(a) The wound gapes unnaturally after the expulsion of the lens, and the clear vitreous may be seen presenting in the wound in the still unruptured hyaloid membrane.

(b) There may be an apparent deepening of the anterior chamber owing to the fluid vitreous making its way forward through the ruptured hyaloid into that cavity.

If the vitreous presents in the wound before the lens has been removed, the latter should be delivered as rapidly as possible by the vectis, as has previously been described.

If the vitreous be lost or one of the phenomena previously mentioned occurs after the delivery of the lens, the speculum should be removed from the eye and the conjunctival flap replaced in position as quickly as possible. The eyelid is then carefully raised from the surface of the eyeball by means of the lashes held in the finger and thumb and carried downwards over the globe until it is in the closed position, and a bandage is then applied.

As little manipulation as possible should be carried out when once the vitreous has shown itself about to present, and unless the iris be obviously in the wound no attempt should be made to replace it.

Loss of vitreous may be the result of subchoroidal hÆmorrhage, which may only make itself manifest after the patient has been put back to bed.

Loss of vitreous is frequently accompanied by hÆmorrhage into the vitreous, as is seen subsequently by the floating opacities therein. As a rule these clear, and useful vision is obtained.

Detachment of the retina may follow loss of vitreous even months after operation. This complication seems more liable to occur if the vitreous which is lost in the first instance be normal and not of the fluid type.

6. Intra-ocular hÆmorrhage (see Glaucoma Iridectomy, p. 224).

Remote. 1. Panophthalmitis is a result of infection of the wound. It usually makes its appearance about the third day and must be treated by evisceration. Occasionally the purulent material is limited to the line of the incision or even to the anterior chamber; in the latter instance the wound should be opened up and the anterior chamber washed out with peroxide of hydrogen solution (10 vols. %). Microscopic examination of the pus should be made and a vaccine prepared and administered; in two cases so treated by the author a good recovery resulted.

2. Escape of the aqueous beneath the conjunctiva usually occurs about the third day, owing to the conjunctival wound having healed without the opening into the globe being properly shut off. This is accompanied by considerable pain, with chemosis and some oedema of the upper lid. It is usually distinguishable from acute iritis by the pupil being evenly dilated and discoloration of the iris being absent. The condition usually subsides in three or four days, when the wound in the globe has become shut off.

3. Acute iritis not infrequently occurs after extraction. It usually comes on about the third day and may be accompanied by hypopyon. It may settle down under atropine, leeching, and dry heat, but may also pass on into the more chronic form; adhesion of the iris to the capsule, however, frequently results. More rarely the disease may not make its appearance till two or three weeks after the operation (latent sepsis), the patient suffering from recurring attacks of hypopyon. In these cases in which the hypopyon persists, washing out the anterior chamber with peroxide of hydrogen (10 vols. %) and the administration of a vaccine is of service.

4. Chronic irido-cyclitis is usually primary, but may occasionally follow an acute attack of iritis. Of all the disastrous complications, this is by far the worst. It may not only destroy the sight of the eye on which the operation has been performed, but may set up sympathetic ophthalmia in the other eye. The eye does not settle down well after the operation, there being usually some prolapse of the iris or capsule into the wound. It remains injected or flushes up on exposure to light. After a time (usually about the end of the third week) keratitis punctata makes its appearance, and the tension of the eye may become decreased or occasionally increased. The disease may resolve or go on to shrinking of the globe. Energetic treatment with atropine and hot fomentations locally, with the internal administration of iron, is indicated. The administration of staphylococcus vaccine causes only temporary improvement in most instances. In six cases so treated by the author the improvement was only temporary, in spite of the fact that there was a definite local reaction to the vaccine and in two cases the staphylococcus albus was isolated from the fluid in the anterior chamber. If at the end of two months the eye be red and well-marked keratitis punctata be present, and if the pupil be beginning to be drawn up and the eye shows no tendency to improve, enucleation should be seriously considered; this is especially advisable if the projection of light has become defective, showing that the retina is probably detached. If any signs of sympathetic irritation, such as mistiness of vision, ciliary flush, or photophobia, appear in the eye which has not been operated on, the exciting eye should be enucleated. On the other hand, if well-marked inflammation has developed in the sympathizing eye, which may also be cataractous, and the other eye has a fair amount of vision, it becomes extremely questionable whether it is advisable to enucleate the exciting eye. Every case must be judged on its own merits according to the extent and severity of the disease. In a few cases in which the incarceration of the capsule in the wound leads to a very chronic cyclitis, its division with a cutting needle will sometimes lead to subsidence of the inflammation. It is most important that every eye that has been operated on should be examined for the presence of keratitis punctata, especially before allowing the patient to use the eye or before another operation is performed on it.

5. Glaucoma following extraction occurs as a result of (a) soft lens matter blocking the angle of the anterior chamber. As a rule the tension will usually subside under eserine, but evacuation of the anterior chamber (see p. 233) may have to be performed; on the whole the results are satisfactory. (b) The incarceration of the capsule in the wound, pulling forward the iris and blocking the angle of the anterior chamber. Division of the lens capsule is usually sufficient to make the tension subside. Failing this, sclerotomy should be performed; the prognosis is not nearly so good when the increased tension is due to this cause.

6. Striate keratitis usually makes its appearance on the second or third day after operation. The cornea near the line of incision presents a grey striped appearance with the striÆ arranged at right angles to the wound. Pathologically the condition is due to an infiltration of the deeper layers of the cornea, the striped appearance being caused by wrinkling of Descemet’s membrane; the condition probably arises from septic infection. As a rule the affection subsides without giving rise to further trouble, but occasionally local suppuration and even panophthalmitis may follow.

A grey horizontal line about the centre of the cornea is sometimes seen after an eye has been too tightly bandaged; this always disappears when the bandage is removed.

7. Erythropsia (red vision) occasionally follows the extraction of the lens, and is probably due to bleaching of the visual purple following the admission to the eye of an unusual amount of light; it usually disappears in a few weeks.

8. Defective vision. Glasses have to be worn after removal of the lens. Usually patients who were previously emmetropic require about + 11 to see clearly for distance and + 15 for near vision.

The section produces some flattening of the corneal curvature at right angles to the line of the incision; this usually amounts to about two diopters.

COUCHING

Couching is the removal of the lens from the pupillary area by depressing it backwards into the vitreous. It is rather a relic of the past than a present-day operation, although it is extensively practised by quacks in India. Under certain circumstances the operation still seems justifiable; it is very simple, and is followed by immediate restoration of vision, but the subsequent risks of irido-cyclitis, retinal detachment, and glaucoma are so great, that, according to some authorities, couching should only be undertaken in preference to extraction when the latter operation has only a chance of one in three of giving satisfactory vision.

Indications. The chief indications for its performance are:—

(i) The presence of a fluid vitreous, the patient having had the lens of the other eye extracted with bad results.

(ii) In the insane, where it would be impossible to carry out the after-treatment of extraction satisfactorily.

Operation. The operation is usually done under cocaine; in the case of the insane a general anÆsthetic is usually necessary. It has been performed by simple depression of the lens backwards into the vitreous with a needle passed through the cornea (anterior route). This operation yields unsatisfactory results owing to the lens being liable to return into the pupil; this can be partly overcome by sweeping the needle round the periphery of the lens so as to divide the suspensory ligament, but the operation is not so satisfactory as when the needle is passed in from behind the ciliary body and the lens pressed down from behind (posterior route), to which the following description applies. The capsule of the lens should be torn freely, so that some absorption may subsequently take place and diminish the risk of complications.

Instruments. Speculum, fixation forceps, needle.

First step. The pupil should be dilated with atropine. The patient’s head should be well raised on the table. The needle is passed through the sclerotic about 5 millimetres behind the limbus to the outer side. The posterior capsule of the lens is then freely divided by a sweeping movement.

Second step. The needle is next made to appear in the lower part of the pupil by carrying it round the lower and outer border of the lens. The anterior capsule is then freely divided.

Third step. The shaft of the needle is laid flat on the surface of the lens towards its upper part, and by raising the handle of the needle the lens is displaced backwards into the vitreous. The tearing of the suspensory ligament on the inner side may be assisted by the cutting edge of the needle during depression.

Complications. Immediate. Difficulty may be experienced in making the lens lie at the bottom of the vitreous, and it is only by frequent depression of the lens backwards and downwards, with a sweeping movement of the needle to divide the suspensory ligament, that the desired effect can be obtained.

Remote. The lens nucleus may prolapse through the pupil into the anterior chamber. If this should happen, the patient should be placed on his back and the pupil dilated with atropine; if the nucleus does not go back into the vitreous chamber it should be depressed by means of a needle passed through the cornea.

Glaucoma may result from the dislocation of the nucleus into the anterior chamber and should be treated as described above. It may also be present with a lens which is dislocated backwards. This condition is very liable to end in loss of sight. Probably the only hope of relieving the tension is by the use of eserine or the performance of a cyclo-dialysis.

Cyclitis and retinal detachment may also follow, and usually end in blindness.

CHAPTER III
OPERATIONS UPON THE IRIS

IRIDOTOMY

Indications. Iridotomy is an operation which is performed when the iris has become drawn up after a cataract extraction, so that there is no pupil, or the pupillary area is covered by the upper lid. A long interval should elapse between the extraction and the iridotomy, since these cases have usually suffered from cyclitis following the operation. Iridotomy should not be performed for at least six months after all signs of cyclitis have disappeared, for the frequent failure of the operation is due to the fact that the opening made in the iris and underlying capsule becomes filled with fibrous exudation as the result of cyclitis, which is frequently set up again by the operation if undertaken before a sufficient time has elapsed for the eye to settle down after the inflammation. The ideal operation, therefore, is to make an artificial pupil with the least amount of trauma to the ciliary body.

Instruments. Speculum; fixation forceps; a long, narrow, bent ‘broad needle’; Tyrrell’s hook, iris scissors, iris forceps, and spatula.

Operation. Many operations have been devised for this most troublesome condition, but the following is the one that the author has found to be successful.

The operation is usually performed under a general anÆsthetic, but this is not essential.

First step. The surgeon stands facing the patient on the same side as the eye to be operated on. The long, bent, broad cutting needle is passed into the anterior chamber from the limbus downwards and inwards, and is driven directly through the iris and underlying capsule. The needle is then made to pass in an upward and outward direction behind the iris into the pupillary area above, or if no pupil be present, again through the iris (Fig. 102). The bent broad needle is made to cut laterally by slightly deflecting the handle so as to produce a band of iris and capsule; the cutting needle is then withdrawn.

Second step. A Tyrrell’s hook, bent to the correct angle, is passed beneath the band (Fig. 103), which is drawn into the wound and removed with iris scissors. A large opening is thus obtained with a minimum amount of trauma. If the hook should slip, the band may be seized with iris forceps, withdrawn from the wound, and removed.

Alternative methods. The following methods have been practised:—

Simple incision across the fibres of the iris by means of Graefe’s or Knapp’s knife.

Division with scissors through a wound of the limbus.

By these two methods the opening produced is small, and is very liable to be closed by the subsequent cyclitis. The following operation yields more satisfactory results.

Kuhnt’s operation.

Instruments. Speculum, fixation forceps, Graefe’s knife, iris forceps and scissors.

First step. The surgeon, standing facing the patient, enters the anterior chamber about 2 millimetres inwards from the limbus at the junction of the middle and lower third of the cornea with a Graefe’s knife, the cutting edge directed downwards. The knife is then made to penetrate the iris and underlying capsule, and to travel beneath this to a similar point on the other side, where it is made to come back again into the anterior chamber by again penetrating the iris, and finally out again through the cornea. The knife is then made to cut out in a downward direction.

Second step. Iris forceps are inserted and the flap of iris and capsule is withdrawn and as much of it removed as possible. A more or less triangular opening usually results.

Ziegler’s operation.

Instruments. Ziegler’s knife needle, speculum, fixation forceps.

The object of the operation is to cut a V-shaped flap in the iris and underlying capsule, folding the flap backwards on its base so as to form a triangular opening in the iris membrane to serve as a pupil.

First step. The knife needle is entered at the corneo-sclerotic junction with the blade turned on the flat and is passed completely across the anterior chamber to within 3 mm. of the apparent iris periphery. The knife is then turned edge downwards, and carried 3 mm. to the left of the vertical plane (Fig. 104).

Second step. The point is now allowed to rest on the iris membrane, and with a dart-like thrust the membrane is pierced. Then the knife is drawn gently up and down with a saw-like motion, without making much pressure on the tissue to be cut, until the incision has been carried through the iris tissue from the puncture in the membrane to just beneath the corneal puncture. This movement is made wholly in a line with the long axis of the knife, the shank passing to and fro through the corneal puncture, loss of the aqueous being avoided in the manipulation (Fig. 105).

Third step. The pressure of the vitreous will now cause the edges of the incision to bulge open immediately into a long oval. The knife-blade is raised until it is above the iris membrane, and is then swung across the anterior chamber to a corresponding point on the right of the vertical plane. Owing to the disturbance in the relation of the parts made by the first cut, this point is somewhat displaced and the second puncture must be made 1 mm. further over.

Fourth step. With the knife-point again resting on the membrane, a second puncture is made and the incision is carried rapidly forward by the sawing movement to meet the extremity of the first incision at the apex of the triangle, thus making a V-shaped cut. Care must be taken that the pressure of the knife-edge on the tissue shall be most gentle, and that the second incision shall terminate a trifle inside the extremity of the first, in order that the last fibres may be severed and thus allow the apex of the flap to fall down behind the lower part of the iris membrane (Fig. 106). When the operation has been completed the knife is turned on the flat and withdrawn.

IRIDECTOMY

The operation of iridectomy differs widely in its performance, according to the different conditions for which it is used. Hence it is better to prefix the condition for which it is employed, thus: preliminary iridectomy, optical iridectomy, glaucoma iridectomy.

Apart from being one of the stages of removal of a cataract, already described, it is performed as an independent operation in the following conditions:—

1. For optical purposes (optical iridectomy).

2. For the relief of glaucoma, primary and secondary (glaucoma iridectomy).

3. For small growths at the free margin of the iris.

4. For prolapse of the iris through a wound.

OPTICAL IRIDECTOMY

Indications. Iridectomy for optical purposes is performed for a centrally situated nebula of the cornea and in some very rare cases of small central opacities in the lens. In the latter condition it is rarely of much value, as nearly all the rays which enter the eye pass through the central portion of the lens. Further, in this condition the lens may be removed and better sight obtained with glasses. Optical iridectomy should always be performed opposite a clear portion of the cornea, the lower segment of the eye being chosen, otherwise the coloboma may be subsequently covered by the upper lid. The site of election for the operation is downwards and inwards, but in all cases the patient should be carefully examined in the following ways: (1) the vision is tested, any refraction being corrected without a mydriatic; (2) the pupil is then dilated, and the best situation for the iridectomy determined by means of a stenopaic slit. The vision must be definitely improved by the use of these before operation can be advised. The disadvantage of an iridectomy is that it allows more light to enter the eye, and, if the periphery of the lens be uncovered, spherical aberration may result. For both these reasons, therefore, it is advisable to make the iridectomy as small as possible. Tattooing of the central scar in the cornea will often diminish the amount of light entering the eye, but before undertaking the latter operation, the eye should be cocainized and the area covered with a piece of black paper to see if the vision is improved thereby.

Instruments. Speculum, fixation forceps, bent broad needle or small keratome, Tyrrell’s hook, iris forceps, scissors, and spatula.

Operation. The operation is usually performed under cocaine.

First step. The eye is fixed by grasping the conjunctiva directly opposite the spot at which the incision is to be made. The incision is then made by means of a keratome or bent broad needle directly behind the limbus, and enlarged laterally if desired (Fig. 107).

Second step. A Tyrrell’s hook, bent at the correct angle, is passed on the flat into the anterior chamber. When the margin of the iris is reached the handle is rotated and the hook is made to engage the free border of the iris, which is then withdrawn from the wound; a small portion is removed with scissors, which should be held at right angles to the wound when dividing the iris (Fig. 108).

Third step. The iris should be carefully replaced and the pupil kept under the influence of eserine until the anterior chamber has re-formed, when atropine should be substituted.

Care must be taken to see that the Tyrrell’s hook presents no sharp angle, and great care is required in its manipulation, otherwise the lens capsule may be damaged, and traumatic cataract will result. If the iris slips from the grasp of the Tyrrell’s hook, iris forceps should be used, the iris being grasped near its free margin and as small a portion as possible withdrawn.

Brudenell Carter’s method. The ordinary optical iridectomy divides the sphincter iridis and so inhibits the activity of the pupil. With the idea of obviating this, Brudenell Carter removed a small portion of the iris (button-hole), leaving the pupillary margin intact. On the whole the results of the latter operation are no more satisfactory, and the operation is more dangerous to perform owing to the likelihood of wounding the lens, and to the fact that monocular diplopia occasionally results.

The pupil should be under the influence of eserine. The incision is made as in the previous operation. De Wecker’s iris scissors are inserted open into the anterior chamber, closed, and the piece of iris which bulges up between the blades cut off; this can usually be withdrawn with the scissors; or if not, it should be removed subsequently by forceps.

GLAUCOMA IRIDECTOMY

Surgical and pathological anatomy. The fluid in the anterior and posterior chambers of the eye is secreted from the ciliary body by a process of modified filtration. The fluid passes partly direct into the posterior chamber and partly behind the suspensory ligament of the lens, making its way forward into the posterior chamber through the fibres of the suspensory ligament. From the posterior chamber it passes into the anterior through the pupil; from the anterior it filters at the angle of the anterior chamber through the ligamentum pectinatum into the canal of Schlemm; thence it is carried into the blood-stream by the venous anastomosis in that region (Fig. 110).

The essential change found in all cases of primary glaucoma is the blocking of the angle of the anterior chamber owing to the root of the iris being applied to the back of the cornea, and thus preventing the filtration of the fluid into the canal of Schlemm, as a result of which the tension of the eye is raised, either acutely (acute glaucoma) or slowly from time to time (chronic glaucoma) (Fig. 111). The aim of every operation for the permanent relief of glaucoma is the opening up of Schlemm’s canal at the angle of the anterior chamber or the creation of a new lymph channel between the anterior chamber and the subconjunctival tissue (filtrating cicatrix). Although this latter condition is not unattended by the risk of the spread of inflammation from the conjunctiva to the interior of the globe, it is not an inadvisable condition to obtain in some cases of chronic glaucoma if the scar be small and free from iris tissue; in this disease the opening up of the canal of Schlemm by iridectomy is often impossible. (See Sclerectomy, p. 231.)

