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Operations On The Orbit

Operations Upon The Conjunctiva, Cornea, And Sclera; Enucleation And Evisceration

THE conjunctiva, being a highly vascular membrane, heals rapidly after injury, and so loosely is it attached to the eyeball that an extensive loss may be replaced by dissecting it from the ball in the vicinity of a wound and drawing the flaps together by sutures. No evil effects are produced by this procedure, and in many cases no visible cicatrix remains. With the conjunctiva of the lids, however, less liberty can be taken, for a loss of the covering in this part may result in entropion, or perhaps a narrowing of the palpebral fissure. Large wounds of the conjunctiva, after thorough cleansing, should be closed by sutures, and require but little after treatment beyond cleanliness and protection by closing the lid.

Foreign bodies that pass through the conjunctiva are often difficult to remove on account of their entanglement in its meshes, and when a sharp instrument is used in the attempt to remove them subconjunctival hemorrhage generally occurs and obscures the field of operation. This is especially the case with grains of powder. The easiest method of dealing with such cases is to seize the body with forceps through the conjunctiva and snip off the entangling part, which causes but a small loss of tissue, and the Wound heals without leaving a scar. Grains of powder may be removed in this way when not too numerous; otherwise by electrolysis, as advised by E. Jackson (see also page 368).

Operations for Pterygium. The instruments used in these operations are a stop speculum, fixation and dissecting forceps, sharp pointed knife, small scissors, strabismus hook or probe, needles, needle holder, sutures, etc.

Operation. The anesthesia produced by cocain is sufficient for this operation, which is performed as follows: (1) Thorough removal of the corneal portion of the growth may be accomplished by shaving or dissecting it away with a sharp knife, and then scraping (Deschamps) off the remnants carefully, or by destroying them with the thermo cautery or by the application of pure carbolic acid (ALt). The method advised by Prince is also effective, and consists in grasping the growth with forceps near the corneal attachment, and by a series of slight jerks its roots or prolongations are withdrawn from beneath Bowman's membrane and even from between the corneal layers. No opacity remains when this is not carefully done, nor does the cornea become inflamed. Next to divulsion, the method of scraping the remnants from the cornea with a knife is preferable to the use of the cautery, as it is difficult to limit the action of the latter agent.

The next step is the disposition of the body of the growth. It may be separated at its borders from the conjunctiva proper as far back as the caruncle, and then excised; or it may be transplanted beneath the conjunctiva, loosened for this purpose either above or below, and fixed in its new position by a suture passing through the growth and its conjunctiva; or it may be split from apex to base, and one half transplanted above and the other below the opening, as advised by Knapp.

Others (Boeckmann, Hotz) advise unfolding and spreading out the growth after separating it from the cornea, first removing all Subconjunctival tissue; which is a most important step in any procedure. Boeckmann fastens the reposed conjunctiva (pterygium) to the head of the internal rectus muscle by a suture, and leaves the small triangular and denuded space near the cornea to heal by cicatrization, which, he contends, will prove an etrectual barrier to a future growth. Hotz, after reposition, covers the denuded spot with a graft taken, after the method of Thiersch, from the inner surface of the forearm or from behind the ear. This graft is cut slightly smaller than the area to be covered, and is placed in position with or without sutures according to circumstances.

Hobbs and others advise removal by means of the electro cautery. The growth is grasped by forceps near the cornea and lifted front the sclera; a curved needle or probe is passed beneath it, and then the neck is burned through with the cautery tip at a cherry red beat. The subconjunctival tissue is drawn out and excised, and the corneal end is scraped away or touched by the cautery. A cross stitch unites the conjunctiva near the cornea.
In all cases of removal or transplantation of the growth the conjunctiva should be loosened above and below and the edges closely united by sutures.

Dressing. After thorough cleansing with warm bichlorid or boric acid solution the eve is closed with sterilized gauze and cotton, which are held in place by any form of light bandage or by adhesive strips. The dressing may be renewed every day, and sutures should remain as long as they do Dot irritate. which is usually four to five days When removing sutures it is advantageous to have the eve under the influence of cocain for a sudden movement may cause the edges of the wound to separate. The simple introduction of the speculum may also cause this accident, so that whenever possible it is safer to have the lids held apart by the fingers of an assistant or even by the patient if be is not too nervous. After the removal of the sutures the dressing may be left off, and the eye, which is often quite sensitive, protected by tinted glasses.

Complications are rare after this operation. Ulceration of the cornea has occurred, and should be treated by the usual methods. Occasionally a small growth of granulation material springs from the wound, but it is easily snipped off with scissors or it may be contracted by astringent solutions. When the growth has extended well over the cornea a hazy spot is apt to remain after its removal. Piety urn often returns, and may, under ordinary circumstances, be again removed.

Symblepharon. Instruments necessary for the operation are stop speculum, vulcanite spatula, fixation and dissecting forceps, probe, scissors, sutures, needles, needle holder, etc.

For the simpler operations cocain may be used, but when the adhesions are extensive ether or chloroform is more satisfactory.

Operations. The slight forms of symblepharon known as Symblepharon anterius are easily cured by separating the attachment and preventing its recurrence by the frequent passage of a probe between the points. Pooley and Searles each report a case in which the formation of symblepbaron was prevented by using a glass or rubber shield which fitted over the globe between the lids, and which was left in place, except during short intervals for cleansing, until healing took place.

There are several methods of operating when adhesions are extensive and involve the fornix (symblepharon posterius). Symblepbaron is often incurable.

(1) The lid is separated from the ball and the dissection is carried well back to the fornix (Arlt). A suture armed with two needles is passed through the separated end; the needles are then passed from the bottom of the cul de sac through the lid to the cheek. Tightening the suture draws the flap down and brings the conjunctival surface next to the raw surface of the ball. The ends of the suture are tied over a piece of cork or drainage tube.

(2) Teale's Operation. Sl idi D g flaps from the adjacent conjunctiva are brought over the denuded portions and sutured in position (Noyes and Teale). The operation is readily comprehended by attention to the accompanying illustrations (Fig. 368).

(3) Riverdin covers denuded surfaces with small pieces of mucous membrane taken from the mouth.

(4) Harlan has devised the following operation where there is extensive adhesion to the lower lid: The adhesion is freely dissected until the upward movement of the ball is entirely unimpaired, and an external incision, represented at _AB in the accompanying cut, along the margin of the orbit is carried through the whole thickness of the lid, which is thus separated from its connections except at the extremity. A thin flap, CD, is then formed from the skin below the lid, care being taken to leave it attached at its base line by the tissue just beneath AB, as well as at the extremities. On this attachment it is turned upward as on a hinge, bringing its raw surface in contact with the inner surface of the lid, and its sound surface presenting toward the ball, and held in this position by suturing its edge to the margin of the lid. In dissecting up the flap the incisions are carried more deeply into the orbicularis muscle when the base line AB is nearly reached, to enable it to turn more readily. The bare space left by the removal of the strip of skin is nearly covered without strain by making a small horizontal incision, DE, at its outer extremity and forming a sliding flap (Fig. 369).

(5) For very extensive adhesions an opening may be made below the attachment and a piece of lead wire inserted, which is left until a fistulous opening is formed, when one of the above operations may be performed (Himly).

(6) Large raw surfaces from extensive adhesions may also be covered by skin grafts after Thiersch's method (Hotz).

Dressings. After minor operations it is sufficient to bandage the eye, and it should be kept closed until the sutures are removed. After transplantations the eye should not be disturbed for three or four days, unless there are signs of irritation, and both eyes should be bandaged.

Complications are due to the failure of grafts to unite and to renewal of adhesions.

Symblepharon posterius due to trachoma is scarcely amenable to surgical treatment.

Transplantation of Rabbit's Conjunctiva. Wolfe. first suggested this mode of dealing with extensive adhesions between the lid and eyeball and several operators have performed the operation with beneficial and even surprising results. General anesthesia is necessary, as the operation is tedious.

The eye and appendages are cleansed and the adhesions are divided. Bleeding is controlled by pledgets of absorbent cotton saturated with hot water and placed in the cul de sac. Two rabbits are anesthetized, in case any accident should happen to one. The size of the graft having been calculated, four sutures are introduced at its corners before it is separated, because after removal it rolls upon itself and it is rather difficult to recognize the proper surface. The graft having been separated, it is rapidly transferred to the denuded area and carefully stitched in position.

Ankyloblepharon is readily relieved when the edges of the lids only are united, but when the adhesions involve the ball also, treatment is of little avail.