Indications. Since the days of von Graefe, who first performed iridectomy empirically for the relief of glaucoma, the operation has held the first place in its treatment.

(i) In primary glaucoma. Iridectomy should be undertaken as early as possible in the disease. In acute cases, unless the tension is relieved, the disease ends in rapid destruction of the sight. Operation should always be undertaken as quickly as possible, provided the patient has not lost his perception of light for longer than about ten days.

Whilst waiting for the operation, the pupil should be put under the influence of eserine (2 to 4 grains to the oz.) with the idea of reducing the tension by contraction of the pupil. Some surgeons, in addition to using eserine, perform a posterior scleral puncture with the idea of temporarily reducing the tension and allowing the acute symptoms to subside, and do the iridectomy some twenty-four to forty-eight hours later. This method is extremely useful (a) in cases where a general anÆsthetic is inadvisable, since the reduction of tension allows cocaine to diffuse into the eye; (b) in cases liable to subsequent intra-ocular hÆmorrhage, a more gradual reduction of tension being obtained, rupture of a choroidal vessel is less likely to occur; (c) a deeper anterior chamber is often obtained, and hence there is less risk of wounding the lens during the operation; (d) in cases where the operation has been performed in one eye and the lens has been subsequently extruded on the dressings.

In chronic cases early iridectomy is desirable, since the root of the iris applied to the posterior surface of the cornea becomes atrophic, so that when an iridectomy is performed the iris tears off at the anterior part of the atrophic portion, leaving the angle of the chamber still occluded by its root (Figs. 112 and 113). It is especially in these cases that a filtrating cicatrix, which sometimes follows iridectomy or sclerotomy, is desirable, and indeed some surgeons (Herbert and Lagrange, see p. 231), have recently performed operations with this idea in view, and it is probable that this operation or cyclo-dialysis will prove to be of use in these cases.

Operation is only contra-indicated in a few very rare cases in which the tension is controlled by the use of eserine.

(ii) In congenital glaucoma (bup[h]thalmos). In this affection the results of iridectomy vary. Without doubt, the tension has been relieved by iridectomy in some cases, and either this operation, sclerectomy, or cyclo-dialysis should be tried if the disease be not too far advanced.

(iii) In secondary glaucoma. For obvious reasons the predisposing causes should always be taken into consideration. Thus it would be of no use to perform an iridectomy in the case of a growth in the choroid. On the other hand, an iridectomy would be unjustifiable for soft lens matter in the anterior chamber, which merely requires evacuation. An early iridectomy in cyclitis is not likely to influence the course of the disease favourably; at the most a paracentesis is required. As the early stages of cyclitis may give rise to tension, it is essential that every case of glaucoma should be examined for keratitis punctata before operation.

In iris bombÉ and total posterior synechiÆ an iridectomy is indicated more to re-establish the communication between the anterior and posterior chambers than to clear the angle, and therefore it need not be so extensive. In cases of iris bombÉ where iritis is still present, and in cases of cysts of the iris, transfixion is all that is necessary.

It is very doubtful if iridectomy in glaucoma following thrombosis of the central vein is justifiable, for as a rule the tension is not permanently relieved thereby. In secondary glaucoma following cataract extraction or anterior synechiÆ, division of the capsule or the anterior synechiÆ will often relieve the tension.

Instruments. Speculum, fixation forceps, Graefe’s knife (with a short, stiff, narrow blade), iris forceps, scissors, and spatula.

Operation. With the idea of opening up the angle of the anterior chamber by removing the iris as near its root as possible, the incision should be made somewhat further back behind the corneo-sclerotic junction than in cataract extraction. At the same time, if the incision be placed too far back the ciliary body is liable to prolapse into the wound. The old idea of opening up the canal of Schlemm by dividing it has been abandoned, as to do so would certainly result in prolapse of the ciliary body; and even if this did not happen, no good would result, since the canal would become closed subsequently by cicatricial tissue.

Although von Graefe used a keratome for making the incision, most British surgeons of the present day use a Graefe’s knife, as it gives an incision that is less shelving and more irregular, thus predisposing to the formation of a filtrating scar; a good conjunctival flap is obtained with it and there is less risk of wounding the lens.

When performing the iridectomy it is practically impossible to cut the iris with scissors at its attachment to the ciliary body, and it is better to rely on tearing it off from the ciliary body, as it is in this situation that the iris is thinnest and most likely to give way, provided it has not become atrophic by prolonged contact with the cornea.

In acute cases and in cases of secondary glaucoma where there are many adhesions a general anÆsthetic is desirable.

First step. The incision. The position of the surgeon is as for cataract extraction. The eye is fixed by grasping the conjunctiva close to the limbus downwards and inwards. If the patient be under an anÆsthetic, two pairs of fixation forceps should be used, one being held by an assistant. Occasionally in glaucoma the conjunctiva tears very easily, and in these cases scleral forceps are of use, or, if the knife be already in the eye, grasping the insertion of the superior or inferior rectus. The Graefe’s knife should be directed downwards and inwards towards the point of fixation, the point being passed through the sclerotic 1.5 mm. behind the limbus to the outer side. Directly the anterior chamber is entered, the handle is depressed towards the patient’s chin. The knife-point is kept superficial to the iris and is passed very slowly across the anterior chamber, close to its periphery until the position of the counter-puncture is reached. The counter-puncture should be situated about 1 mm. behind the limbus in a direct line with the original puncture. Care must be taken in making the counter-puncture that the knife-point does not slip back on the sclerotic and so emerge further back in the eye than is desired. The knife is then made to cut out upwards and a good conjunctival flap is obtained. The incision should be carried out slowly, so that the aqueous escapes gradually, as sudden reduction in the intra-ocular tension is liable to lead to intra-ocular hÆmorrhage.

Second step. The iridectomy. The iris forceps are inserted closed into the anterior chamber, opened, and made to grasp the iris near the periphery (Fig. 114) towards the side of the wound on which the iris is first to be divided; then with a slight side-to-side movement of the forceps the iris is withdrawn from the wound until its peripheral attachment to the ciliary body, near where it is held by the forceps, is felt or seen to give way (irido-dialysis) (Fig. 115). The iris is then drawn a little further out from the wound, and one side of the dialysis is divided with the scissors as near the scleral wound as possible. The iris held in the forceps is then pulled over to the other angle of the wound, and as much of it as possible is pulled out and divided close to the scleral incision (Fig. 116). The angles of the incision are freed from iris by means of the spatula and the conjunctival flap is replaced in position. Both eyes are then bandaged.

After-treatment. The patient should be kept in bed for a week, and during the first four days should not be allowed to raise the head from the pillow. After that time the eye not operated upon may be uncovered; eserine should have been instilled into it before the operation and at subsequent dressings to prevent the possible onset of glaucoma owing to the dilatation of the pupil which follows the application of the bandage to the eye. It is not necessary to use any mydriatic or myotic for the eye which has been operated upon.

Complications. These may be immediate or remote.

Immediate. 1. In passing a Graefe’s knife into the anterior chamber to make the section, care must be taken that the cutting edge is directed upwards. If by accident it should be inserted with the cutting edge directed downwards the knife should be withdrawn and the operation postponed for a day or two until the anterior chamber has re-formed.

Care must be taken that the cutting edge is kept on the same plane as the upper edge of the back of the knife, otherwise the incision is liable to pass further back than is intended.

2. Splitting the cornea. The anterior chamber often being little more than a potential space, the knife may be passed between the lamellÆ of the cornea and may not enter the anterior chamber at all. The indication that the knife-point is not in the anterior chamber is that there is no diminished resistance, such as is usually felt when the knife enters the chamber; if its point be slightly depressed, the cornea will be seen to dimple in over the position of it, showing that the point is not free in the anterior chamber.

3. Locking of the knife. This is due to the fact that the puncture and counter-puncture are not made in the same plane, the knife being twisted. It is much more liable to occur if a knife be chosen with a blade which is not sufficiently stiff. As a rule the blade can be made to cut out, but failing this, the knife should be withdrawn sufficiently to allow a fresh counter-puncture to be made, or else withdrawn altogether and the operation postponed.

4. Wound of the lens. The great safeguard against wounding the lens is to keep the point of the knife always superficial to the iris and in the periphery of the anterior chamber. If the lens be definitely wounded at the time of the operation it should be extracted immediately after the iridectomy. If the wound be only subsequently discovered (usually about the third or fourth day), provided the lens be not presenting in the wound, the eye should be allowed to settle down and the traumatic cataract extracted some time after the tenth day.

5. Presentation of the lens in its capsule. The lens may present in its capsule at the time of the operation or be found subsequently on the dressings. In the latter instance it is very liable to carry iris into the wound, and a cystoid cicatrix results. This accident is usually due to increased tension in the vitreous chamber; a large incision, especially if placed rather far back in the sclerotic, will also favour its occurrence. If the accident should happen to one eye, and acute glaucoma be present in the other, it is advisable to do a posterior scleral puncture before the iridectomy is performed. Partial dislocation of the lens forward may occur after the wound has healed, leaving the tension of the eye not reduced. This is a condition extremely difficult to recognize, and it is usually only discovered pathologically; if recognized clinically, extraction of the lens should be performed (Fig. 117).

6. Intra-ocular hÆmorrhage. HÆmorrhage into the anterior chamber occurs at the time of the operation and is readily absorbed; occasionally it may persist for a considerable time in cases of glaucoma of long standing.

After the operation hÆmorrhage may also occur from the cut margin of the iris, which never heals, viz. never becomes covered with endothelium. The hÆmorrhage may occur as late as two weeks after the operation and may recur from time to time; it is especially liable to occur in old people with arterio-sclerosis. It is usually absorbed without giving rise to any trouble beyond delay in the convalescence.

Retinal hÆmorrhages are frequent and usually small, but a considerable hÆmorrhage may take place into the vitreous. As a rule these clear up satisfactorily unless the macular region be involved.

Subchoroidal hÆmorrhage. Of all the immediate complications which follow an intra-ocular operation this is by far the worst. The hÆmorrhage is due to the giving way of a large choroidal vessel following the sudden reduction of tension, with the result that the choroid and retina are stripped up from the sclerotic, and, with the lens, may be partially extruded from the wound in the globe, from which the hÆmorrhage then proceeds. It may occur whilst the patient is still on the operating table, or it may be discovered only after he has been put back to bed, the blood being seen coming through the dressings. Patients who have this condition complain of pain in the ‘corner of the eye’ at the time of the operation. The treatment consists in evisceration or enucleation. It is probable that limited extravasation of blood may also occur, which need not end in disintegration of the eye, but may cause vitreous opacity and defective vision for some weeks after the operation.

Remote. 1. The tension is not reduced by the iridectomy. In acute cases the prognosis with regard to the reduction of the tension and the improvement of vision is very satisfactory. The same cannot be said of chronic cases, especially those which have been operated on rather late in the disease. If iridectomy, which may be repeated downwards or extended from the previous coloboma, fail to reduce the tension, one or more of the following measures should be adopted:—

(a) The use of eserine.

(b) Sclerotomy.

(c) Cyclo-dialysis.

(d) Sclerectomy.

(e) Post-scleral puncture.

It is probably in this order that they should be tried.

2. Prolapse of the iris and irido-cyclitis should be treated as already indicated under cataract extraction (see p. 208).

3. The onset of glaucoma in the other eye may be induced by the dilatation of the pupil caused by bandaging, and is best avoided by the use of eserine. If it should occur, an iridectomy should be performed.

4. Astigmatism produced by the incision is corrected with glasses. This astigmatism is very marked, often amounting to six or eight diopters or more.

IRIDECTOMY FOR SMALL GROWTHS OF THE IRIS

Indications. This is performed—

In the latter instance it is obvious that the growth must be very small and situated at the free margin of the iris to yield a satisfactory result, especially if it be of a malignant character.

Operation. The operation is performed under cocaine, eserine having been previously instilled in order to contract the pupil.

First step. An incision should be made with a narrow Graefe’s knife in the limbus in a position most suitable for removing the growth. The incision should be as large as possible so as to avoid wiping off any portions of the growth into the anterior chamber.

Second step. The iris should be seized well in the periphery so as to avoid breaking up the growth; it is then withdrawn with the growth, and the latter removed.

IRIDECTOMY FOR PROLAPSE OF THE IRIS

This operation is usually performed for prolapse of the iris following a wound of the cornea or limbus, and may be attempted up to about the third day after the original injury.

Operation. A general anÆsthetic is usually desirable. The prolapsed iris should be seized with the forceps and withdrawn from the wound. A second pair of forceps is used to take a fresh hold on the iris, which can usually be drawn out further (Fig. 118). It is then divided as close to the corneal wound as possible. The iris usually flies back into the anterior chamber clear of the corneal wound by its own elasticity, but if it does not do so it should be freed with a spatula. The pupil should be kept subsequently under atropine.

TRANSFIXION OF THE IRIS

Indications. This operation is undertaken in cases of iris bombÉ when iritis is still present and when an iridectomy would subsequently lead to a drawn-up pupil. It is also of service to evacuate the contents of cysts of the iris (local iris bombÉ).

Instruments. Speculum, fixation forceps, Graefe’s knife (narrow).

Operation. The knife is entered at the limbus from the outer side directly opposite the occluded pupil. The apex of the iris bombÉ is transfixed and the point of the knife made to appear above the pupillary area; the iris bombÉ on the other side of the pupil is then transfixed and the knife is withdrawn.

THE DIVISION OF ANTERIOR SYNECHIÆ

Indications. Anterior synechiÆ rarely require division unless they are likely to cause tension or the adherent iris is considered a source of danger to the eye on account of its liability to septic infection. If the synechiÆ are causing tension, the method of division described under sclerotomy is probably the most satisfactory; otherwise the following method devised by Lang can be used.

Instruments. Speculum, fixation forceps, Lang’s knives—one with a sharp point, and one blunt.

Operation. Under cocaine. The incision is made at the limbus in a favourable situation for the division of the synechia. The sharp-pointed knife is introduced into the anterior chamber and then rapidly withdrawn so as not to lose the aqueous. The blunt knife is then inserted through the incision and, partly by cutting and partly by tearing, the synechia is divided in a direction from the periphery towards the pupil.

The operation is not at all easy to perform, since the iris gives before the knife. Great care should be taken to avoid evacuating the aqueous, as the operation is thereby rendered much more difficult or even impossible.

CHAPTER IV
OPERATIONS UPON THE SCLEROTIC

ANTERIOR SCLEROTOMY

Indications. Sclerotomy is an operation undertaken for the relief of increased intra-ocular tension. It is performed—

(i) Usually as a secondary operation when iridectomy has failed.

(ii) As a primary operation for the division of anterior synechiÆ causing tension.

A few surgeons prefer the operation to iridectomy, especially in cases of bup[h]thalmos. When practised after an iridectomy which has been done upwards, the sclerotomy is sometimes performed in a downward direction; otherwise the section is usually made upwards. The intra-ocular tension is probably relieved by the formation of a filtration cicatrix, and it is therefore probable that it may be largely superseded by the operations of cyclo-dialysis and sclerectomy.

When performed for the division of anterior synechiÆ the position of the incision should be planned according to the situation of the synechia to be divided.

Instruments. Speculum, fixation forceps, Graefe’s knife with a narrow blade.

Operation. The operation is done under cocaine. Eserine should have been previously instilled in order to contract the pupil and prevent prolapse of the iris.

Graefe’s knife should be passed across the anterior chamber in the same manner and position as for a glaucoma iridectomy (see p. 221). In the complete method the knife is made to cut out through the sclerotic, leaving a band of conjunctiva to hold the flap in position. In the incomplete method a band of sclerotic is left in the periphery. If the operation is done in a downward direction, it is better for the surgeon to stand on the opposite side of the patient to the eye on which the operation is to be performed, operating across the patient.

Complications. Any of the complications which follow an iridectomy for glaucoma may occur (see p. 222). Prolapse of the iris is probably the most frequent.

CYCLO-DIALYSIS

Indications. This operation has only recently come into general use in this country, so that statistical results have at present by no means been worked out, but most satisfactory results have been obtained from it in individual cases; according to German authorities about 30 per cent. are permanently cured. Although at present its performance is largely limited to blind eyes and to eyes that have undergone previous operations for glaucoma, it is probable that it may come into further use as a primary operation in the treatment of chronic glaucoma and bup[h]thalmos. It is also of service in cases of dislocation of the lens backwards, associated with increased tension, where iridectomy would certainly be followed by loss of the vitreous.

The operation has for its object the separation of the ligamentum pectinatum from its attachment to the sclerotic, with the probable result that the ciliary body and iris root become retracted by the ciliary muscle, so that the canal of Schlemm is opened up and again communicates with the anterior chamber. It also opens up a free communication between the anterior chamber and the suprachoroidal lymph-spaces. The reduction of tension is often not fully manifest for about ten days after the operation.

Instruments. Speculum, fixation forceps, Graefe’s knife, fine pair of straight iris forceps, fine pair of sharp-pointed straight scissors, iris spatula.

Operation. The operation is best performed under a general anÆsthetic, as it is attended with considerable pain, although cocaine and adrenalin are frequently used and are always advisable, since the hÆmorrhage from the scleral vessels renders it difficult to gauge the depth of the wound in the sclerotic.

First step. By means of the straight iris forceps and sharp-pointed scissors a semilunar conjunctival flap is first raised over the site for the scleral incision. The incision in the sclerotic should be situated about 5 mm. behind the corneo-sclerotic junction over the ciliary region, the outer and upper quadrant of the eye being the easiest position for subsequent manipulation (Fig. 119).

Second step. With a Graefe’s knife the fibres of the sclerotic are carefully divided in an oblique direction forward until the suprachoroidal lymph-space is opened for about 3 mm. The first part of the incision is performed with the blade and completed with the point of the knife, the anterior flap of sclerotic being held forward by straight iris forceps. Heine uses a keratome, dividing the fibres of the sclerotic with the point by stroking it along the line of the incision. The depth of the incision should be carefully gauged from time to time with the iris spatula; the pigment of the ciliary body is usually seen in the bottom of the wound when the sclerotic has been penetrated.

Third step. The iris spatula is directed forwards and inserted between the sclerotic and the ciliary body, keeping close to the former. With a gentle side-to-side movement the spatula is made to separate the ciliary body from the sclerotic for about one-eighth of its whole circumference; then the ligamentum pectinatum is detached from the sclerotic for about the same distance by gently passing the spatula forwards and making the latter appear in the anterior chamber (Fig. 120). If it be desired to evacuate the anterior chamber, the spatula is slightly rotated so as to allow the escape of the aqueous. As a rule this is not necessary or even advisable. The spatula is then withdrawn and the conjunctival flap is replaced in position. Eserine should be instilled.