Operations for Trachoma. Expression of trachomatous bodies is performed in various ways by different surgeons and according to the gravity and duration of the case. The roller forceps devised by Knapp (Fig. 370) and the modifications of this instrument have aided very much in the thorough performance of this operation.

Where follicles are discrete, as in follicular disease, they are easily expressed between the thumb nails, or preferably by dissecting forceps.

General anesthesia is desirable for the surgical treatment of trachoma, though there are those who prefer to operate under the influence of cocain.

Operation of Expression. The lid is grasped with forceps near the ciliary border and rolled upon itself until the conjunctival surface is well exposed. The roller forceps are then used as follows: one blade is pushed well up into the retrotarsal folds while the other is placed near the ciliarv edge. The morbid material in the conjunctiva is then thoroughly expressed by milking process, each portion being subjected to the squeezing. The retrotarsal folds may be treated separately by still further everting the lid and drawing them out. When, the conjunctiva near the edge of the lid is to be expressed, one blade should be placed upon the cutaneous surface. The surgeon should wear protecting glasses, as the expressed material often flies out suddenly and to a considerable distance.

After treatment. After careful cleansing with warm bichlorid solution iced compresses are applied to the lids for several hours to prevent pain and swelling. The conjunctiva is not as much mutilated as might be expected by this rough handling, and but little reaction follows. Adhesions are very apt to form, and should be broken down by the daily passage of a probe through the cul de sac. The subsequent treatment of the case requires the application of a solution of nitrate of silver (gr. v f3j), and later that of a crystal of sulphate of copper.

George Lindsay Johnson has described the following operation for trachoma:

The lid is everted over a vulcanite spatula and held tense in this position by a double hook inserted near its edge. With a tri bladed scalpel the conjunctiva is incised parallel to the free border of the lid from end to end. The instrument is then moved so that the last blade shall pass through the foremost cut, and so on until the entire surface has been incised. The thicker the lid the deeper the cuts, and vice versa. Bleeding is controlled by cotton compresses saturated with hot water. An electrolizer, connected with a Stohrer's battery of twenty cells and having two platinum blades, is next used. The blades pass through the incisions made by the scalpel. About thirty milli-amperes are used, and a thick foamy cream at once arises about the blades. Strong currents should be avoided. The lids are then washed, sprinkled with a 5 per cent. solution of cocain, dusted with calomel, and smeared with an ointment of hydronaphthol and vaselin, 1 to 800. Inflammation and swelling are controlled by icea compresses. There is considerable discharge and sloughing for forty eight hours. Care should be taken not to injure the cornea.

The after treatment consists in using boric acid wash and the ointment of betanaphthol and vaselin. No entropion or ectropion has resulted.

Grattage is an operation recommended for trachoma by Abadie, Darier, and other French surgeons. As the operation is necessarily quite painful, ether or chloroform should be used.

The lid is everted and held by forceps (Fig. 373), as in the operation for expression, and the conjunctiva is freely incised from the ciliary border to the fornix, and from end to end of the lid, by the tri bladed scarificator (Fig. 372) or a similar instrument. The incised surface is next thoroughly scrubbed with a nail brush that has been saturated in a strong solution (1 : 500) of bichlorid of mercury. By this proceeding all trachomatous material is washed out, and the lids are then treated by cold applications, as described on page 564. The same care must be exercised to prevent the formation of adhesions.

Excision of the Cul de sac. This method of treatment is very old, but Galezowski in 1874 brought it again prominently before the profession. Stephenson also advocates its performance in certain cases, and reports a number of successful operations. The operation advised by him is as follows:

The lid is everted, and two moderately strong sutures are passed through the extremities of the fold. The sutures are held by an assistant, who by their manipulation keeps the parts “on the stretch." An incision' is now made along the attachment of the fornix to the tarsal conjunctiva with blunt pointed scissors, but should never go beyond the anterior laver of the fold. This laver is freed from its attachments, and the dissection into the subconjunctival laver is carried as far back as is deemed necessary. The operation is completed by cutting transversely through the posterior laver of the cul de sac, which comes away with tile sutures. Bleeding is often profuse, but may be arrested by twisting the vessels. Sutures are never employed to close the wound. The eye is cleansed and closed, and is not inspected for five or six days, unless complications arise.

Complications are of two kinds viz. wound granulations and ptosis. The former should be snipped off with scissors. The latter may be due to the swelling of the lid which naturally follows, and will soon disappear, or to interference with the tarsal insertion of the levator palpebral muscle. Stephenson always excises the upper cul de sac, as it is more difficult to reach for treatment than the lower, and never advocates the operation for cases that can be cured by other means.

Choice of an Operation. Expression is especially valuable in cases of spawn like granulations and diffuses hyaline infiltration. It may be used in cicatricial trachoma with patches of hyaline infiltration. Grattage may be employed in cicatricial trachoma and in cases characterized by sclerotic masses of trachornatous tissue. It is inferior to expression preceded by scarification the indications for excision of the cul de sac have been given.

Peritomy, or syndectomy, is performed for getting rid of a thick pannus. A narrow strip of conjunctiva 2 to 4 mm. in width is removed from around the cornea, and all vessels going to the cornea are divided.

Kenneth Scott proposes a substitute for peritomy, as he believes the latter operation is rarely a success, in cases of vascular cornea. By the aid of a magnifying glass lie is enabled to divide with a Greets knife every vessel passing to the cornea. He slits them throughout their entire length, which destroys the vessel and further anastomosis is prevented.

Subconjunctival Injections of Germicides. After thorough conjunctival antisepsis and anesthesia have been secured, a fold of conjunctiva is seized with a pair of forceps about 8 mm. from the corneal margin, and the point of a hypodermic or Pravaz syringe charged with the germicide is introduced, very much in the same manner as when an ordinary hypodermic injection is given, and 2 to 4 minims of the fluid are injected. The strength of' the solution varies with different operators. Of bichlorid 1 : 2000 or 1 : 4000 may be employed. Trichlorid of iodin and cyanuret of mercury may be used in the same way.

Precisely the same results follow similar injections of physiologic salt solution, and it is probable that all of these injections act by stimulating the lymph channels, and therefore promoting absorption. They act favorably at times in iritis, irido cyclitis, scleritis, and corneal ulceration. They have also been recommended in diseases of the retina and optic nerve, but the author doubts their value under these circumstances.


Foreign Bodies in the Cornea. Small particles of dust, cinders, iron, steel, emery, stone, etc. frequently adhert to or become partially or wholly imbedded in the cornea.

When simply adherent to the corneal surface or but slightly imbedded the foreign body is easily wiped off with a wisp of cotton or scraped away by a sharpened matchstick or clean wooden toothpick. Such means are preferable to steel instruments in these cases, as they are less liable to injure the cornea. When the body is more firmly fixed, however, it is necessary to use the ordinary steel spud or cataract needle (Fig (374). Bodies which have sunk below the surface are by no means easy to extract, for slight pressure suffices to force them into the interior chamber.

When, therefore, such a condition exists, a small lance knife (Figs. 375, 376) should be entered beneath the body to prevent its going nearer the chamber. It is then cut down upon and grasped by forceps or pushed from its position with a small probe or spud. W. B. Johnson has devised a magnet for such cases. Cocain anesthesia is sufficient.

After treatment Especial care should be taken in the after treatment of these corneal wounds, for it not infrequently happens that poisonous germs are introduced and infectious ulcers follow, causing abscess and loss of vision from resulting leukoina or loss of the entire eye from panophthalmitis. After removal of the body the wound and eye should be carefully cleansed with an aseptic solution, atropin instilled, and the eye closed by a bandage to prevent reinfection from the air; all instruments should be carefully sterilized.

Removal of Gunpowder Grains from the Cornea. E. Jackson treats these cases by the galvano cautery, as follows:

A small cautery tip, such as is used for cauterizing corneal ulcers, is brought to a white heat and the imbedded pow er grains are touched in rapid succession, sufficient time being allowed for destroying tissue. The resulting scars are not worse in appearance than the stains. When possible the operation should be done early and before diffusion of the carbon takes place (see page 368).

Paracentesis of the Cornea. The instruments required for this operation are a stop speculmn or elevator, fixation forceps, paracentesisneedle, and a small spatula.