Complications. (1) Unless the incision be carried carefully through the sclerotic, or the manipulations with the iris spatula be very gentle, loss of vitreous is liable to take place. As a rule, this, if not great, is of little consequence. (2) In passing the iris spatula forward to separate the ligamentum pectinatum the point may pass between the layers of the cornea; this is recognized in the resistance offered to the side-to-side movement of the spatula, which should be withdrawn slightly and the point depressed so as to engage the ligamentum pectinatum. (3) Subchoroidal hÆmorrhage has been known to occur after the operation.

SCLERECTOMY

The object of the operation is the production of a filtration cicatrix free from iris tissue for the relief of intra-ocular tension in chronic glaucoma.

Instruments. As for glaucoma iridectomy, with the addition of a small curved pair of scissors.

Operation. Under cocaine.

First step. The incision is performed as for glaucoma iridectomy (see p. 221), except that the incision should be rather smaller and should be carried more obliquely through the sclerotic, so that a long scleral flap is obtained. A large conjunctival flap is very essential to cover the wound.

Second step. An iridectomy is usually performed as for glaucoma; this may be omitted.

Third step. After all the bleeding has ceased, the conjunctival flap is turned forwards on to the cornea so as to expose the scleral flap; with small curved scissors made for the purpose, an elliptical portion is removed from the sclerotic by a single snip (Figs. 121 and 122), and the conjunctival flap is replaced in position. As a result, a hole is made into the anterior chamber, which thus communicates with the subconjunctival tissue, which is bulged forwards in the form of a clear vesicle by the escaping aqueous when the wound has healed.

The immediate results of this operation are satisfactory provided that enough sclerotic be removed to produce a filtration cicatrix. As yet sufficient time has not elapsed for any statistical results to be obtained, but the cases in which the operation has been performed are reported as satisfactory.

POSTERIOR SCLEROTOMY

Indications. Posterior scleral puncture is performed—

(i) For the relief of tension, the indications for which have already been described under the indications for iridectomy in glaucoma (see p. 218).

(ii) For the evacuation of fluid behind a detached retina.

The operation in the latter instance, although not yielding very satisfactory results with regard to the reattachment of the retina, may be carried out with some hope of success in certain cases. Before performing the operation the pathological cause of the detachment should be carefully investigated, for it is obvious that it would be useless to perform the operation in a case of detachment due to a choroidal tumour or if definite bands of fibrous tissue could be seen in the vitreous pulling off the retina. Undoubtedly it should be undertaken as soon as possible after the detachment has occurred and the puncture should enter the space filled with subretinal fluid. Whether the puncture should penetrate the overlying retina is still a disputed point.

After the operation a pressure bandage should be applied and the patient should be kept on his back and not allowed to raise his head from the pillow for at least three weeks. This latter part of the treatment is most essential; indeed as good results may be obtained with complete rest as by performing scleral puncture. Unfortunately, recurrence is very liable to take place whichever method be used, even if reattachment of the retina be obtained.

Instruments. Speculum, fixation forceps, Graefe’s knife.

Operation. Under cocaine. If no special position be indicated the puncture is best made upwards and inwards. The patient is made to look outwards and downwards. The conjunctiva over the sclerotic, well behind the ciliary body, is drawn down so that when released it shall form a valvular opening to the scleral wound. The Graefe’s knife is driven through the conjunctiva and sclerotic, the incision being made antero-posteriorly in the direction of the fibres of the sclerotic to avoid wounding the choroidal vessels. It is probably better to enlarge the wound when withdrawing the knife than to turn the latter at right angles before it is withdrawn, as has been recommended by some surgeons. A bead of vitreous usually escapes under the conjunctiva. If the tension be not lowered, gentle massage of the globe through the lid should be employed.

PARACENTESIS OF THE ANTERIOR CHAMBER

Indications. Evacuation of the contents of the anterior chamber is performed for several conditions:—

(i) To reduce the tension of the eye when due to an altered consistency of the aqueous, as for instance in cyclitis.

(ii) To evacuate pus from the anterior chamber following metastatic infection.

(iii) To evacuate the anterior chamber in bad corneal ulceration, especially when associated with hypopyon and tension.

(iv) To examine the aqueous for organisms in cases of cyclitis following operation or of metastatic origin.

(v) To evacuate soft lens matter (see p. 194).

The operation is usually performed through an incision directly behind the limbus. In the case of corneal ulceration it is sometimes performed by dividing the base of the ulcer with a Graefe’s knife (SÄmisch’s section). When collecting the aqueous for bacteriological examination, a sterile hollow needle with a point similar to a discission needle, attached to a hypodermic syringe, should be passed into the anterior chamber at the limbus and the fluid withdrawn into the syringe by an assistant (Fig. 123). The spot through which the needle is passed is first touched with the electro-cautery to ensure asepsis.

Instruments. Speculum, fixation forceps, bent broad needle, iris spatula.

Operation. Under cocaine. The puncture is usually made upwards and outwards unless there be some other special indication for its position, such as a mass of pus in the lower angle of the anterior chamber. The eye is fixed opposite the spot at which the puncture is to be made, and the bent broad needle is passed into the anterior chamber through an incision directly behind the limbus. The needle is then withdrawn and is usually followed by a rush of aqueous. The remainder of the aqueous is then evacuated by pressing the lower margin of the wound with an iris spatula. In some cases where a very tenacious hypopyon is present it may be withdrawn with the iris forceps. The only complication liable to occur is prolapse of the iris into the wound, which should be replaced with the spatula, or failing that, removed.

OPERATIONS FOR PENETRATING WOUNDS OF THE GLOBE

Indications. Of all the conditions which a surgeon is called upon to see, penetrating wounds of the globe may present the most difficult problems as to treatment. The most important factors in their treatment and prognosis are—

1. The time at which the patient presents himself for treatment and the condition of the wound are all-important in the prognosis. Thus in the case of a wound which is obviously septic and going to terminate in panophthalmitis the eye should be eviscerated.

2. The position and extent of the wound. Formerly it was taught that if the ciliary body were wounded the eye should be excised. The reason for this was that these injuries were so frequently followed by sympathetic ophthalmia owing to prolapse of the iris and ciliary body. It is now generally recognized that sympathetic ophthalmia only follows if the wound becomes septic, irido-cyclitis with keratitis punctata being present, and it is only after the latter symptom manifests itself that the eye should be excised, provided that the wound be not so extensive as to preclude all chance of recovery from the outset.

In wounds of the sclerotic all portions of the uveal tract and vitreous which prolapse should be removed, and the wound closed with sutures passed through the superficial episcleral tissue. Unless the wound be small the prognosis is not good, as it is liable to be followed by irido-cyclitis, or, if this does not occur, detachment of the retina may ensue, following on organization of the exudates in the vitreous.

Wounds of the cornea usually result in prolapse of the iris, which should be removed in the manner described under iridectomy (see p. 208).

3. If the lens be injured. Unless the wound amounts to little more than a punctured wound of the globe involving the lens, the prognosis is bad. The wound in the lens capsule and the breaking up of the lens mean the presence of soft matter in the anterior chamber—a condition which favours sepsis and is liable to produce increased tension from blocking the angle of the chamber. In patients under thirty the pupil should be dilated with atropine and the lens allowed to absorb—assisted at a later date by needling, when the eye has entirely settled down after the original injury. If the patient be over thirty it is often extremely difficult to decide whether extraction of the lens should be undertaken at the time of the injury or at a later date. The results of both procedures are very unsatisfactory, and the surgeon should be guided partly by the position and extent of the wound. Given these in a fairly favourable position, it is probable that immediate extraction will give the best result.

4. If the eye contain a foreign body. Usually these are pieces of metal or glass. The following points should be investigated to determine whether the foreign body be in the eye:—

(i) The history of these accidents is usually the same. The patient is chipping with a hammer and chisel, and a piece flies off and strikes the globe. In the case of glass it is usually a mineral-water bottle which bursts.

(ii) The position and nature of the wound in the cornea and sclerotic.

(iii) The condition of the anterior chamber—whether evacuated or not.

(iv) The tension of the eye, which may be lowered.

(v) The presence of a hole in the iris.

(vi) The presence of traumatic cataract.

(vii) Whether the foreign body is visible with the ophthalmoscope or by focal illumination.

(viii) The localization of the foreign body by the X-rays. The latter is the most important factor of all, since the foreign body may pass right through the globe and be embedded in the orbit.

Operative treatment. If the injury be a recent one and the foreign body a metal of magnetizable properties, it is best removed by an electro-magnet after localization by the X-rays (Fig. 124). Sideroscopes have been used, but are not so satisfactory. If the foreign body be non-magnetizable, such as a piece of copper cap or manganese steel, an attempt may be made to remove it with forceps after localization. If the foreign body be embedded in the lens it is often advisable to extract the lens together with it. If the foreign body be of glass, and it be only small, it is usually best left alone, unless capable of easy removal, e.g. if it be situated in the anterior chamber; the eye will often tolerate the presence of glass provided it be aseptic.

The eye should be removed—

(i) If the wound be obviously septic.

(ii) If the wound be very large, more especially if the lens be injured.

(iii) If the foreign body be a large piece of metal and cannot be extracted.

(iv) If the eye does not settle down after one of the operations described below, especially if irido-cyclitis with keratitis punctata should have supervened.

If the injury be of long standing. It is of little use as a rule attempting to extract a foreign body from the eye after three days, unless it be loose in the vitreous or embedded in the lens, as it becomes surrounded by lymph. Under these circumstances it is better to leave it alone, or, if it be causing signs of irritation, to enucleate the eye.

ELECTRO-MAGNET OPERATIONS

Magnets for the removal of magnetizable foreign bodies from the eye are of two types—(1) a small magnet, which is inserted into the globe, (2) a giant magnet, which is used to attract the foreign body in the eye from the outside.

Surgeons differ as to which is the best method to employ. The statistical results of both are about the same. Many surgeons in this country, and with them the author, prefer the small magnet, especially of the recent more powerful type (Hirschberg), which runs off the main electric current, for the following reasons: it is more accurate (after localization by the X-rays), there is less trauma to the globe involved, it is more portable, and, when the foreign body is in the anterior or the posterior chamber, it is much easier to extract it with a small magnet than with a large one.

With the small magnet. Instruments. Beer’s knife, fixation forceps, magnet (Fig. 125), and suture. The points of the magnet, which are detachable, are sterilized by boiling.

Operation. The foreign body is first localized accurately by means of the X-rays. If it lies near the wound of entrance the magnet point is inserted, the electric circuit completed, and the foreign body withdrawn, the wound of entrance being enlarged if necessary. If the foreign body lies at some distance from the wound, as for instance in the vitreous, an antero-posterior incision is made in the sclerotic, as near to it as possible, by plunging the knife through the conjunctiva and the sclerotic, the former having previously been drawn to one side so as to form a valvular opening. The size of the incision should be such that it will admit the point of the magnet and allow the foreign body to come out, the size of the foreign body being judged by the X-ray photograph. After the knife has been withdrawn, the point of the electro-magnet is inserted and the circuit closed, the magnet being withdrawn with the foreign body attached to it. The conjunctival wound is closed by a suture if necessary. If the foreign body be situated in the anterior or posterior chamber or the lens, an incision should be made into the anterior chamber with a keratome, the point of the magnet inserted, and the foreign body withdrawn. In cases in which the foreign body is deeply embedded in the lens, more especially in patients over thirty years of age, extraction of the lens together with the foreign body should be performed.

Complications. Immediate. Failure to extract the foreign body may arise from—

1. The foreign body being embedded in lymph. It is therefore of the utmost importance that the operation should be performed as soon as possible after the injury.

2. The foreign body being deeply embedded in the sclerotic so that the magnet will not exert sufficient traction to withdraw it.

3. The foreign body being non-magnetic (all steel is not magnetic).

4. Too small a wound being made for its extraction, the metal being wiped off on the edges of the wound as the magnet is withdrawn.

5. Insufficient power in the magnet.

Remote. 1. Panophthalmitis, which must be treated by evisceration.

2. Irido-cyclitis; if this be prolonged, and keratitis punctata appear, enucleation should be performed.

3. Traumatic cataract; this may subsequently require needling.

4. Detached retina as the result of organization in the vitreous; this may occur months after the original injury.

With the giant magnet. The foreign body should have been previously localized by the X-rays, and its position and size determined, so that it may be removed by the shortest possible route and with the least amount of injury to the eye.

Instruments. Giant magnet (Fig. 126), steel spatula. (Watches and magnetizable metal should be removed from both the patient and the surgeon.)

Operation. Under atropine and cocaine. The patient is at first seated in a chair some three feet in front of the magnet, the eyelids being held apart by the surgeon; the electric circuit is closed. The patient’s head is next gradually advanced towards the magnet. If a foreign body be present in the eye and be magnetizable, the patient will usually withdraw his head or cry out with pain, and the foreign body may be seen bulging forward the iris from the posterior chamber. From this position it may be removed by manipulating the head and eye in relation to the magnet so as to withdraw it into the anterior chamber, from whence it is removed through the entrance wound or an incision at the limbus either by the giant magnet directly applied to the wound or by magnetizing a steel spatula which is inserted into the anterior chamber and connected with the magnet by a flexible steel cable. The small magnet previously described may be used, or the foreign body removed by means of iris forceps.

A piece of steel in the vitreous always travels round the posterior surface of the lens and through the suspensory ligament, and does not injure the lens capsule.

Complications. These are similar to those described under the small magnet operation.

CHAPTER V
OPERATIONS UPON THE CORNEA AND CONJUNCTIVA

OPERATIONS UPON THE CORNEA

REMOVAL OF A FOREIGN BODY FROM THE CORNEA

Removal of a foreign body from the cornea requires a good light (focal illumination). The use of a binocular lens is also of service. Foreign bodies lodged on the surface of the cornea can be removed easily under cocaine with a spud. If the foreign body be deeply embedded in the cornea a fine sterile discission needle should be used. When a foreign body, such as a chip of iron, is deeply embedded, the needle should be inserted slightly to one side of the entrance wound and passed beneath the foreign body so as to lift it from its bed. When the foreign body has partially penetrated the anterior chamber but still lies in the cornea, an incision should be made with a keratome at the limbus and the foreign body pushed back through the entrance wound with the aid of an iris spatula. If the foreign body be iron, the electro-magnet may be of use, and in this case should be tried before resorting to an incision in the anterior chamber. A stain is left frequently after the removal of foreign bodies; this should be removed as far as possible. Subsequently the eye should be bandaged for a few days and bathed with boric lotion. Atropine should be instilled if there be any signs of infiltration around the wound.

CAUTERIZATION OF THE CORNEA

Either a chemical or the actual cautery may be used.

Indications. Corneal ulceration. The cornea being extremely dense, organisms do not penetrate very deeply into its substance, so that destruction of the bacteria is effected by cauterization of the spreading portion of an ulcer; the albumin is also coagulated and so a barrier is presented to their advance.

Operation. The eye is thoroughly cocainized, and the spreading portion of the ulcer is first defined by staining with fluorescine, washing away the excess of stain with boric lotion.

By a chemical caustic. Liquefied carbolic (carbolic acid crystals liquefied in 10 per cent. of water) is applied upon a sharpened match. Any excess should be removed so as to prevent its running on to the cornea. A speculum is inserted and the cornea is dried by blotting with cigarette paper; the stained area is lightly touched with the point of the stick, particular attention being paid to the spreading margin. A dense white plaque is the result; this usually clears up in a few days. Atropine ointment is applied daily to the conjunctival sac.

By the actual cautery. The electro-cautery (Fig. 127) point should be extremely fine and only raised to a dull red heat. The stained area should be touched lightly with the point.

The actual cautery is best for serpiginous corneal ulcers, carbolic acid being more satisfactory for those of the vesicular type.

OPERATIONS FOR CONICAL CORNEA

Indications. Since the operation for conical cornea is not without serious risks, it should only be undertaken when the vision cannot be improved with glasses to 6/18; high + or - cylinders will often yield satisfactory results. The object of all forms of operation is the flattening of the cone.

Operation. This may be carried out either by excision of the apex of the cone or by cauterization.

Excision of the apex of the cone is probably the more satisfactory method, although it is somewhat more difficult to perform. The object of the operation is to remove an elliptical portion of the whole thickness of the cornea from the apex of the cone, the long axis of the ellipse being placed horizontally. It leaves the eye with only a minute scar as compared with the nebula produced by the cautery, which is often so great as to require an optical iridectomy to restore vision.

Instruments. Speculum, fixation forceps, a narrow Graefe’s knife, straight iris forceps, and scissors.

The operation is done under cocaine, atropine having been previously instilled.

First step. The apex of the cone is transfixed by the Graefe’s knife with the blade directed slightly upwards and forwards, the knife being made to cut out. The cornea in this situation is extremely thin, being often not more than 1 mm. in thickness. The length of the incision should not exceed 2 mm.

Second step. The flap of corneal tissue thus made is seized with the straight iris forceps and removed with iris scissors, producing a small elliptical opening. The chief difficulty of the operation is the seizing of the corneal flap, which is most difficult to hold; care must be taken not to injure the lens capsule with the iris forceps or scissors when the cornea has collapsed as the result of the evacuation of the anterior chamber. The eye should be firmly bandaged subsequently, and the patient kept in bed until the anterior chamber has re-formed.

Complications. Slow re-formation of the anterior chamber. The anterior chamber will often take two or three weeks to re-form, owing to the hole in the cornea not closing. During this time the eye is open to septic infection and therefore the greatest care should be taken to keep it aseptic when dressing it. For this reason and also because the following complications are due to the same cause, it is desirable to remove as little corneal tissue as possible in performing the operation. It is probable that conjunctivoplasty (see p. 245) would considerably facilitate the rapid closure of the wound.

Anterior polar cataract may result from prolonged contact of the lens with the wound in the cornea. As a rule this seldom interferes much with vision.

Anterior synechiÆ from incarceration of the iris in the wound occasionally result and may require subsequent division.

Acute glaucoma is by no means an infrequent complication—indeed the author has seen four successive cases of conical cornea, operated on both by excision and by the cautery, followed by this complication. It is probably due to adhesion of the root of the iris to the back of the cornea during the time the anterior chamber is empty. It can usually be relieved by an iridectomy.