Operation. The anesthesia of cocaine’s sufficient, except with children, for whom ether, chloroform, or bromid of ethyl should be used. The eye is fixed by grasping the conjunctiva with the forceps as near the point to be opened as is possible, because by this means the eye can be held more firmly, the opening made gradually, and a sudden evacuation of the aqueous humor prevented. The needle is entered within the corneo scleral border at right angles to the surface, and as the blade is pushed onward the handle is slightly depressed in order to avoid wounding the iris and lens capsule. Next the needle is gently withdrawn, allowing at the same time a gradual escape of the aqueous, so that the iris shall not be swept into or against the wound. Careful cleansing, the instillation of atropin or eserin, as the case may be, and a light bandage, which should be worn two or three days, generally comprise all measures needful in the way of treatment. The operation may be repeated when necessary.

Complications. Prolapse of the iris into the wound may occur, and when it cannot be replaced with the spatula, it should be excised, unless the prolapse is very small or the iris rests against, rather than falls into, the incision.

Curetting the Cornea. A small curette or spud may be used for this operation, which is done for indolent or spreading ulcers.

By the aid of a curette the necrosed tissue is carefully scraped from the sides and bottom of the ulcer, after which the ordinary treatment for corneal ulceration is followed. De Wecker and Santarneechi (Cairo) advise what is called hydraulic curetting as a substitute for the ordinary methods and the use of the cautery. A syringe having a small nozzle is filled with a solution of bichlorid of mercury (1 : 1000), which is then thrown in a steady stream upon the ulcer and gradually washes away the necroses tissue. Santarnecchi claims that ii is more thorough and less dangerous than ordinary curetting and the use of the cautery, as injury to the sound iissues is much less likely to occur.

Application of the Actual Cautery. For this purpose a platinum tipped probe of the galvano cautery may be used.

The point, having been brought to a red beat, is lightly applied to the floor and sides of the ulcer, care being taken not to perforate the anterior chamber. The area to be cauterized is colored green by dropping upon it a solution of fluorescin (see page 145).

The after treatment consists in the use of atropin and mild aseptic washes, such as boric acid and salt. The application of a bandage depends upon the quantity of the discharge.

Saemisch's Section. The instruments necessary are a stop speculum, fixation forceps, v. Graefe knife, spatula, and perhaps a small syringe.

Operation. The pupil should be dilated as much as possible, and if the patient is a child general anesthesia is necessary. The eye is steadied by grasping the conjunctiva with the forceps while the knife is entered, edge out, in the healthy tissue near the ulcer. The point is passed through the anterior chamber and emerges at a corres ponding spot beyond the ulcer, when the intervening corneal tissue is cut through, allowing the pus and aqueous humor to escape.

Sometimes the pus is caught between the lips of the wound, but is easily removed with a spatula or iris forceps, or by washing out the chamber with any specially devised syringe charged with normal salt solution. The iris should be replaced as well as possible, but synechie are likely to result.

The after treatment consists in cleanliness, the instillation of atropin, and the application of a bandage until the cornea has healed. The operation may be repeated as often as the pus re forms.

Complications are synechie and the resulting leukoma, which latter is due to the ulceration rather than the incision. Panophthalmitis and entire destruction of the cornea may result if the ulceration is not checked.

Conical Cornea; Staphyloma Pellucidum. There are various operations for this deformity, all of which have for their object the removal of the cone.' Von Graefe shaved off the apex of the cone and applied the solid Ditrate of silver stick to the wound, which, as it healed, caused contraction and diminution of the cone. Bowman accomplished the same result by means of a trepan, and Knapp has devised a special point for the galvanocautery, with which the cone is cauterized as deep as Descemet's membrane, avoiding, if possible, entrance into the anterior chamber (Fig. 380).

After healing, an iridectomy is usually necessary. The sear left by the cautery may be tattooed a procedure which not only improves the appearance of the eye, but also the vision, by excluding unnecessary light. It may be necessary to repeat the operation, which is preferable to running the risk of destroying the eye by attempting too much at first.

Tattooing the Cornea. The instruments required area stop speculum, fixation forceps, and tattooing needle (Fig. 381).

Operation. Thorough anesthesia of the cornea is essential in order that the ink may be driven well into its layers. The India ink should be of the consistency of paste and plentifully applied to the leukoma, as it soon fades when thinner. The pigment is then pricked into the cornea over the area to be covered, after which the excess is washed away by a boric acid solution. Atropin is next instilled and a light bandage is applied. The reaction subsides within a few days, and the operation may be repeated, if necessary, after all inflammation has disappeared. Different colored inks may be used to match the varying colors of the irides. Tattooing is also useful for covering colobomata which admit too much light to the eye.