The electro-cautery operation. The operation generally adopted is known as the target operation. It consists in surrounding the apex of the cone with two rings of cautery marks, the outer made at a dull red heat, the inner with the point slightly brighter, whilst the apex is cauterized at a red heat, so that rings of different depth are obtained. Cauterization of the apex should stop just short of perforation, the inner ring being deeper than the outer. With this method secondary glaucoma and anterior synechiÆ are not so liable to occur. On the other hand, an optical iridectomy has to be performed more frequently. A few surgeons still cauterize the apex of the cone until a perforation is produced. This latter operation seems to have the disadvantages of both methods and the advantages of neither.

REMOVAL OF TUMOURS INVOLVING THE CORNEA

Tumours which involve the cornea are usually secondary to tumours occurring at the limbus. The chief of these are: simple—dermoid patches, moles of the limbus; malignant—sarcoma, endothelioma, epithelioma. Dermoid patches should be shaved off as close to the cornea as possible; the white area left after their removal can be improved by tattooing.

Malignant tumours in very early stages may be removed locally with scissors and forceps, the cautery being applied to their base, since they do not tend to invade the sclerotic deeply.

TATTOOING THE CORNEA

Indications. (i) To do away with the blinding effects of light through a scar after iridectomy has been performed (see p. 215).

(ii) To simulate a pupil on a white scarred cornea.

The operation is not without risks, as it may light up old inflammation in a previously quiet eye. Panophthalmitis and sympathetic ophthalmia have both been known to follow it. The pricking of the needle may carry in epithelium and implantation dermoids may arise.

Instruments. A fine single needle is generally used, occasionally a bundle of needles (Fig. 128).

Operation. Under cocaine. Chinese ink, sterilized and prepared by rubbing up with 1–6,000 perchloride of mercury, is smeared over the area to be tattooed. Multiple punctures in an oblique direction are then made into the cornea over the area desired. More paste is then rubbed in over this area. The cornea should be intensely black after the operation, as a certain amount of the ink is carried away by phagocytosis and shedding of the epithelium. Subsequent reaction may be reduced by means of an iced compress. Atropine should be instilled.

SCRAPING CALCAREOUS FILMS

Calcareous films, when not associated with active irido-cyclitis, may be removed with advantage to the vision. Care should be taken to see that no keratitis punctata is present before the operation is undertaken.

Instruments. Speculum, fixation forceps, a spoon which should have rather a blunt edge.

Operation. Under cocaine. The area is very lightly scraped with the spoon. The calcareous changes are in the deeper layers of the epithelium and Bowman’s membrane and hence are easily removed. The scraping should be carried well beyond the apparent margin of the film. The epithelium often takes some time to regenerate. As a rule the results are satisfactory, although the film is apt to recur in the course of years, but it may be removed again if necessary.

OPERATIONS UPON THE CONJUNCTIVA

THE REMOVAL OF FOREIGN BODIES

Foreign bodies lodged in the conjunctival sac, unless embedded in the conjunctiva, are usually found by the surgeon under the upper lid, the sulcus subtarsalis being a favourite situation. They are easily removed with a spud or needle, after the instillation of a drop of 4% cocaine solution. Subsequently the eye should be bandaged for a few hours until the effect of the cocaine has passed off, as in wiping the eye the patient may wipe off the epithelium of the cornea whilst it is insensitive from the cocaine.

In order to evert the upper lid the patient is made to look strongly down, the eyelashes are seized between the thumb and forefinger of the left hand, the skin of the upper lid is pushed down above the tarsal cartilage with the thumb of the right hand, and the lid is everted by pulling it upwards against the point of the thumb.

OPERATION FOR PTERYGIUM

Indications. Pterygium should be removed when advancing across the cornea, especially when the pupillary area is becoming involved. The operation of ablation is the one now generally in use.

Instruments. Speculum, straight iris forceps, small sharp-pointed scissors.

Operation. Under adrenalin and cocaine the neck of the pterygium is seized with the forceps and the body and neck are carefully dissected from the conjunctiva. The body and neck should be very carefully separated right up to the corneal margin by means of forceps and scissors. The head is then stripped off the cornea with a sharp pull. The wound in the conjunctiva should be subsequently closed with fine sutures, otherwise the disease will certainly recur. In stripping the head from the cornea some of the epithelium may be torn off with it. This usually regenerates without impairing the vision.

EXPRESSION

This is an operation for the removal of follicular formations in the conjunctiva, and is used more especially in trachoma.

Instruments. Graddy’s forceps (Fig. 129), fixation forceps.

Operation. The operation may be performed under cocaine and adrenalin, a little solid cocaine being rubbed into the area to be expressed. In severe cases in which both eyes are affected, and in small children, a general anÆsthetic may be necessary.

Although a number of instruments are in use, perhaps the best, and certainly the least painful, is Graddy’s forceps. In the case of the upper lid it is everted, one blade of the forceps being passed into the fornix, the other being placed over the upper surface of the everted lid. A gentle steady pressure is applied, and the lid is drawn out between the blades. In this way as much of the conjunctiva is gone over as is necessary. The lower fornix is best expressed by picking up the loose fold of the fornix with ordinary forceps and then expressing with Graddy’s.

If only one or two follicles be present they can be picked up with the ordinary fine dissecting forceps and expressed, but when situated on the tarsus the follicles are best enucleated with a spud; a solution of 1 in 50 perchloride of mercury in glycerine is then rubbed into the conjunctiva. The operation may have to be repeated several times as new follicles form.

CONJUNCTIVOPLASTY

Conjunctivoplasty is an operation for the transplantation of a flap of conjunctiva to cover some loss of substance or defect in the continuity of the globe.

Indications. The operation may be necessary—

(i) To close large recent wounds of the cornea.

(ii) To close the wound made by the excision of a cystoid scar.

(iii) To facilitate the healing of a clean ulcer such as Mooren’s ulcer, or to cover the aperture made by an ulcer that has perforated.

(iv) In the treatment of conical cornea by excision of the apex of the cone, it might facilitate the rapid closure of the wound and assist in flattening of the cornea.

Operation. First method. Under cocaine. A flap of conjunctiva is raised from around the limbus, having its base as near the area to be covered as possible; its breadth should be one and a half times the width of the area to be covered. This flap is drawn across the defect in the cornea and stitched to the conjunctiva on the other side; the wound made in raising the flap should be allowed to heal by granulation.

The stitches holding the flap in position cut through in two or three days, but by that time their purpose will have been served. If the flap be still adherent to the wound its base may be divided and any superfluous tissue removed; the remainder will disappear rapidly.

Second method. The conjunctiva is dissected up all round the cornea as close to the limbus as possible, and backwards as far as the insertion of the recti. A purse-string suture is then inserted around its margins and drawn tight so that the whole cornea is covered by conjunctiva. The operation is suitable for cases in which large areas have to be covered.

REMOVAL OF TARSAL CYSTS

The Meibomian glands being embedded in the tarsal plate, cysts in them present both on the conjunctival surface and towards the skin, but the contents are always evacuated from the former.

Instruments. Walton’s iris knife, sharp spoon.

Operation. Under adrenalin and cocaine. The eyelid is everted and a drop of the solution is injected into the cyst with a hypodermic syringe. A vertical stab is made into the cyst with the knife and the contents are then evacuated with a sharp spoon.

Difficulty may arise in fixing the cyst whilst making the incision; this is best obviated by holding the everted lid between the finger and thumb.

In some cases, when the cyst has persisted for a considerable time, the sac-wall becomes so thickened that it has to be dissected out before the mass in the lid will disappear.

CHAPTER VI
OPERATIONS UPON THE EXTRA-OCULAR MUSCLES

SQUINT OPERATIONS

Indications. Operations upon eyes with concomitant squint are undertaken for two purposes:—

(i) For cosmetic reasons, to remedy a deformity due to a squinting eye which is amblyopic.

(ii) To rectify the muscular equilibrium in alternating or latent squints, so that binocular vision may be regained.

When the operation is performed for the latter reason the adjustment will naturally have to be much more accurate than for the former, so as to bring about the superimposition of the images falling on each macula. The muscular balance is interfered with by the administration of a general anÆsthetic, and therefore the results cannot be gauged accurately. Thus it is desirable that operations upon the ocular muscles should be performed under local anÆsthesia. This is usually possible, except in the case of very small children.

During and after the operation muscular equilibrium is tested by means of an electric light fixed to the ceiling immediately over the head of the patient (see Fig. 74). The room is darkened and the patient is made to look at the light. In a case with an amblyopic eye the reflection of the light should appear in the middle of each cornea if the eye be properly adjusted. In cases where good vision is present in both eyes the Maddox rod test should be used, the rod being placed before the eye not being operated on; the bar of light produced by the rod should pass through or within a few inches of the light if the adjustment has been performed accurately.

The tendons of the recti muscles are inserted into the globe at the following distances from the corneo-sclerotic junction: internal, 5 mm.; inferior, 6 mm.; external, 7 mm.; superior, 8 mm. Each muscle is held in place by expansions on either side of the tendon as well as by the tendinous insertions. Division of these expansions allows a greater retraction of the muscle and is, therefore, to be undertaken when a considerable degree of squint has to be overcome. On the other hand, there will be a danger that the muscle may not regain a proper attachment to the globe if division be too freely performed, and a squint in the opposite direction may result; proptosis also may be caused thereby. It is, therefore, better to combine tenotomy with advancement in high degrees of squint over twenty degrees convergent and in all cases of constant divergence. This is usually better than performing a tenotomy in the other eye, as there still remains the muscle of the other eye in reserve to tenotomize if necessary, if the advancement be insufficient to correct the squint. Further, it is much easier to rectify a muscular error by accurate tenotomy than by advancement. Division of the tendon of the internal rectus only, without its expansion, will usually rectify cases of latent convergent strabismus with a deviation of about 12° prism (Maddox test). Cases of latent divergent strabismus of about 8° prism (Maddox test) require complete division of the tendon of the external rectus, and, in some cases, of the expansion as well. Tenotomy of the superior rectus for hyperphoria should only be undertaken in bad cases; that is to say, of over 12° prism, any lateral deviation being first corrected, as occasionally the correction of the lateral deviation, especially when this is due to the faulty insertion of a muscle, will sometimes correct the hyperphoria present.

Partial tenotomies are performed by some surgeons for the correction of latent muscular errors, but the experience of most in this country is that little benefit is gained unless the tendon be completely divided. Tendon-lengthening by various methods has been performed, but has not come into general use.

After all operations upon the ocular muscles both eyes should be occluded to keep the eyes at rest whilst the muscle is gaining its fresh attachment to the globe; this usually takes about seven days, after which time both eyes should be uncovered, and if there is a tendency to convergence atropine should be used. Glasses correcting any error of refraction should be worn.

TENOTOMY

Tenotomy may be performed by (1) the open, or (2) the subconjunctival method.

Instruments. Speculum, straight blunt-pointed scissors, strabismus hook, needle and silk, needle-holder.

Operation. The operation is performed under adrenalin and cocaine.

1. By the open method. The surgeon stands on the right side facing the patient when dividing the right external or the left internal rectus, but at the head of the table when dividing the right internal or the left external rectus.

First step. The speculum is inserted and the patient is made to look away from the muscle to be divided. The conjunctiva is freely divided vertically with scissors directly over the insertion of the tendon into the globe (see Fig. 130) and dissected backwards.

Second step. The tendon of the muscle is then seized with fixation forceps and button-holed about its centre as close to the globe as possible (Fig. 131). The lower blade of the scissors is then passed through the hole in the tendon, and the rest of the tendon and its expansions are divided upwards and downwards to the extent required to bring the eye straight as tested by its appearance or by the Maddox rod test. The strabismus hook may be inserted, both upwards and downwards, to see that the tendon is properly divided, but all pulling on the muscle with a hook should be avoided, as it is painful and disturbs the muscular equilibrium. The conjunctiva is then brought together with a fine silk suture. If the squint be over-corrected by the tenotomy, a deep hold should be taken with the stitch so as to draw the eye back into position.

2. By the subconjunctival method. This is unsatisfactory in that accurate adjustment by division of the expansion of Tenon’s capsule is not possible. It is painful, and is sometimes followed by a troublesome hÆmorrhage into the capsule of Tenon. Occasionally it may be of use in some cases of amblyopic eyes where a small wound is desirable. The conjunctiva is button-holed below the tendon, and separated from the surface of the muscle. The capsule of Tenon is then opened below the tendon, a strabismus hook is passed through the opening with its concavity against the globe, and is then rotated upwards beneath the tendon, which is subsequently divided between the hook and the globe.

Complications. These may be immediate or remote.

Immediate. 1. HÆmorrhage into the capsule of Tenon, leading to intense proptosis, only occurs when the subconjunctival method is adopted. As a rule the hÆmorrhage ceases on the application of pressure, but occasionally it may be necessary to open up the wound and turn out the blood-clot.

2. Perforation of the globe has been known to occur during the division of a tendon in an obstreperous patient. It should be treated as a wound of the sclerotic (see p. 235).

3. Tenonitis very rarely occurs, but may lead to matting down of all the extra-ocular muscles and defective movements of the globe. Panophthalmitis has been known to follow this condition.

Remote. 1. Failure to correct the muscular error. If the error be large it must be rectified by tenotomy of the corresponding muscle of the other eye or by the advancement of the opposing muscle of the same eye. This should not be undertaken until five or six weeks have elapsed since the previous operation.

2. Over-correction of the muscular error at the time of the operation may be remedied by stitching the tenotomized muscle forward to the extent required to bring the eye straight. Advancement of the tenotomized muscle should be performed if the over-correction be only discovered after the operation. In cases with binocular vision lesser degrees of deviation may be corrected with prisms if they are causing symptoms, while small errors of over-correction, of about 3° prism, often disappear after the first few weeks.

3. Defective movement in the tenotomized muscle is usually present for the first week or two after the operation, but recovery usually takes place after the muscle has regained its attachment to the globe; it may persist, however, to a slight extent; this is most liable to occur after free division of the tendon and its expansion (more especially in the case of the external rectus), or because the tendon has not been divided close enough to the globe. In patients with previous binocular vision diplopia is present after the operation on turning the eyes towards the same side as the tenotomized muscle, but this usually disappears.

4. A granulation may form at the site of the tenotomy wound. It may be due to a tag hanging from the wound or to a portion of a stitch that has been imperfectly removed. It should be snipped off with scissors and the conjunctiva drawn together over its base.

5. Proptosis may result from too free a division of a tendon.

6. Retraction of the caruncle is best avoided by closing the conjunctival wound with a stitch, and thus pulling the caruncle forward.

ADVANCEMENT

Advancement is an operation undertaken to rectify a squint by forming a fresh attachment for one of the ocular muscles nearer the cornea, and at the same time shortening it. There are three main types of operation performed:—

1. The capsulo-muscular, in which the tendon, together with the attachment of the capsule of Tenon to it, is advanced.

2. The tendon only is isolated, shortened, and advanced.

3. The tendon is shortened by folding it upon itself.

The first operation is by far the most satisfactory of these, owing to the fact that a broader new insertion of the muscle is obtained, which is less likely to yield subsequently; it is the operation usually performed in this country.

The chief cause of unsatisfactory results after advancement operations is the cutting through of the sutures holding the tendon in position. The various operations, which are some fourteen in number and have mostly their respective surgeon’s name attached, differ principally in the method of insertion of these sutures. Whichever method of inserting sutures be used, the main factors which aim at preventing the stitches from cutting out are (1) that the stitches should take a good hold in the scleral and episcleral tissues on the corneal side of the wound, for the passing of which it is most essential that the needles should be sharp; (2) that complete rest of the muscles should be ensured by bandaging both eyes for the first seven days after the operation; (3) that the opposing muscle should be tenotomized so as to prevent traction on the sutures.

Of the many operations that have been devised the capsulo-muscular advancement or some modification of it is most frequently used.

Instruments. Speculum, straight scissors, fixation forceps, Prince’s advancement forceps (Fig. 132), four sharp needles and strong silk, needle-holder.

Operation. Under adrenalin and cocaine. First step. The patient is made to look away from the side on which is the muscle to be advanced, and the conjunctiva over the muscle is freely divided with scissors, by a curved incision with the convexity towards the cornea, and dissected back.

Second step. The capsule of Tenon is button-holed by a small incision well above or below the tendon. A tenotomy hook is passed beneath the tendon and its expansion and brought out through a small hole in Tenon’s capsule on the opposite side of the tendon. The smooth blade of Prince’s forceps is then inserted in place of the hook, and the tendon with its expansion is grasped between the blades. The forceps are given to an assistant, who should avoid all traction on the muscle. The eye is then rotated in the direction of the muscle to be advanced, and tenotomy of the opposing muscle is performed by the open method.

Third step. The muscle to be advanced and its expansion, which are clamped between the blades of Prince’s forceps, are separated from the globe with the scissors and given again to the assistant to hold. Three strong silk sutures are passed in the following order, middle, upper, and lower, first through the conjunctival and episcleral tissue on the corneal side of the wound and then as far back as possible through the muscle and out through the conjunctiva near the cut margin on the other side of the wound (Fig. 133). Care should be taken that the middle stitch is passed through the episcleral tissue exactly opposite the horizontal plane of the cornea and the central portion of the tendon. The portion of the tendon and capsule within the grasp of the forceps is then removed with scissors by cutting close to the blades of the Prince’s forceps, taking care not to cut the sutures.

Fourth step. The middle suture should be first tightened to the extent required to bring the eye straight. The upper and lower sutures are then tied.

If, on testing with the Maddox rod, the error be found to be slightly over-corrected by the advancement, the eye can be drawn back by taking a firm hold with the conjunctival stitch over the tenotomy wound. The conjunctival stitch may be removed on the fourth day, but the stitches holding the advanced muscle in position should not be removed till after the tenth day. Atropine in both eyes is desirable, especially when there is any tendency to convergence. Glasses should be worn on uncovering the eyes.

Complications. 1. The eyes may not be straight after the operation. No further operation for rectification should be undertaken for at least two or three months. If there be a tendency to convergence, glasses should be worn and atropine used. Small latent errors may be corrected by prisms. If the muscular error be insufficiently corrected tenotomy may be performed on the other eye. If the muscular error be over-corrected it may also require tenotomy on the other eye, the adjustment by tenotomy being more accurate than that by advancement.

2. Thickening over the site of the advanced muscle usually disappears in a few months.

Other complications as described under tenotomy may occur (see p. 250).

CHAPTER VII
ENUCLEATION OF THE GLOBE AND ALLIED OPERATIONS

The principal substitutes for simple enucleation are evisceration, Mules’s and Frost’s operations.

ENUCLEATION

Enucleation is the removal of the globe from Tenon’s capsule.

Indications. Enucleation should be performed in preference to Mules’s operation in—

In malignant tumours enucleation should only be performed when there are no signs of extra-ocular extension. If extra-ocular extension be present, evisceration of the orbit should be performed, provided there be no evidence of general metastasis. In cases of glioma of the retina it is especially desirable that the optic nerve should be cut as far back as possible and the cross-section carefully examined for gliomatous tissue, since the disease spreads to the brain along this structure.

In injuries followed by non-suppurative cyclitis enucleation or Frost’s operation is preferable to Mules’s operation, since cases have been recorded of sympathetic ophthalmia following the latter operation, and it is these cases of non-suppurative cyclitis which are especially prone to give rise to that disease.

Blind painful eyes, especially when affected with glaucoma, are best removed, as occasionally the underlying cause, when not known, may prove to be an intra-ocular growth.

Instruments. Speculum, fixation forceps (two pairs), straight scissors, strabismus hook, strong curved scissors.

Operation. Before the anÆsthetic is administered the forehead should be marked over the eye to be enucleated, so as to guard against the accident of removing the wrong eye. It is usual, at any rate in the case of hospital patients, to get their written consent for the operation.

First step. The speculum is inserted. In the case of the right eye the conjunctiva is seized with the fixation forceps downwards and outwards, or in the case of the left eye, downwards and inwards. The straight scissors being held with the right thumb and ring finger, the conjunctiva is divided freely all the way round, as close as possible to the cornea, and dissected back.

Second step. The capsule of Tenon is opened below the external rectus by grasping it with forceps and buttonholing it with the scissors. The strabismus hook is passed through the opening made in Tenon’s capsule with its concavity against the globe, turned upwards beneath the tendon, and the latter is pulled well forward and freely divided from above downwards between the hook and the globe. The superior and inferior recti are treated in a similar manner. In dividing the internal rectus a small portion should be left attached to the globe, so that subsequently it can be grasped with forceps to rotate the globe outwards when dividing the optic nerve.

Third step. The globe is dislocated between the lids by opening the speculum widely and pressing it backwards. If the globe will not dislocate, it is either because the tendons are imperfectly divided, or the palpebral aperture is too small to allow of its delivery; the latter is liable to be the case in small children or in those with a staphylomatous globe. In such cases the palpebral fissure should be enlarged by dividing the outer canthus.

The fourth step is the division of the optic nerve. The globe is rotated strongly outwards, either by pulling on the tendon of the internal rectus or by pulling the globe outwards with the finger; the optic nerve is felt for by passing the strong curved scissors behind the globe. When the nerve is defined the blades are opened widely, pressed backwards, and the nerve divided. The globe is then pulled forward with the finger, and the oblique muscles and remaining attachments divided. HÆmorrhage is easily controlled by pressure and the use of adrenalin.

Fifth step. When the bleeding has ceased, the conjunctival wound is united in a horizontal direction by means of a thick silk suture running over and over; no knot is required and the ends are left long, so that it may subsequently be removed easily (Fig. 134). The usual dressings are applied with a firm pressure bandage for the first six hours. The suture should be removed at the end of the seventh day. No artificial eye should be worn for at least six weeks after the operation, and then only for a few hours at a time until the conjunctiva becomes accustomed to it. It should always be taken out at night.

Complications. These may be immediate or remote.

Immediate. Cutting into the globe. This may occur during the division of the optic nerve, and is usually due to imperfect dislocation of the globe. Although of little consequence as a rule, it may be extremely serious, as for instance in the case of an intra-ocular growth, when it is conceivable that a portion of it might be left behind. If this accident should happen, the portion of the sclerotic and choroid left behind should be carefully sought for and removed.

Adhesion of Tenon’s capsule. Eyes that have been the subject of acute inflammation are much more difficult to enucleate, owing to adhesion of the surfaces of Tenon’s capsule. In these cases the globe has practically to be dissected out of that structure.

Remote. HÆmorrhage into the stump may occur, leading to proptosis of the conjunctiva and extravasation into the eyelids and beneath the skin of the face. The use of a firm pressure bandage and the omission of the suture is usually sufficient to prevent this occurring, but the blood-clot may have to be turned out and the bleeding point sought for and ligatured.

Granulations and polypi in the socket are usually the result of leaving some tag of tissue between the margins of the wound, and are therefore more likely to occur when no suture is used to close the wound. They should be removed with forceps and scissors.

Polypoid masses sometimes form in a socket as the result of an imperfect artificial eye causing an oedematous condition of the conjunctiva. They should not be removed, owing to the contraction caused thereby, but the artificial eye should be left out, when they will often disappear.

Contracted socket is usually the result of an imperfectly performed enucleation or loss of large portions of the conjunctiva; for the operations for its relief, see p. 261.

EVISCERATION

Evisceration is the removal of the intra-ocular contents.

Indications. It is the ideal operation for a suppurating globe; in these cases enucleation is contra-indicated because the lymph-space round the optic nerve is opened up by the division of the latter and the inflammation may spread directly to the meninges.

Instruments. Speculum, fixation forceps, Beer’s knife, scissors, scoop and stitches.

Operation. A general anÆsthetic is necessary.

First step. The eye is transfixed about 4 mm. behind the corneo-sclerotic junction with a Beer’s knife, which is made to cut out upwards (Fig. 135). The flap of corneal and scleral tissue is then seized with forceps and the cornea removed entirely by completing the incision in the sclerotic round it with scissors (Fig. 136).

Second step. The contents of the globe are then eviscerated by means of a spoon, and the cavity flushed out with 1 in 4,000 perchloride of mercury lotion. Great care should be taken to remove all portions of the uveal tract; this is best ensured by visual inspection after the hÆmorrhage has ceased. The interior of the sclerotic should appear perfectly white.

Third step. Although not absolutely necessary, and inadvisable in the case of a septic globe, a single suture may be passed through the centre of the wound in the conjunctiva and sclerotic.

Complications. As the operation is not infrequently performed for panophthalmitis, much swelling of the lids and discharge from the socket may take place after the operation; these symptoms usually subside in the course of a few weeks without further trouble. The interval which must elapse before an artificial eye can be worn is considerably longer than after enucleation.

MULES’S OPERATION

Mules’s operation is the insertion of a celluloid globe into the sclerotic after evisceration, followed by closure of the scleral wound over it. In both this and Frost’s operation a better stump is formed, so that more movement may be obtained in the artificial eye which is subsequently worn over the inserted globe.

Indications. (i) The operation is especially suitable for anterior staphyloma following ophthalmia neonatorum. In young children the presence of the ball in the orbit assists the development of that structure.

(ii) It is also suitable for large, recently made, fairly aseptic wounds in the globe.

Operation. The first two steps are the same as for evisceration.

Third step. A glass or, better, a celluloid or gold-plated ball is inserted into the sclerotic, which is closed over it by two rows of interrupted sutures, one of catgut passing through the sclerotic, the other of silk closing over the conjunctival wound. To facilitate the closure of the conjunctival wound it is advisable to dissect the conjunctiva back from the limbus before excising the cornea. The ball inserted in the sclerotic should fit the cavity loosely.

Complications. In about 17% of the cases the ball is not retained; this is not infrequently due to too large a size being used, or to the wound being imperfectly closed by the sutures. If two rows be used, as described above, extrusion of the ball is far less frequent than if one only be inserted. If the globe be extruded the patient is in the same position as if he had had evisceration performed.

FROST’S OPERATION

In this operation the eye is enucleated, a celluloid globe is inserted into Tenon’s capsule, and the conjunctiva is closed over it by means of sutures passing through Tenon’s capsule and the conjunctiva.

Operation. The first four steps in the operation are similar to those described under enucleation.

Fifth step. A small, loosely-fitting glass globe is inserted into Tenon’s capsule. A purse-string suture of strong catgut is then inserted into the cut margin of Tenon’s capsule, taking care to include in the sutures the cut ends of the tendons of the recti muscles. The suture is drawn tight and tied so that Tenon’s capsule and the muscles are thereby drawn over the globe. The conjunctival wound is closed over this by a separate suture of silk.

The advantage of this operation over the other substitutes for simple enucleation is that it can be used after any enucleation. The chief disadvantages are that the globe is sometimes extruded unless the wound be carefully closed by sutures, and occasionally it may become dislocated from Tenon’s capsule beneath the conjunctiva, thus preventing an artificial eye from being worn, and requiring removal. These disadvantages are largely done away with if the method of suture described above be used.

OPERATIONS UPON THE SOCKET AFTER THE REMOVAL OF THE EYE

PARAFFIN INJECTION

Indications. Occasionally after an eye has been removed the movements in the socket are not communicated sufficiently to the artificial eye which is placed over it, so that the glass eye has a fixed, staring appearance. As a rule, this can be remedied by the use of a Snellen’s improved eye, which has a rounded posterior surface and fits well on to the stump. If this be not satisfactory, the injection of paraffin into the stump will often improve the movements considerably. The injection should be made by what is known as the ‘cold method’.

The ‘cold method’ of paraffin injection is by far the most satisfactory, for the following reasons:—

(a) The temperature need not be so high, and no damage is therefore done to the tissues.

(b) It is more easily regulated (see Vol. I, p. 682).

(c) Embolism is less likely to occur.

Instruments. Fixation forceps, tenotomy knife, speculum, a large paraffin syringe, and a short needle having a big bore.

Operation. This may be performed under adrenalin and cocaine.

First step. The stump is drawn forwards with forceps. A tenotomy knife, inserted well to the outer side of the stump, is then swept freely round and a pocket is formed in the centre of the orbit into which the injection can be made. The tenotomy knife is then withdrawn.

Second step. The sterile melted paraffin (melting-point 115° F.) should be poured into the syringe, which should have been previously kept in a hot-water bath. The paraffin is then allowed to cool slowly until it just becomes opalescent. The injection should be made through the hole made by the tenotomy knife, sufficient paraffin being inserted to obtain the desired result. The operation is usually followed by considerable swelling of the tissues, which will subside in three or four weeks.

OPERATIONS FOR THE RESTORATION OF A CONTRACTED SOCKET

As the result of wearing badly-formed artificial eyes or of subsequent inflammation in the conjunctival sac, the socket not infrequently becomes so contracted that the prosthesis cannot be retained. Enlargement of the sac may be obtained by two methods:—

(a) Skin-grafting (Thiersch’s method).

(b) Transplantation of skin from the surrounding structures (Maxwell’s operation).

SKIN-GRAFTING

Indications. This procedure is especially suitable for cases in which the base of the socket opposite the palpebral aperture has to be enlarged, and it is usually performed prior to Maxwell’s operation for the restoration of the fornices in severe cases.

Instruments. Scalpel, speculum, skin-grafting razor, probes, and a piece of thick style wire.

Operation. First step. The base of the socket is freely divided in a horizontal direction opposite the palpebral aperture so as to produce a gaping wound.

Second step. This gaping wound is put on the stretch in the following way: A thick piece of style wire is bent round to fit into the fornices of the socket, the ends being brought out over the lid at the inner canthus. The circle of wire is opened out as far as possible so as to put the wound at the bottom of the socket on the stretch to its fullest extent.

Third step. Skin grafts are then cut from the inner surface of the arm (see Vol. I, p. 670), applied by means of probes, and pressed down on to the raw surface. No dressings should be applied directly to the grafts, but a watch-glass may be placed over the palpebral aperture and dressings applied over it. The style wire should be removed on the fourth day.

INCLUSION OF FLAPS. MAXWELL’S OPERATION

Indications. It is especially useful for the enlargement of the socket by the formation of new fornices. As a rule it is performed for the reproduction of the lower fornix, as it is frequently due to the obliteration of this cul-de-sac that the artificial eye cannot be retained. The operation, however, may be modified and applied to the formation of both the upper and outer culs-de-sac.

Instruments. Scalpel, forceps, scissors, and sutures.

Operation. A general anÆsthetic is required.

First step. An incision is made in the lower fornix throughout its whole length and carried downwards for a distance of about half an inch (Fig. 137, A).

Second step. A crescentic piece of skin is marked out on the lower lid by two incisions which have their concavity directed upwards. The upper one is parallel with the margin of the lower lid and about 5 millimetres below it. This crescentic flap is then dissected up from the deeper tissues all round, except for a small pedicle at its centre (Fig. 137, B).

Third step. The incision forming the upper margin of the crescentic piece of skin is deepened until it meets the incision made in the fornix, so that the lower lid is converted into a band of tissue attached only at each end.

Fourth step. The upper margin of the incision in the fornix is stitched to the upper margin or concavity of the crescentic piece of skin after the latter has been displaced upwards beneath the band of tissue carrying the lashes, and the lower margin of the crescentic piece of skin is stitched to the conjunctival edge of the band, so that the crescentic piece of skin is folded on itself and forms the new lower fornix, being held down in its position by the pedicle (Fig. 138). The sutures should be of catgut, as their subsequent removal is somewhat difficult.

Fifth step. The surface wound is closed by silkworm-gut sutures. The socket should be packed with gauze, or else a piece of style wire should be inserted, as in the previous operation, so as to maintain the groove in the new lower fornix.

CHAPTER VIII
OPERATIONS UPON THE EYELIDS

SURGICAL ANATOMY

The eyelids consist of well-marked planes of tissue, which are, from without inwards—

1. Skin with very little subcutaneous fat.

2. Orbicularis muscle.

3. Tarsal plates, which are attached to the orbital margins by the palpebral ligaments and which thereby form a barrier to the passage of infection backwards into the orbit.

4. Subconjunctival tissue and conjunctiva.

It is most important for successful results that flaps and incisions should be made accurately down to and in the correct layer of the lid.

Along the lid margin, between the eyelashes and the posterior border of the eyelid, is a white line (intermarginal line) formed by the edge of the tarsal plate. In the many operations in which the lid is split the incision is carried along this line.

The blood-supply to the eyelids is derived from arterial arches—two in the top lid, and one in the lower—which run parallel to the margins. As far as possible, therefore, flaps should be planned with their bases at right angles to the course of the vessels. The extreme vascularity of the lid, together with the small amount of subcutaneous fat, allows of almost complete detachment of flaps of skin without fear of necrosis, but at the same time every care should be taken to avoid injuring these flaps when manipulating them. HÆmorrhage is controlled during the operation by means of clamps or by direct pressure of the lid between the finger and thumb. As a rule a general anÆsthetic is required for most of the operations.

SUTURE OF WOUNDS OF THE EYELIDS

Wounds which involve the skin only are brought together in the ordinary way with a few fine sutures. In wounds of the upper lid care should be taken to suture the levator palpebrÆ, if divided, as otherwise traumatic ptosis may result.

Suture of wounds involving the lid margin.

(a) In simple division the margins of the lids are brought together by means of a fine suture; the conjunctival surface is first approximated, and then the skin by a deep suture which includes the tarsal cartilage. Accurate apposition of the lid border is very essential. Unfortunately a certain amount of ectropion frequently follows, which may require for its relief one of the operations given below (see p. 284).

(b) Occasionally the lid margin carrying the lashes may be torn off. As a rule, the strip remains attached to the lid. It should then be accurately sutured in position, taking care that the lashes take their correct turn outwards. In cases where the strip is torn off entirely, the skin and conjunctiva should be sutured together. When large portions of the lid are lost, some form of plastic operation, such as is performed for making a new lid, is required (see p. 287).

(c) When the canaliculus has been divided the end attached to the lachrymal sac should be sought for and divided for a short distance inwards from the wound (see p. 291), the entrance being kept open daily by a probe to prevent traumatic stricture.

OPERATIONS FOR ANKYLOBLEPHARON

Fusion of the eyelids together is either a congenital condition or the result of injury, and may take the form of bands or firm fibrous union. It is rarely complete and is often associated with symblepharon. The union should be divided on a director, or by careful dissection, taking care not to wound the underlying globe. The raw surfaces are kept apart by daily dressing until they are covered by epithelium. No externa[l] dressing should be applied.

OPERATIONS FOR SYMBLEPHARON

Partial adhesion of the lid to the globe in which a few bands pass from the lid to the globe are best treated by division followed by union of the ocular conjunctiva over the raw surface; no external dressing should be applied. Any tendency to fresh adhesion may be prevented by daily inspection.

In extensive adhesion of the lid to the globe, where the lids are entirely adherent to the globe and the cornea is destroyed, interference is inadvisable. In less extensive adhesion, the lid is first separated from the globe, reunion being prevented by covering the denuded area on the globe with a flap of bulbar conjunctiva transplanted from an area that does not come in contact with the raw surface on the eyelid (Teale’s operation), or by Thiersch’s grafts from a situation where there are no hairs; or by grafting mucous membrane from the mouth of the patient or a frog. Teale’s operation, or some modification, is by far the most satisfactory, but unfortunately it cannot always be carried out when the loss of conjunctiva is large.

OPERATIONS UPON THE PALPEBRAL APERTURE

CANTHOPLASTY

Indications. In contraction of the palpebral aperture, either due to a congenital condition, or the result of a wound, trachoma, or other cicatricial contraction.

Instruments. Speculum, forceps, scissors, and three sutures.

Operation. The speculum is inserted and opened as widely as possible. One blade of the scissors is passed into the cul-de-sac at the outer angle of the lid and the palpebral aperture enlarged by dividing the outer canthus horizontally. The external tarsal ligament which is split longitudinally is then cut across with scissors passed into the upper and lower wound. The conjunctiva is drawn up into the wound and stitched to the skin at the margin to prevent reunion. The stitches should be removed about the sixth day.

CANTHOTOMY

Canthotomy is simple division of the outer canthus without stitching the conjunctiva into the wound. It is useful in some cases of blepharospasm associated with fissure at the outer canthus.

CANTHORRHAPHY

Union of the eyelids, usually at the outer canthus.

Indications. (i) When the eyelids do not cover the globe as the result of—

(a) Cicatricial contraction of wounds, burns, &c., about the lid.

(b) Long-standing facial paralysis.

(c) Exophthalmic goÎtre.

(ii) To help maintain the lid in position after ectropion operations.

Instruments. Beer’s knife, fixation forceps, spatula, and sutures.

Operation. First step. The position for the new external canthus is determined by holding the lids together at the outer canthus, and is marked on the upper and lower lids. From these points incisions are carried outwards to the external canthus along the intermarginal line in the top and bottom lids. These incisions are deepened to about 5 millimetres.

Second step. From the inner end of the incision in the lower lid a vertical one is made downwards for about 5 millimetres, and is then carried out to the external canthus. The tissue thus marked out, bearing the lashes, is then removed.