Wounds of the Cornea. Incised wounds usually heal without trouble, it being simply necessary to cleanse the eye carefully, to bring the lips of the wound accurately together, to replace the iris 'if it has fallen into the wound, and to apply a bandage. Eserin or atropin may be used according to the position of the wound. If the prolapse continues and cannot be replaced, it should be excised. Large gaping wounds, whether incised or lacerated, may be closed with sutures, which should be composed of very fine silk.

De Weeker has advised the following method for closing and protecting large wounds of the cornea : The conjunctiva is dissected from the corneal limbus and beyond the attachments of the recti muscles. A suture is then passed in and out near its edge, which, when tightened like a string at the mouth of a bag, draws the conjunctiva over and entirely covers the cornea. It should remain until the cornea has healed, when it may be dissected loose. Adhesions do not take place, except, perhaps, in the line of the wound, and these are readily freed.

Von Hippel's Operation for Transplanting the Cornea. In cases of central leukoma von Hippel has transplanted a graft from the cornea of a rabbit, but the results have not been very satisfactory, because the transplanted cornea has also finally become opaque. He restricted the operation to those cases where the entire corneal thickness was not involved in other words, where the leukoma was not totally adherent.

Operation. A general anesthetic should be used for patient and rabbit. The eye having been prepared, the trepan is gauged so that it shall Dot enter the anterior chamber. It is placed accurately over the center of the cornea, and by touching the spring the cut is quickly made. The plug is lifted out by the aid of special forceps and cut off with a Graefe knife. Ina like manner the plug is cut from the rabbit's eye and quickly transferred to the patient's. After cleansing, both eyes should be bandaged and the patient kept quiet in bed for a few days.

Complications may be ulceration of the cornea and general infection of the eye.

Operations for Closing scleral Wounds. Wounds of the sclera are common near the corneal border, over the ciliary body, and on the upper surface of the ball. Owing to the frequent involvement of the ciliary body, extreme care must be exercised in their management.

Small punctured wounds require no special care beyond the usual antiseptic precautions; but if exposed, they should be covered with the conjunctiva. Small incised and lacerated wounds, when inclined to gape or when their edges are separated by a bead of vitreous humor, should be closed, after the prolapsed vitreous has been excised, with small animal sutures introduced through the outer layers in order to avoid wounding the inner coats of the eye. The conjunctiva is to be sutured over the scleral wound with animal or silk sutures. Large scleral wounds may at times be approximated simply by closing the conjunctiva over them, but it is probably safer to suture the sclera to avoid the danger of staphyloma. Care must be taken that the ciliary body and choroid are not imprisoned in the wound. The subsequent treatment requires cleanliness and bandaging until healing is complete.

Complications arise from injuries to the ciliary body, choroid, and retina, which may cause sympathetic ophthalmia and separation of the retina. Prolapse of the vitreous interferes with healing.

Selerotomy. The, instruments for this operation are a stop speculum, fixation forceps, Graefe knife, and spatula.

Operation. A Graefe knife. is entered in the sclera about 1 mm. from the cornea, and, passing through the anterior chamber, emerges at a corresponding point on the opposite side. The cut is made upward by a to and fro motion, as in the operation for removing cataract, until a narrow bridge is left connecting the sclera with the cornea. The knife is then withdrawn carefully to prevent, if possible, the prolapse of the iris, which is apt to occur, and which should then be excised (Fig. 382).

This operation is not as effective as iridectomy, and Fuchs says should only be performed under the following conditions: 1, Glaucoma simplex, with a deep anterior chamber and without distinct elevation of tension. 2. Inflammatory glaucoma, when the iris through atrophy has become so narrow that one cannot hope to perform excision of the iris that would be according to rule. 3. Hemorrhagic glaucoma. 4. Hydrophthalmos. 5. Instead of a second iridectomy in those cases of glaucoma in which the increase of tension returns in spite of an iridectomy performed according to rule (compare with page 578).

Posterior Selerotomy. Tbe incision should be placed so as not to wound the ocular muscles or endanger the ciliary body, and should, therefore, not approach the cornea nearer than 6 or 7 mm. The cut is made with a Graefe knife from behind forward, so as to correspond with the direction of the scleral fibers. There is probably less danger from infection if the incision in the sclera is not directly under that in the conjunctiva. When it is desired to produce a fistulous opening the incision should be made near the equator, as healing is less likely to take place here than farther forward.