Third step. A corresponding, slightly larger, area is similarly removed from the under or conjunctival surface of the upper lid (Fig. 139).

Fourth step. These two areas are brought into apposition by means of a strong suture passed through their centre. The suture should have a needle at either end, and these should be passed from the conjunctival surface and brought out through the middle of the raw area in the lower lid, about 2 millimetres apart, and then through the middle of the raw area in the upper lid and out through the skin. The suture is tied so that the two raw areas are brought into accurate apposition. The margins of the wound may then be brought together by sutures if necessary. The main suture should be left in for at least ten days.

TARSORRHAPHY

Indications. (i) Complete union of the eyelids may be required when an eye has been removed and for some reason an artificial one cannot be worn.

(ii) Partial union is effected in cases of paralysis of the first division of the fifth nerve when corneal ulceration threatens. A similar union is also useful in keeping the lower lid in position during the process of cicatrization in many of the operations for ectropion described below. The adhesions produced can be subsequently divided when contraction has ceased.

Instruments. Knife, forceps, scissors, spatula.

Operation. Complete. As narrow a strip of tissue as possible is removed from the lid borders behind the eyelashes. This is best performed by everting the upper lid and shaving off the posterior margin with a sharp knife; the lower lid is then treated similarly. The raw areas are brought into apposition with fine sutures.

Partial. When only a temporary adhesion is required, as after ectropion operations, it is sufficient to make raw corresponding areas of about 2 millimetres on the posterior margins of the top and bottom lids on either side of the central position of the cornea and unite them with sutures, which may be removed about the end of the first week.

PTOSIS OPERATIONS

The following operations are usually only undertaken for congenital ptosis, but they are occasionally required for the paralytic and traumatic varieties. All the operations are far from satisfactory, and should only be undertaken when the lid covers the pupil completely or so nearly that the head has to be thrown back to see objects directly in a line with the eyes. The relative value of the various operations apart from their indications is a matter of opinion amongst ophthalmic surgeons; therefore the various types of operations which are performed are given below.

There are four types of operation, which respectively aim at—

1. Shortening the eyelid by excision of a portion of the tarsal plate.

2. Attachment of the lid to the occipito-frontalis muscle.

3. Advancement of the levator palpebrÆ muscle.

4. Grafting of part of the superior rectus muscle into the lid to take the place of the levator palpebrÆ superioris.

SHORTENING THE EYELID BY EXCISION OF A PORTION OF THE TARSAL PLATE

Fergus’s operation (modified). The object of this operation is to shorten the eyelid by removing the upper portion of the tarsal plate, the cut margin of which is subsequently sutured to the tendon of the levator palpebrÆ and the palpebral ligament.

The results of the operation are satisfactory, especially in cases in which there is some movement in the eyelid. The author, who has performed most of the ptosis operations on several occasions, has had most uniform results by this method, the modification of which was first suggested to him by Mr. Treacher Collins.

It has the advantage that the amount of retraction required may be more easily estimated, the corneal complications are of much rarer occurrence, and the resulting scar forms a natural fold in the lid. It is obviously not applicable to cases in which the eyelid is already short, as in the cases of ‘Chinese eye’ in which little can be done beyond enlarging the palpebral aperture.

Instruments. Spatula, scalpel, artery and dissecting forceps, scissors, and sutures.

Operation. First step. The spatula is inserted into the superior fornix. A curved incision is made directly below the orbital margin throughout its whole length. The skin and orbicularis muscle are divided and dissected downwards so as to expose the upper surface of the tarsal plate. A suture is then passed through this flap so that it may be drawn down by an assistant.

Second step. A narrow strip about 3 millimetres broad is excised from the whole length of the tarsal plate; in doing this care must be taken not to button-hole the conjunctiva or flap of skin.

Third step. The cut margin of the tarsal plate is sutured to the levator palpebrÆ and palpebral ligament by two sutures passed in the following manner: A thick catgut suture armed with a curved needle is passed through the upper cut margin of the orbicularis palpebrarum, palpebral ligament, and levator palpebrÆ (if the latter be present) at about the junction of the middle and inner thirds of the wound, a firm hold being taken on these structures. The needle is then passed through the tarsal cartilage parallel to the lid border for a distance of about 3 millimetres and out again on to its anterior surface. The needle is then again carried through the levator palpebrÆ, palpebral ligament, and orbicularis in the upper part of the wound. A similar suture is passed about the junction of the middle and outer thirds of the wound. When both sutures are in position they are tied sufficiently tightly to produce the retraction of the lid desired, slight over-correction being necessary. The skin wound is then closed with sutures.

ATTACHMENT OF THE LID TO THE OCCIPITO-FRONTALIS MUSCLE

There are three chief methods of affecting this attachment:—

(a) By cicatricial bands (e.g. Hess’s operation).

(b) By a suture left permanently in position (e.g. Harman’s operation).

(c) By the attachment of the skin of the lid to the muscle (e.g. Panas’ operation).

Indications. In the majority of the cases of congenital ptosis the levator palpebrÆ is completely absent, as shown by the want of upward movement in the lid, and it is for this condition that one of the operations of this type is performed. In rare cases the occipito-frontalis muscle is also absent or imperfectly developed, and in these cases these operations should not be undertaken.

Hess’s operation. The object of this operation is to insert silk stitches between the eyelid and the occipito-frontalis muscle, and to leave them in long enough for a fibrous band of union to form along the stitch tracks.

Instruments. Scalpel, dissecting forceps, needle and holder, spatula, artery forceps.

Operation. First step. The eyebrow having been shaved, an incision 2 inches long is made about in the line of the brow, and the skin is dissected down almost to the lid margin.

Second step. Three sutures are passed, one in the middle, and one at each end of the lid; each suture carries two needles. The needles are inserted in the intermarginal line of the lid about 3 millimetres apart and brought out into the wound above, so that the lid margin is held by the loops. These threads are then carried deeply beneath the upper edge of the wound into the substance of the occipito-frontalis muscle, brought out through the skin well above the eyebrow and tied over a piece of drainage tube. The sutures should be drawn tight enough to produce an undue amount of retraction of the lid, as this tends to drop again after removal of the sutures. The skin wound is then closed and a small dressing is applied to cover the drainage tube on the forehead. The eye itself should be covered with a celluloid shield, as it is usually impossible for the patient to close the palpebral aperture, and the cornea is liable to be injured by exposure. The deep sutures should be left in for at least three or four weeks, so that they may bring about a fibrous band between the muscle and the eyelid by their irritation. The immediate result of the operation is usually excellent, but the lid is very apt to drop again in the course of six months or a year after removal of the stitches.

Harman’s operation. The aim of this operation is to insert a fine metal chain between the occipito-frontalis and the lid, the chain being left permanently in position. The operation has not yet been performed sufficiently often to allow any definite statement about the final results to be made.

The results have not been very satisfactory in three cases in which the author has performed this operation.

Instruments. A 4-inch straight surgical needle, to which is attached the fine wire chain such as is used by spectacle makers to attach glasses to the dress. It measures about O.75 millimetre in diameter. It is attached to the needle by a soldered ring or by means of a piece of silk doubly looped through the needle without a knot.

Operation. Under a general anÆsthetic. ‘The method of implanting the chain will be followed readily by reference to Fig. 140. The chain-needle is inserted above the external angular process at A, is passed inwards, and with a slightly upward inclination deeply beneath the tissues of the forehead, to be withdrawn at B; as much of the chain is drawn through as desired. The needle is reinserted at B, passed beneath the brow close to the orbital margin and through the tissues of the lid to C, where it is withdrawn and the chain after it. In like manner it is passed from C to D through the substance of the tarsus and withdrawn. It is now returned from D to E above the brow and withdrawn, and a final length embedded above the brow from E to F, which is just above the internal angular process. The chain should be buried completely and stretched evenly between the points A, B, C, D, E and F; and by traction the loop BCDE should be adjusted at B and E; when the lid is at the desired height the slack at B and E is taken up by traction on A and F.

‘The position of the points E and B is of importance; they must be situated in the region of the most effective elevation of the brow by contraction of the frontalis muscle, as determined by experiment before the commencement of the operation (and they should be placed well above the eyebrow).

‘The lengths of chain lying buried above the brows from A to B and E to F, and the angles A B C and D E F, are arranged so that there is sufficient holding power to prevent the subsequent drop of the lid, but will not prevent adjustment to forcible traction on the lid until the links of the chain have become interwoven and surrounded by the growth of connective tissue. This growth should be sufficiently vigorous by the end of a week to securely fix the chain against all the force of traction of the orbicularis muscle. (In one case in which the author removed the chain after two weeks there was no connective tissue in the links and it was easily withdrawn.) Until this time the free ends of the chain should be turned towards each other over the skin of the brow and cemented in position by a cotton-wool and collodion dressing, after which time the free ends, A and F, are cut off and the free extremities pushed beneath the skin.’

Panas’ operation. In this operation a direct adhesion of the skin of the lid to the occipito-frontalis muscle is aimed at.

Instruments. Lid spatula, scalpel, dissecting forceps, scissors, sutures.

Operation. Under a general anÆsthetic.

First step. An incision, 2 inches long, is made in the line of the brow, and an incision of a similar length is made into the skin of the lid about half an inch below it. The tissue between these two incisions is undermined so as to produce a band of skin and subcutaneous tissue. From the ends of the lower wound vertical incisions are made into the lid, running slightly outwards and inwards respectively towards the outer and inner canthus (Fig. 141).

Second step. The flap, C (Fig. 141), thus produced is raised, and doubly armed sutures, D D, are passed through its upper margin and are carried beneath the band of skin and subcutaneous tissue. The needles are then carried deeply beneath the upper margin of the wound A into the substance of the occipito-frontalis muscle and brought out on to the forehead. Outer and inner sutures, E E, are passed deeply into the substance of the tarsus both ends are then passed beneath the band and brought through into the upper wound, whence they are passed beneath the upper margin of the wound into the occipito-frontalis muscle and are tied over a piece of drainage tube. They hold the lid in position during the process of cicatrization. Considerable over-correction should be employed as the lid tends to drop subsequently. No dressings should be applied over the open palpebral aperture. The stitches are removed on the tenth day. A small depression is usually seen where the skin of the lid passes beneath the band.

ADVANCEMENT OF THE LEVATOR PALPEBRÆ MUSCLE

This is especially suitable for cases in which the levator palpebrÆ has some power, that is to say, when there is some movement of the lid present. It is also suitable for cases of traumatic and paralytic origin. The movement of the lid by the levator palpebrÆ is best estimated by eliminating the action of the occipito-frontalis by holding down the brow and asking the patient to raise the lid.

Instruments. Lid spatula, knife, forceps, scissors, sutures.

Operation. Under a general anÆsthetic.

First step. A spatula is inserted into the upper conjunctival fornix. An incision is made just below the eyebrow over the upper margin of the tarsal plate throughout its length. The skin, especially of the lower margin of the wound, is dissected up and the orbicularis muscle divided, the tarsal plate, with the superior palpebral ligament attached to it, and the orbital margin being exposed. The superior palpebral ligament is then divided carefully high up near the orbital margin and directly below, in a small quantity of fat, will be found the tendon of the levator palpebrÆ superioris. The tendon can usually be distinguished from the palpebral ligament by the fact that it is elastic when pulled on.

Second step. The advancement of the muscle is then performed in one of the three following ways: (a) by excising a portion of the tendon and suturing the divided ends together; (b) detaching the tendon from the tarsal plate and bringing it from behind forward through a hole made in the upper margin of that structure and suturing it on its anterior surface towards the lower margin; (c) by folding the tendon on itself. The last method is the one most usually performed. Two sutures with a needle at each end are passed through the substance of the muscle and tied (Fig. 142). The ends of these sutures are then carried downwards between the tarsal cartilage and the orbicularis palpebrarum and out in the intermarginal line of the eyelid. The sutures are then tied tightly so as to secure rather more than the amount of retraction required (Fig. 143). The palpebral ligament and orbicularis palpebrarum are then united and the wound in the skin is closed.

GRAFTING A PORTION OF THE SUPERIOR RECTUS INTO THE LID

Motais’ operation. Indications. This operation is performed for cases of ptosis in which there is partial or complete loss of upward movement of the lid. In cases of congenital ptosis the superior rectus is not infrequently absent or imperfectly developed, as is shown by the defective upward movement of the eye. It need hardly be said that it is most important to see that the superior rectus is well developed before undertaking the operation. Vertical diplopia always follows the operation, and therefore it is advisable only to undertake it when the ptosis is bilateral, a similar operation being performed on both sides. Another somewhat hypothetical objection is that during sleep the eyelids are rolled upwards by the superior recti so that the lids are slightly open, but this occurs in almost all successful ptosis operations. Occasionally there is some defective upward movement of the eye after the operation.

Instruments. Speculum, straight strabismus scissors, lid retractor, needle holders and stitches.

Operation. A general anÆsthetic is desirable in all cases.

First step. The superior rectus is exposed through a horizontal incision in the conjunctiva, as in the first stage for advancement. The tendon is defined in the wound and a strabismus hook passed beneath it; its middle portion is isolated and two silk sutures, with a needle at each end, are passed through it and tied.

Second step. The speculum is removed and the eyelid everted and pulled upward by means of a retractor or two silk stitches passed through the substance of the lid. Starting from the middle of the wound the conjunctiva of the fornix is divided backwards and the under surface of the tarsal plate is exposed.

Third step. An incision is carried through the tarsal plate parallel to and near its upper border well into the substance of the orbicularis muscle on the other side. The needles on each end of the doubly armed sutures holding the isolated portion of the superior rectus muscle are passed through the hole in the tarsal plate and are carried downwards between the orbicularis muscle and the tarsal plate to near the lid margin, where they are brought out through the skin and tied over a piece of drainage tube. The conjunctival wound is closed by sutures.

Complications. Ulceration of the cornea is more likely to occur after those operations in which the lid is much over-retracted, such as Hess’s, Panas’ operation, and the advancement of the levator palpebrÆ. It usually affects the lower corneal margin and may be merely roughening and opacity of the epithelium or deep septic ulceration. If the ulceration be severe, the sutures holding the lid in position should be taken out and the eye treated as for corneal ulceration; on the other hand, slight abrasion of the epithelium will often heal without taking out the sutures.

Sepsis. The difficulty of keeping the wound aseptic after these operations is considerable, and not infrequently inflammation may take place; provided it does not go on to suppuration, the final result is improved thereby; should suppuration take place the sutures must be removed.

CHAPTER IX
OPERATIONS FOR ENTROPION, REPAIR OF THE EYELIDS
TRICHIASIS, AND ECTROPION

The operations commonly performed for entropion and trichiasis are of three types:—

1. Operations for the destruction of the individual hair follicles.

2. Rectification of a faulty curvature of the tarsus.

3. Transplantation of the lash-bearing area.

ELECTROLYSIS

Indications. In cases of trichiasis where a few eyelashes turn in on the conjunctiva or cornea they may be removed by this method.

Operation. A platinum electrolysis needle (negative pole) is passed alongside each lash into the follicle, and a constant current of about 5 milliampÈres allowed to pass for a half to one minute. There is usually some bubbling seen around the hair, which will fall out when touched if the operation has been properly performed. It is a comparatively painless operation and free from scarring if the hair follicle be not penetrated by the needle. This is best ensured by using a rather blunt point and not turning on the current until the needle is in position.

SKIN AND MUSCLE OPERATION

Indications. This operation is especially suitable for the senile or spastic forms of entropion of the lower lid, not infrequently seen after much bandaging in old people, which has failed to yield to treatment by pulling the lid outwards with strapping.

Instruments. Straight scissors, fixation and entropion forceps.

Operation. Adrenalin and cocaine solution is injected beneath the skin of the lower lid. A horizontal strip of skin as near the lid margin as possible is seized with the entropion forceps (Fig. 144) and removed by one snip of the scissors. The underlying orbicularis muscle is then removed over the same area and the wound closed with sutures. If a more pronounced result is required, a vertical piece of skin is removed at the outer end of the previous wound and allowed to granulate.

RECTIFICATION OF A FAULTY CURVATURE OF THE TARSUS

DIVISION OF THE TARSAL CARTILAGE FROM THE CONJUNCTIVAL SURFACE OF THE LID

Burow’s operation. The object of this operation is to restore the inverted tarsal edge of the lid by dividing the cartilage from the conjunctival surface, and it is especially suitable for those cases in which the whole of the upper lid border is buckled inwards to a slight extent owing to cicatricial contraction such as is often seen in the late stage of trachoma and occasionally as a congenital deformity in the lower lid.

Instruments. Lid spatula and Beer’s knife.

Operation. The operation is performed under a general anÆsthetic.

First step. The lid is everted over the lid spatula. An incision is then made along the white line, the result of cicatricial contraction, seen in the sulcus subtarsalis about 3 millimetres behind the upper lid margin; the incision should extend throughout the whole length of the lid and completely divide the tarsal plate. Care should be taken that the cut is made at right angles to, and not obliquely through the tarsal cartilage. When the eyelid is replaced the lid margin will be found to lie in its proper position.

Second step. If the skin of the upper lid be very lax or a more marked result be desired an elliptical piece of skin may be removed from the upper lid above the site of the underlying incision and the wound stitched together so as to exaggerate the outward curve of the lashes; this is usually desirable in most cases, since there is a strong tendency for the lid to become inverted again owing to the contraction of the wound, which is allowed to heal by granulation.

DIVISION OF THE TARSAL CARTILAGE FROM THE ANTERIOR SURFACE OF THE LID

Streatfield’s operation. The object of this operation is the removal of a wedge-shaped piece of the tarsal cartilage directly behind the lashes throughout the length of the upper lid. The division is made from the outside, and the wound is subsequently sutured so that the margin of the lid is everted. It has the advantage over the previous operation that no granulating area is left to cicatrize; it is especially suitable for cases in which there is much buckling inwards of the upper tarsal plate, and yields most satisfactory results even when the deformity is great.

Instruments. Beer’s knife, fixation forceps, lid clamp (Fig. 145), spatula, and sutures with a glass bead threaded on each.

Operation. The operation is performed under a general anÆsthetic.

First step. The lid is fixed in a clamp. The surgeon makes an incision in the skin directly above the lash-bearing area throughout the whole length of the lid and parallel to its margin. A second incision is made about 3 millimetres above this, and its extremities are curved downwards to join the first. The piece of skin and orbicularis muscle between them is removed and the tarsal cartilage is exposed.