Posterior selerotomy is indicated in cases where the anterior chamber has been obliterated and iridectomy or anterior selerotomy cannot be performed, for separation of the retina, for staphyloma, and for those cases in which reduction of tension is indicated and other operations are not available. In cases of corneal staphyloma it may be necessary to repeat the operation a number of times before satisfactory results are obtained.

Selerectomy, as described by H. Parinaud, is for the purpose of obtaining less resistance from the sclera, more efficacious drainage, and the formation of a staphyloma when desired.

Operation. At a point near the equator a curved needle is plunged into the external layers of the sclera, which are then slightly elevated. With a Graefe knife, held parallel to the needle, a flap is cut, at the bottom of which the choroid should be visible. It is advisable not to cut entirely through the sclera, though this may be punctured later if thought necessary.

Operations for Staphyloma. Small staphylomata of recent formation may frequently be cured by pressure from well applied bandages, which should be kept in place until the cornea has regained its tonicity. When this proves unsuccessful an iridectomy may be performed at or near the point of bulging; after this the eye must be bandaged until healing is complete and the parts are strong.

A staphyloma involving the entire cornea is difficult to treat successfully, and many methods of operating have been devised. Probably the most effective is entire excision of the growth; though the safer, but more tedious .method, which sometimes succeeds admirably, is by posterior selerotomy.

For the operation by excision the following instruments are necessary: a stop speculum, fixation forceps, Beer's knife, scissors, needles, and sutures. Ether or chloroform should be administered.

De Weeker and Critchett both, after having inserted needles or sutures through the base of the staphyloma to prevent loss of vitreous, excise the staphyloma with the knife and scissors and allow the lens to escape. De Weeker closes the wound by drawing the conjunctiva together over it, while Critchett passes the sutures through the sclera and draws its edges accurately together. The conjunctiva is then closed over the scleral wound. Reference to the figures will make the steps of' these operations evident, which are not now much practised, as evisceration with insertion of artificial vitreous is preferable (Figs. 383 385).

After treatment. The eye is dressed and kept closed for several days unless there are symptoms of inflammation. Healing is slow.

Complications. Wounding the ciliary body may cause sympathetic oplithalmia, and a general infection may be followed by panophthalmitis.

Unucleation of an Eyeball. Most operators prefer general anesthesia for this operation, but there are a few who advise cocain. J. J. Chisolm., speaks highly of bromid of ethyl. The instruments required are a stop speculum, fixation and dissecting forceps, strabismus book, and enucleation scissors (Fig. 386).

Operation Bonnet's Method. The conjunctiva is grasped by the forceps near the cornea, and with the scissors is loosened entirely around the latter and as near to it as possible. The dissection is then carried well back in every direction. The recti muscles are next caught up separately by a strabismus hook and their tendons divided close to the ball. The scissors are now pressed close to the ball and dissect it from the orbital tissues on every side. The enucleation scissors are then passed well back into the orbit until the points touch the optic nerve, when they are separated and the nerve is severed as far back as possible. The scissors may be entered from the nasal or temporal side. Care should be taken not to divide the nerve too close to the ball or the sclera may be perforated.

Vienna Method. By this method the operation is much more quickly performed, but there is greater loss of orbital tissue, which prevents the accurate fitting of an artificial eye. This operation, however, is to be recommended when for any reason a quick manipulation is necessary.

The conjunctiva is opened near the outer or inner margin of the cornea and dissected away over the attachment of the rectus muscle, which is caught up and divided. The scissors are then passed rapidly around the ball, dissecting it from the orbital tissues until the nerve is reached and divided. The arms of the speculum are opened and pressed back to force the ball from the socket. The conjunctiva, muscles, and orbital tissues are then easily divided by rotating the ball. If hemorrhage is profuse after enucleation, it should be checked at once by hot water to prevent the orbital tissues from becoming infiltrated. The hot water is best applied by saturating balls of absorbent cotton and forcing them into the orbit. Some operators suture the edges of the conjunctiva, though this is unnecessary.