Second step. A wedge-shaped strip is removed from the tarsal cartilage throughout the whole length of the lid, the apex of the wedge reaching just through the cartilage, but not the conjunctiva on its under surface.

Third step. Mattress sutures are then inserted. Each suture should have a needle at either end. A bead may be threaded on the stitch to prevent it cutting into the lid margin. The needles are passed from the margin of the lid directly above the eyelashes, about 3 millimetres apart, and brought out through the lower margin of the wound. They are then passed from within outwards through the tarsal plate and the upper margin of the wound, being brought out through the skin about half an inch above it and tied (Fig. 146). A few points of suture in the skin may be added if necessary.

THE TRANSPLANTATION OF THE LASH-BEARING AREA

Arlt’s operation. Indications. The operation is suitable for cases of trichiasis in which part or the whole of the lashes of the upper lid turn inwards and rub on the surface of the cornea.

Instruments. Beer’s knife, forceps, scissors, sutures, lid clamp.

Operation. First step. A lid clamp is applied to the upper lid. An incision is made in the intermarginal line and the tarsal cartilage is split behind the lash-bearing area for a depth of about 5 millimetres throughout the whole extent of the lid (Fig. 147).

Second step. An incision through the outer surface of the lid above the lashes is made to meet the other at right angles, so that the lashes are carried on a band of tissue attached at each end.

Third step. A semilunar piece of skin is then removed by a curved incision above the last, joining it at the outer and inner ends, and the band carrying the lashes is stitched to the upper margin of this incision; the line of the incision along the intermarginal zone behind the lashes is allowed to heal by granulation. The subsequent contraction caused thereby pulls down the band carrying the lashes to a certain extent. It is, therefore, desirable to pull the band of lashes upwards at the time of operation to a greater extent than is required for the final result in order to overcome this tendency for the condition to re-form as a result of cicatricial contraction of the granulating area. In order to obviate the cicatricial contraction some surgeons cover the area with a graft of mucous membrane.

ECTROPION OPERATIONS

Ectropion may affect the upper lid, but it occurs far more frequently in the lower. Operations undertaken for its relief vary very considerably for the following reasons:—

1. The cause of the ectropion. The active or cicatricial form requires different and more extensive operations than the passive form, such as occurs after facial paralysis, senile ectropion, or that occurring after blepharitis.

2. The degree of ectropion, whether it is partial, affecting merely the lid margin; or complete, affecting the whole lid.

Ectropion of the lower lid is always accompanied by epiphora, owing to the want of application of the canaliculus to the lacus lachrymalis. The canaliculus is also apt to become obliterated as the result of marginal blepharitis. Before undertaking any of the operations described below this condition must be remedied, either by dilating the canaliculus or by slitting it inwards for a short distance (see p. 290), otherwise, even if the operation be successful in restoring the deformity, the overflow of tears causes the patient to pull down the lower lid constantly in wiping them away, and this tends to reproduce the condition.

After many of the operations a temporary tarsorrhaphy is required to keep the lid in position during the process of cicatrization. The temporary bands produced by this operation are so placed on either side of the cornea as not to interfere with vision altogether. Canthorrhaphy is also desirable in some cases, especially when the ectropion affects the outer end of the lid.

The deformity to be overcome in ectropion is not only the turning outwards of the lid; in cases which have existed for any length of time the lid border becomes permanently elongated and requires to be shortened before it will keep in position. The exposed conjunctiva, especially in cases secondary to blepharitis, becomes thickened near the lid margin, and, though it may regain a more or less normal appearance after the lid has been replaced in position, the thickened margin frequently prevents the proper apposition of the canaliculus, and in these cases it is often desirable to remove this tissue (see Fergus’s operation).

OPERATIONS FOR PASSIVE ECTROPION

Snellen’s suture method. The object of this operation is to pass sutures through the lower lid from rather above the apex of the eversion out on to the cheek, so that when tightened they draw the lid up into position. The inflammation which occurs around the sutures leaves a permanent band of cicatricial tissue which continues the action of the sutures after they have been removed.

Indications. Snellen’s sutures are useful in moderate degrees of the senile form of ectropion in which there is not much thickening of the lid margins. Although the results are satisfactory in carefully selected cases, the operation is attended with considerable pain and is very liable to be followed by a marked inflammation along the stitch tracks; indeed, the final results are not very satisfactory unless some inflammation does occur.

Instruments. Two, and occasionally three, sutures of thick silk armed at either end with 3-inch straight needles.

Operation. A general anÆsthetic is desirable, although not absolutely necessary. The needles belonging to each stitch are inserted about 3 millimetres apart, from the conjunctival surface above the apex of the everted lid, and after passing deeply near the lower cul-de-sac on the posterior surface of the tarsus, they are brought out on the cheek low down and tied over a piece of drainage tube. The loops, when drawn tight, draw the lid margin inwards (Fig. 148). Two of these sutures are usually required at such a distance apart as to divide the lower lid into thirds. They should be left in place some two or three weeks.

Fergus’s operation. This operation consists in excision of the apex of the everted lid.

Indications. It is a most satisfactory operation for cases in which the lid margin has undergone thickening from blepharitis and for cases of slight senile ectropion.

Instruments. Beer’s knife, fixation forceps, and sharp-pointed scissors.

Operation. Under adrenalin and cocaine, a little solid cocaine being rubbed into the conjunctiva. A strip of thickened conjunctiva and subconjunctival tissue corresponding to the apex of the eversion is removed along the whole length of the lid (Fig. 149). The wound produced is united with sutures. The pull of the conjunctiva, which is stitched to the lid margin, is sufficient to draw that structure inwards into position.

Kuhnt’s operation (modified). The object of this operation is the removal of a triangular piece of conjunctiva and tarsal cartilage from the centre of the lower lid, the base of the triangle being placed towards the free margin of the lid so as to produce sufficient shortening of the elongated lid border to hold it in position. The skin of the lid is also shortened by removal of a triangular portion at the external canthus.

Indications. It is especially suitable for cases of paralytic ectropion (lagophthalmos) and severe degrees of senile ectropion of the lower lid.

Instruments. Lid spatula, Beer’s knife, scissors, forceps and sutures.

Operation. A general anÆsthetic is required.

First step. The lower lid being held between the finger and thumb is split in the intermarginal line along the outer two-thirds of its length, and the incision deepened till the lower border of the tarsus is reached. For this purpose some surgeons use a broad keratome instead of a Beer’s knife.

Second step. A triangular piece of conjunctiva and the whole thickness of the tarsus are removed from the centre of the lower lid, the base of the triangle being towards the free margin of the lid and being of sufficient length to produce the shortening desired to bring the lid up into position (Fig. 150); this is best estimated by making the incision forming the inner limb of the V and overlapping the outer flap until the lid is pulled upwards into position.

Third step. A triangular piece of skin with its base upwards is excised from the outer canthus in the following manner (Fig. 150). An incision is made outwards and slightly upwards from the canthus. A vertical incision, twice the length of the preceding one, is made directly downwards from its outer end to the outer canthus, and the lower end of this is then joined by an incision completing the triangle. The skin marked out by this triangle is then dissected up and removed. The undermining of the flap formed by the skin and subcutaneous tissue of the outer part of the lid is continued inwards until the flap, when pulled up into place, restores the lid to its proper position.

Fourth step. The lid is sutured into position. The V-shaped wound in the conjunctiva and tarsus is sutured, the knots being placed on the conjunctival surface with the exception of the suture at the lid border, which is turned the other way, the ends being brought out through the skin of the outside flap, after the latter has been sutured in position, and the two ends tied over a bead. The outside flap of skin is brought up into position by a suture at its upper angle. As the result of this a few eyelashes project beyond the outer canthus; these should be excised. Additional sutures to hold the flap in position are then inserted. Both eyes should be bandaged after the operation, otherwise the knots in the conjunctiva may rub on the cornea.

Argyll Robertson’s operation. The operation aims at shortening the border of the lower lid and at the same time pulling it upwards into position by means of a strap of skin and subcutaneous tissue cut from the outer side, the attached end of the strap being formed by the outer portion of the skin of the lower lid.

Indications. It is especially useful for paralytic cases, and as a subsequent measure to the VY operation described below for cicatricial ectropion. The operation is likely to be successful if a marked reduction in the deformity is effected by pulling the skin at the side of the outer canthus upwards.

Instruments. Scalpel, dissecting forceps, artery forceps, scissors, sutures.

Operation. First step. An incision, 2 millimetres below the lid margin and opposite its outer third, is carried through the skin parallel to the border of the lower lid outwards to the canthus; having reached this point the direction of the incision is changed and it is carried more upwards and outwards till the upper end is on a level with the upper orbital margin. The incision is then carried outwards for about 6 millimetres and again downwards, slightly diverging from the former incision, until it is opposite the lower orbital margin. This flap of skin and subcutaneous tissue is dissected up from above downwards (Fig. 152).

Second step. A V-shaped portion is removed from the margin of the lower lid near the outer canthus, the base of the V being of sufficient length to produce the shortening of the lid required when the edges of the incision are brought together.

Third step. The strap of skin is pulled upwards to the extent required to replace the lid in position, and sutured there. The raw area must be enlarged upwards so as to accommodate the upper end of the strap. It is better to do this than to shorten the strap, since a firm hold is thus obtained (Fig. 153).

OPERATIONS FOR THE ACTIVE OR CICATRICIAL FORM OF ECTROPION

The numerous operations which have been devised for this condition are divided into two groups: (1) the transplantation of flaps in the neighbourhood of the lesion, and (2) the grafting of skin flaps from other parts of the body. The latter method is usually only undertaken when the employment of flaps from the neighbourhood of the deformity is impossible, as the cicatricial contraction which follows the grafting of flaps from other parts of the body is usually attended by considerable shrinkage and therefore does not yield such satisfactory results.

BY THE TRANSPLANTATION OF FLAPS

VY operation (Wharton Jones). Indications. This operation is useful for cases of ectropion affecting the middle parts of the lower lid, generally due to a scar such as would result from a healed sinus after tuberculous periostitis of the lower orbital margin.

Instruments. Dissecting forceps, scalpel, artery forceps, sutures.

Operation. The operation is performed under a general anÆsthetic. A V-shaped incision, with the apex downwards, is made to embrace the whole margin of the lower lid. The upper ends of the V should skirt the outer and inner canthus and roughly lie over the lower orbital margin, enclosing the scar, the apex of the V falling rather below the orbit. The incision should include the skin and subcutaneous tissue. The V-shaped flap is dissected up and the lid liberated from the underlying scar tissue. The incision is then sewn up in the form of a Y (Fig. 155). Temporary tarsorrhaphy (see p. 266) is always desirable. Subsequent shortening of the lid margin by the Argyll Robertson method is sometimes necessary.

Denonvillier’s operation. This procedure is useful to remedy an ectropion of the outer portion of the lower lid by the transposition of flaps at the outer canthus.

Instruments. Scalpel, dissecting and artery forceps, scissors, sutures.

Operation. The operation is performed under a general anÆsthetic.

First step. An oblique incision (Fig. 156), starting from below the inner end of the deformity, A, is carried outwards and slightly upwards for 12 mm. to the point B. From the point B a curved incision B C is carried upwards to and along the orbital margin. This marks out a triangular flap. From C the incision is carried outwards and downwards in a curved direction to D, which is situated about 2 cm. from the external canthus, thus marking out another triangular flap B C D.

Second step. Both flaps are dissected up, and, when all bleeding has ceased, the apices of the triangles are transposed and sutured in position, the incision thus forming a Z-like figure (Fig. 157). A canthorrhaphy is generally required.

Fricke’s operation. This has for its object the transplantation of flaps from the side of the forehead or face into the lid to remedy a loss of tissue resulting from operation or cicatricial contraction.

Indications. The operation is usually performed for cicatrices about the upper lid, the flap being turned down from the side of the forehead. A flap may be turned in from the inner side in addition if necessary. The operation may also be applied to ectropion of the lower lid.

Operation. When planning the flaps the following points must be taken into account:—

(i) The flap must be cut so that its base contains the main blood-supply of the part made use of.

(ii) It should be at least one-third larger than the area to be covered. This is estimated by cutting a piece of protective the size of the area to be covered and laying it on the skin before the flap is cut.

(iii) The base of the flap should consist of a considerable amount of subcutaneous tissue as well as skin, but the apex may be little more than the skin itself.

(iv) The direction of the subsequent contraction should be taken into account so as to assist the final result.

First step. The lid is first freed by dividing all the cicatricial bands, or, if only a small cicatrix be present, by excising that. The lid is then pulled down into position and put fully on the stretch. This is best performed by stitching the margin of the lid to the cheek.

Second step. The flap is marked out at least one-third larger than the size required to cover the raw area. The base of the flap should be placed a little below the raw area to be covered, so that the rotation of the flap into position is easily performed without danger of constriction to the base (Fig. 158).

Third step. The flap having been raised and all bleeding stopped, it is rotated and sutured in its new position, the wound made by the removal of the flap being brought together by sutures or, if it be too large for this, covered by skin grafts (see Vol. I, p. 670).

BY THIERSCH’S SKIN-GRAFTING METHOD

Indications. As has already been pointed out, this method is not so satisfactory as the method by flaps described above, but it is frequently the only one available when the surrounding skin has been destroyed, as after extensive lupus of the face.

Instruments. Scalpel, forceps, skin-grafting razor, probes.

Operations. First step. As for the previous operation.

Second step. Grafts are cut from a situation free from hairs, such as the inner side of the upper arm (see Vol. I, p. 671).

Third step. After all bleeding has been stopped, the grafts are applied, straightened with probes, and pressed firmly down on to the raw surface. The edges of each graft should slightly overlap the one next to it. Great care should be taken in applying the dressings not to disturb the grafts (see Vol. I, p. 673).

If the whole thickness of the skin be used (Wolff’s method), care should be taken to see that the under surface is free from fat.

THE REPAIR OF LARGE LOSSES OF SUBSTANCE FROM THE EYELIDS

Losses of portions of the lid margins usually result from operations for malignant growths. When the loss is in the upper lid, some modified form of Fricke’s operation is the best method of remedying the deformity. When a large area is to be covered, transplantation of a flap from the arm by the Tagliacotian method has to be performed (see Vol. I, p. 679).

Fricke’s operation is also applicable to the outer portion of the lower lid. When the inner end of the lower lid is affected, De Vincentiis’ operation yields satisfactory results. When the whole lower lid has been lost, a modified Dieffenbach’s method with the use of the ear cartilage is indicated.

De Vincentiis’ operation. The operation aims at shifting the remains of the lid bodily inwards to cover the gap left by the removal of the growth.

Instruments. Scalpel, dissecting forceps, artery forceps, scissors, sutures.

Operation. First step. The portion of the whole thickness of the lid together with the growth is excised by a V-shaped incision (Fig. 159).

Second step. The outer canthus and orbito-tarsal ligament are divided with the scissors. The incision is then carried outwards and upwards with a scalpel, in a line with the lower margin of the lid, the incision being long enough to free the lower lid sufficiently to slide it inwards and to enable the edges of the V-shaped wound to be united (Fig. 160).

Dieffenbach’s operation (modified with the use of ear cartilage). This operation consists in shifting inwards a flap of skin and subcutaneous tissue derived from the outer side of the face to take the place of the eyelid which has been removed, the conjunctiva and tarsal plate being represented by a piece of skin and cartilage taken from the posterior surface of the ear and stitched to the inner surface of the flap.

Operation. First step. The growth, together with the eyelid, is first removed by a V-shaped incision, the base of the V being formed by the margin of the lower lid.

Second step. An incision is carried directly outwards from the external canthus. The length of this incision should be 1¼ times the length of the lid margin. An incision is then carried downwards from its outer end parallel to the outer limb of the V by which the lower lid has been excised. This flap is then raised freely (Fig. 161).

Third step. The ear is turned forward and a semilunar portion of the skin is marked out and deepened down to the cartilage. The base of this semilunar portion should be equal in length to the upper margin of the flap that is to form the new lid (Fig. 162). The skin is then dissected up for about 3 millimetres from the crescentic part of the incision back towards the straight one forming the base of the semilune. When this part of the skin has been raised the cartilage is divided, first by a curved incision, 3 millimetres behind that through the skin, and then along the straight incision joining the ends of the curved one. It is separated from the skin on the anterior surface of the ear, and the semilunar piece of skin and cartilage is thus removed. The portion of cartilage removed with the skin is smaller than the latter; the two portions coincide in length along their straight margins, but the depth of the crescent of cartilage is considerably less than that of the skin (Fig. 162). The cartilage is usually too thick to form the new tarsus and must be pared down until the right thickness is obtained. It is then applied to the inner surface of the flap to form the new lid, the skin surface being directed inwards to help to form the lower conjunctival sac. It is fixed firmly by sutures at its margin, which are passed through the whole substance of both flaps, and tied on the outer surface of the new lid.

Fourth step. The flap forming the new lower lid is sutured in position. The surface from which the flap is taken is closed as far as possible with sutures after undermining the edges, any raw area being covered by skin grafts taken from the arm.

CHAPTER X
OPERATIONS UPON THE LACHRYMAL APPARATUS

Operations upon the lachrymal apparatus are divided into—

The majority of operations are undertaken for the relief of obstruction to some portion of the canal which leads from the conjunctival sac to the nose, obstruction to which causes an overflow of tears (epiphora)—a condition which must be distinguished from hypersecretion (lachrymation).

The obstruction may occur in any part of the canal, that is to say, in the puncta, canaliculi, lachrymal sac or duct; and it is most important to determine the cause and position of the obstruction in every case before undertaking an operation for its relief. Hence it need hardly be said that the nose should be carefully examined in every case unless the cause is obvious. The operations are divided into two classes:—

1. Those which are undertaken for the relief of the obstruction.

2. Those which are undertaken for the obliteration of the canals.

Except under exceptional circumstances, the latter operations are only undertaken when a cure cannot be brought about by the former.

The presence of a septic focus, such as a distended lachrymal sac, apart from the irritation and increased lachrymal secretion caused thereby, is a source of grave danger to the eye if not relieved, as it is a frequent cause of serpiginous corneal ulceration.

OPERATIONS FOR THE RELIEF OF LACHRYMAL OBSTRUCTION

DILATATION OF THE CANALICULUS

Indications. (i) Contraction of the puncta following marginal blepharitis, especially when associated with ectropion.

(ii) Preparatory to syringing or probing.

(iii) To dilate a stricture of the canaliculus.

Instruments. Nettleship’s canaliculus dilator (Fig. 163).

Operation. The operation is performed under adrenalin and cocaine, a little solid cocaine being rubbed in over the canaliculus.

The lid is slightly everted and put on the stretch by pulling it downwards and outwards with the thumb. The depression caused by the punctum is seen on the top of a small elevation. The point of the dilator is entered vertically into the punctum and then turned parallel with the lid margin and passed onwards with a steady pressure. At the same time it should be rotated between the finger and thumb, until the inner bony wall of the lachrymal sac is felt. The only difficulty which may be experienced is in entering the dilator into the punctum, owing to the small size of the latter. For this reason the fine point of Nettleship’s dilator is more suitable than the form modified by Lang. Even Nettleship’s dilator is too large in a few cases, and here a large sharp-pointed pin is sometimes of use in defining the punctum before using Nettleship’s dilator.

SLITTING THE CANALICULUS

Indications. To enlarge the punctum and direct the entrance to the canaliculus inwards. This is especially desirable before ectropion operations and for the removal of concretions (leptothrix) from the duct. In former days the canaliculus used to be slit with the idea of passing very large probes down the lachrymal duct; this has now been abandoned, since slitting the canaliculus throughout its whole length, as is required for this treatment, does away with the capillary attraction.

Instruments. Dilator, canaliculus knife (Fig. 164), straight iris forceps, sharp-pointed scissors.

Operation. It is usually performed on the lower canaliculus. The eye is cocainized as in the previous operation and the patient is made to look up.

First step. The canaliculus is first dilated. The knife is inserted for a short distance with the handle parallel to the lid margin. The lower lid being held on the stretch by the thumb, the handle of the knife is raised towards the brow, thus dividing the canaliculus. The blade of the knife should be directed upwards and slightly backwards.

Second step. As the lips of the wound are liable to reunite, it is better to remove the posterior lip of the groove. This is performed by seizing the latter with forceps and dividing it with scissors. The entrance to the canaliculus should be kept open by means of the dilator passed twice a week for a month.

SYRINGING THE LACHRYMAL DUCT

Indications. (i) To test whether the lachrymal canals are patent.

(ii) By constantly cleansing the sac and washing away all purulent discharge the mucous membrane may regain a more healthy condition, and so an obstruction due to an alteration in the mucous lining may be relieved. In cases with a purulent discharge a small quantity of protargol (10% solution) may be left in the sac after syringing.

(iii) The injection of adrenalin and cocaine into the sac before its excision.

Operation. The eye is cocainized and the patient made to look up. The punctum is everted by pulling down the lower lid. The canaliculus is then dilated. The nozzle of the lachrymal syringe (Fig. 165) should be passed until it is felt to impinge on the bony outer wall of the sac. Withdraw the syringe slightly and apply gentle pressure to the piston. The fluid will either regurgitate through the upper canaliculus or, if the duct be patent, pass down into the nose and so into the throat.

Complications. If too forcible syringing be used extravasation of the fluid may take place. This is accompanied by pain and swelling in the lachrymal region. It usually subsides under hot fomentations, but suppuration and even cellulitis of the orbit have been known to occur.

PROBING THE LACHRYMAL DUCT

Indications. (i) In cases of congenital lachrymal obstruction due to dÉbris blocking the duct.

(ii) When syringing has failed to bring about a cure, a probe may be passed once or twice to see if dilatation causes any improvement. It is especially useful in children.

(iii) As a preliminary to the insertion of styles.

Various forms of probes are employed, those of Bowman being in general use. Too fine a probe should not be used, otherwise a false passage is liable to be made.

Operation. This is performed under adrenalin and cocaine, which should be injected into the lachrymal sac.

The lower punctum is dilated and the probe passed parallel to the lid margin until it is felt to impinge upon the lachrymal bone. Keeping the point applied to the bone, the handle of the probe is rotated upwards through rather more than a quarter of a circle and passed by a gentle pressure downwards and slightly outwards into the duct, keeping the point of the probe close to the bone the whole way. The direction of the probe after entering the duct should be downwards, outwards, and backwards in the direction of the first molar tooth on the same side. The backward direction of the duct is much more marked in young children than in adults.

Complications. A false passage may be made into the antrum of Highmore. If such an accident should occur, no further attempt should be made to pass a probe for a few days until the wound has healed.

THE INSERTION OF STYLES

A few surgeons still insert styles into the lachrymal duct with the idea of continuous dilatation. The hollow styles used by Bickerton are the ones most frequently employed.

Instruments for dilating, slitting the canaliculus, probing, and styles. Also Stilling’s knife.

Operation. A general anÆsthetic is desirable.

First step. The canaliculus is dilated and slit up, the posterior lip being removed (see p. 29).

Second step. The duct is dilated by probing (vide supra) or enlarged by passing Stilling’s knife down it.

Third step. A style is passed down the dilated duct. The lower end of the style should rest upon the floor of the nose, otherwise there is a tendency for the style to slip into the duct and disappear. Care should be taken that the upper end does not rub on the globe. Styles should generally be left in position from three to six months. A style should at first be made of lead wire and moulded until a suitable pattern is obtained, from which a hollow gold style can be made subsequently.

Complications. 1. Dacrocystitis may follow the insertion of a style, which should then be removed until the inflammation has subsided.

2. The style may slip down the duct. If this should occur an attempt should be made to grasp it through the slit canaliculus. The lower end may present in the nose and the style can then be withdrawn with forceps. Occasionally styles lodge in the antrum of Highmore, in which case they must be removed after localization by the X-rays through an opening from the mouth above the canine tooth.

OPERATIONS FOR THE OBLITERATION OF THE CANALS

When syringing and probing have failed to relieve the lachrymal obstruction, one of the following operations for the obliteration of the lachrymal passages may be employed.

OBLITERATION OF THE CANALICULI

Indications. In cases of lachrymal obstruction in which an immediate operation upon the globe is required.

Operation. Under cocaine. Fine sutures armed with a small curved needle are passed beneath both the upper and lower can[al]iculus and tied so as to include them in the ligature. Permanent obliteration may be caused by the destruction of the lining membrane with the actual cautery.

EXCISION OF THE LACHRYMAL SAC

Indications. (i) For mucocele in cases of lachrymal obstruction which have failed to yield to other treatment.

(ii) In all cases of tuberculous disease of the sac.

(iii) For a recurrent lachrymal abscess after subsidence of the acute inflammation.

(iv) For hypopyon ulcer associated with lachrymal obstruction.

(v) Before operation on the globe in cases of lachrymal obstruction.

(vi) For lachrymal fistula.

Instruments. Small scalpel, forceps, Muller’s speculum (Fig. 166), Axenfeld’s retractor (Fig. 167), straight scissors, horsehair sutures.

Operation. HÆmorrhage is the most troublesome part of this operation; it is best controlled by injecting adrenalin (made from the dried gland, ?j, and ?j of water) and cocaine, 10%, into the sac a quarter of an hour before operating. Swabs on the end of a glass rod dipped in adrenalin and cocaine may also be used during the operation. A general anÆsthetic is desirable, but many surgeons perform the operation under local anÆsthesia, produced by injecting 5% cocaine with 1 in 1,000 adrenalin into the tissue surrounding the sac; but the latter plan has the disadvantage that the mixture may cause severe toxic effects, and the patient usually experiences some pain while the upper portion of the incision is being made and the lower end of the sac is being divided.

First step. The internal tarsal ligament is first defined by putting the lids on the stretch. An incision should be made, 15 millimetres in length (5 millimetres of which should fall above the tarsal ligament), backwards and inwards directly over the lachrymal sac. Muller’s retractor is then inserted to retract the wound laterally, the hooks being made to engage the margins of the incision by means of forceps. The superficial fascia and the fibres of the orbicularis muscle are then divided. The internal tarsal ligament in the upper part of the wound, together with the glistening deep fascia, is exposed and divided carefully so as not to injure the lachrymal sac, which is found directly beneath it (Fig. 168).

Second step. With scissors the sac-wall is then separated from the deep fascia which encloses it, first externally and then internally, the canaliculi being divided. Axenfeld’s retractor is then inserted in the longitudinal axis of the wound (Fig. 167). The middle of the sac is grasped with forceps and pulled forward, and the top of the sac is defined and detached. This is frequently difficult owing to the troublesome hÆmorrhage which often occurs. The sac is pulled well forward, and the posterior wall is separated, the neck of the sac being divided as far down the duct as possible by means of scissors. A large probe is passed down the duct into the nose. Some surgeons remove the periosteum of the lachrymal bone as well as the sac, which is unnecessary. The wound is closed by three sutures, the middle one including the divided ends of the internal tarsal ligament. A firm dressing should be applied so as to keep the walls of the cavity in contact. In tuberculous cases it is desirable to curette the lower end of the duct after removal of the sac. The stitches are removed on the seventh day.

Complications. These may be immediate or remote.

Immediate. 1. Inability to find the sac. This may happen to a beginner, and is generally due to the fact that the dissection is carried too much inwards towards the nose. It should not occur if the guides to the sac carefully borne in mind, namely, the internal tarsal ligament and, on the inner side, the lachrymal crest, which can easily be felt with the finger or forceps in the wound.

2. Opening the conjunctival sac. This may take place when dividing the canaliculi. It is more likely to occur if the deep fascia has been imperfectly divided before carrying out the dissection to the inner side. As a rule the opening heals readily.

3. Opening of the orbit, due to the division of the fascia attached to the posterior lip of the lachrymal groove. It is recognized by the fact that orbital fat presents in the wound, and for this reason it makes the operation more difficult. It is most likely to happen when the lower end of the sac is being divided. It lays the orbit open to the possibility of septic infection. The internal rectus has been divided, no doubt due to the fact that the fascia, which passes from the outer surface of this muscle, is attached to the posterior lip of the lachrymal groove, and the muscle has been thereby pulled up into the wound; with ordinary caution such an accident is impossible.

4. Injuries to the cornea. Corneal abrasions by the clumsy insertion of retractors may lead to severe corneal ulceration.

Remote. 1. Epiphora. Normally the lachrymal secretion is largely removed from the conjunctival sac by a process of evaporation. It is only when the hypersecretion of tears takes place that the lachrymal apparatus is called much into use. As a rule, patients who have had the lachrymal sac excised do not complain of epiphora, except in a cold wind. Occasionally this epiphora may be so troublesome that removal of the palpebral portion of the lachrymal gland is desirable for its relief. There is no fear of the conjunctival sac becoming dry after this operation, since there are numerous accessory lachrymal glands (glands of Waldeyer and Krause) opening on to the superior fornix.

2. A sinus. The wound may break down and a sinus may form at the site of the incision. These cases are nearly always of tuberculous origin and not infrequently have underlying bone trouble. They can usually be made to heal by the use of iodoform and scraping.

3. Recurrence of the mucocele or lachrymal abscess. Occasionally the mucocele may re-form, or an abscess result after removal of the sac. This is due either to a piece of sac-wall being left behind, or to the relining of the cavity with epithelium from the cut end of the duct. It is particularly liable to occur in cases of a tuberculous nature. Firm pressure with the dressings after the operation is the best method of preventing the cavity relining with epithelium. If the condition has arisen, the pseudo-sac should be excised.

OPENING A LACHRYMAL ABSCESS

Indications. Lachrymal abscess is due to an inflammation around the sac-wall through which infection of the cellular tissue has taken place. The abscess should not be opened until pus is present, as even considerable swelling and oedema will often subside without suppuration; this is usually about the end of the third day. Further, if the opening be made too soon, the inflammation takes considerably longer to subside.

Instruments. Beer’s knife, forceps, and probe.

Operation. Usually performed under gas. An incision is made over the lachrymal sac and is carried downwards and inwards to the bone by a single puncture of the knife. The pus is evacuated, and the cavity stuffed with gauze, which should be changed daily for the first three days. Hot fomentations should be applied. As soon as the swelling has subsided, the lachrymal obstruction should be treated by one of the methods previously described.

OPERATIONS UPON THE LACHRYMAL GLAND

REMOVAL OF THE PALPEBRAL PORTION

Indications. For obstinate epiphora after removal of the lachrymal sac.

Instruments. Fixation forceps (two pairs), two sharp hooks, strabismus scissors, suture.

Operation. Usually performed under adrenalin and cocaine.

First step. The upper lid is doubly everted. The eversion is best carried out by holding the singly everted lid between forceps and then re-everting it; the forceps are then given to an assistant to hold. With a syringe a few drops of 5% cocaine are injected through the conjunctiva into the area to be operated upon.

Second step. The gland is seen beneath the conjunctiva at the outer part of the upper fornix, seized with forceps, and drawn forwards. A horizontal incision is made with scissors through the conjunctiva, which is dissected backwards. The edges of the wound are then held apart by means of sharp hooks (Fig. 170).

Third step. The gland, which is seen as a nodule, is drawn forward with forceps. By means of the scissors the gland is separated from its attachments along its whole length, starting on the inner side, the wound being subsequently closed with a few points of catgut suture.

REMOVAL OF THE ORBITAL PORTION

Indications. It is usually undertaken for tumours (endotheliomata, &c.) and retention cysts.

Instruments. Knife, artery and dissecting forceps, retractors, ligatures.

Operation. Performed under a general anÆsthetic.

First step. An incision, three inches long, is made through the skin immediately below the outer third of the orbital margin. The underlying orbicularis palpebrarum is divided, and the orbital fascia covering the gland is defined and incised.

Second step. The gland is first separated from the periosteum of the depression in the bone in which it lies, and is drawn forward and carefully dissected out from the lid. The wound is then closed with sutures.

An abscess in the lachrymal gland should be opened by an incision similar to, but not so long as that in the above operation.

OPERATIONS UPON THE ORBIT

EXPLORATION OF THE ORBIT (KRÖNLEIN’S METHOD)

In this operation the bony outer wall of the orbit is divided above and below, and turned outwards so as to expose the orbital contents without interfering with the globe; the bony wall, being kept attached to the overlying tissue, can be replaced subsequently without fear of necrosis.

Indications. The operation is performed in cases of a suspected tumour of the orbit, which, if small and non-malignant, can be removed, the eye being left in situ. If doubt exists as to the nature of the tumour a piece can be removed and examined microscopically, either at the time of the operation or later. It is especially suitable for tumours of the optic nerve and for orbital cysts behind the globe.

Instruments. Scalpel, dissecting forceps, artery forceps, scissors, periosteum detacher, chisel and hammer, or preferably, a motor rotary saw, and retractors.

Operation. Performed under a general anÆsthetic.

First step. A slightly curved incision with the convexity forwards is made so as to expose the outer margin of the orbit and carried down to the bone. The periosteum is separated from the inner surface of the outer wall of the orbit by means of a periosteum detacher and divided horizontally, the finger is inserted, and the orbit explored. If a small tumour or cyst be found it can sometimes be shelled out through this incision without enlarging the wound further.

Second step. The eye and orbital contents are carefully protected with a large flat retractor. The bone is first divided above, by means of either a chisel or a saw. The upper incision should pass through the base of the external angular process of the frontal bone, and run backwards and slightly downwards to the posterior end of the spheno-maxillary fissure. The lower incision should run directly backwards from the lower orbital margin into the spheno-maxillary fissure. The triangular wedge of bone attached by its outer surface to the soft tissues in the temporal fossa is then forced outwards. In doing this care must be taken not to fracture the orbital wall anteriorly, otherwise the space to work in will be much reduced.

Third step. Consists in the removal of the tumour. Care must be taken to displace the external rectus to one side so as to avoid injury to it as much as possible. If the case should be one of an optic nerve tumour, for which the operation is most frequently performed, the optic nerve is divided close behind the globe. The tumour is freed from the surrounding ciliary nerves and the ophthalmic artery and brought up into the wound as much as possible. The optic nerve is then divided at the apex of the orbit and the tumour removed. The wound in the periosteum of the outer wall of the orbit is closed with a catgut suture, the bone, together with the soft parts, replaced in position and the skin wound closed by sutures. A drainage tube should be inserted for at least twenty-four hours.

Complications. 1. Proptosis. The operation is liable to be followed by great proptosis as the result of hÆmorrhage into the orbit. If the optic nerve has been removed, the globe may be dislocated forwards between the lids and come in contact with the dressings.

2. Corneal ulceration. As the cornea is frequently anÆsthetic from division of the ciliary nerves, ulceration is very liable to follow. It is, therefore, desirable in many cases to stitch the lids together after closing the skin wound.

3. Defective outward movement in the globe is of frequent occurrence, owing either to injury of the external rectus or the sixth nerve, or to involvement of them in the scar tissue. Stitching the periosteum together obviates the latter to a certain extent.

4. As the wound cicatrizes a certain amount of enophthalmos is very liable to result.

EVISCERATION OF THE ORBIT

Indications. This operation is usually performed for some form of new growth originating either in the eye or the orbit.

Operation. This may be modified (1) according to the position of the growth. In severe cases of rodent ulcer and sarcomatous growths, which involve the lids, it is desirable that the lids should be removed with the tumour; but in cases of tumour of the optic nerve, or disease situated far back in the orbit, and not involving the lids or conjunctiva, these structures may be retained, since a much better socket is thus obtained. (2) The nature of the growth. In simple tumours, such as nÆvi and some cases of arterio-venous aneurism which have failed to yield to other treatment, the incomplete method, in which the lids are retained, is all that is necessary, but in malignant cases they should be removed.

The Complete Method. An incision down to the bone is first made, completely encircling the orbital margin and including any growth that may be involving the skin. The periosteum is then separated completely, as near to the optic foramen as possible. Care must be taken in dealing with the periosteum over the lachrymal bone, as the bone is liable to be fractured and an opening made into the nose if undue force be used. The apex of the cone formed by the periosteum is divided, as far back as possible, with curved scissors, and the whole orbital contents are removed. The wound is packed with gauze, and skin-grafting is subsequently performed when the bone has become covered with granulations; this usually occurs about the end of the second week.

The Incomplete Method. The globe is first enucleated and the outer canthus divided. The lids are well retracted and an incision is carried down to the bone along the orbital margins. The periosteum is then stripped up from the walls of the orbit and the apex of the cone divided as far back as possible, as in the previous operation. The conjunctiva and outer canthus are then united with sutures. As a rule, skin-grafting is not necessary after this operation.

OPENING AN ORBITAL ABSCESS

Orbital abscesses should be incised where they point. In the upper lid care should be taken not to divide the levator palpebrÆ muscle; the incision should be placed well to one side. In making an incision over the inner side of the orbit care should be taken not to detach the pulley of the superior oblique. The cause of the abscess should be ascertained if possible. Suppuration in the ethmoidal sinuses coming through from the nose is the commonest cause, and should be treated appropriately (see Section V).