After bleeding has ceased the orbit should be flooded with hot bichlorid solution (1 : 5000). A piece of sterilized gauze is placed next to the lids, upon this a goodsized pad of absorbent cotton (sterilized), and over these a roller bandage is tightly applied, care being taken to make the turns from below upward, so that the compress shall be forced into the orbit.

After treatment When possible the dressing should be changed a few hours after its application, as it adds much to the comfort of the patient. The eye should be dressed every day, and the orbit thoroughly flooded with warm bichlorid solution. Rest in bed for two or three days after the operation is a safe plan to follow, though many surgeons do not require it. After three or four days the roller bandage may be replaced by a lighter form.

Complications. Secondary hemorrhage rarely occurs, and may be controlled by applying hot water and tightening the bandage.

Cellulitis meningitis, acute mania, and tetanus have followed enucleation. In cases of cellulitis and meningitis deep incisions sboul it be carried to the back of the orbit, hot applications should be made to the lids, and a free evacuation from the bowels should be encouraged.

Exenteration or Evisceration. This operation should under no circumstances be performed upon an eye that may be capable of causing sympathetic ophthalmitis, and is therefore applicable to but a few cases.'

The instruments required' are a stop speculum, fixation forceps, Beer's knife, small scissors, curette or scoop, needles, sutures, etc.

Operation. The conjunctiva having been dissected to the equator of the eyeball, the cornea is excised by passing a Beer's knife through the corneo scleral juncture from side to side and cutting out above, then reversing the knife and cutting down, or after the first incision with the knife the remaining flap is removed with the scissors. The contents of the globe are evacuated and the inner coats scraped away with scoop or curette. Hemorrhage is controlled by hot water and the cavity cleansed with hot bichlorid solution J : 2000 or 3000). It is very essential that every portion of the contents should be thoroughly removed and hemorrhage completely controlled, for tinder these conditions healing, which is necessarily slow, progresses more favorably. Prince advises cauterizing the scleral cavity with 95 per cent. carbolic acid to relieve pain and to hasten healing. The edges of the sclera are approximated accurately with catgut sutures, and the conjunctiva is closed with silk sutures.

Dressings and the after treatment are the same as for enucleation, but the period of recovery is more protracted.

Evisceration of the Eyeball, with Insertion of an Artificial Vitreous (mules's Operation). Mr. Mules has modified the operation of evisceration by the introduction of a g lass ball into the cavity of the sclera. In general terms the operation is performed in the same manner as an ordinary evisceration, but certain special precautions require to be noted.

The con unctiva having been dissected from the corneo scleral attachment in all directions to the equator of the eyeball without disturbing the muscles, evisceration is performed, after abscission of the cornea, in the ordinary manner. A perfectly clean white scleral cavity must be secured, and hemorrhage absolutely controlled by packing the cavity with sterilized gauze saturated with a hot solution of bichlorid of mercury, 1: 2000, and by frequently irrigating it with a tepid solution of the same drug. Sometimes the hemorrhage is more readily controlled with repeated dry packings of sterilized gau2e than with hot solutions. A glass sphere (Fig. 389), of such size that it may be introduced within the scleral cup without difficulty, is selected, its introduction being facilitated by slitting the sclera vertically for about 4 mm. at the upper and lower corneo scleral margins. The introduction of the sphere is further facilitated by the use of an instrument specially devised for this purpose (Fig. 388). The concluding steps of the operation consist in stitching the sclera vertically, the conjunctiva horizontally, dusting iodoform within the socket, and applying a full antiseptic dressing. Indeed, the greatest care should be exercised to secure absolute antisepsis during the operation and at the subsequent dressings.

After treatment. The patient should be confined to bed for at least three days, and both eyes should be bandaged for forty eight hours., At the end of this time there may be a daily dressing, and at the end of five or six days, or at most at the end of a week, the patient may be discharged from his room. Usually an artificial eye can be worn at the expiration of two weeks.

Complications. Severe reaction occasionally follows, with mark edema of the lids and chemosis of the conjunctiva. The chemotic conjunctiva may be incised, and the reaction controlled by continuous iced compresses.

Early absorption of the sutures, if catgut is used, may cause the scleral wound to separate and the glass ball to extrude. Should this happen, the ball may be removed and the operation converted into an ordinary evisceration, or a still smaller ball may be placed in position and the scleral wound once more closed with catgut sutures.

The stump after a successful Mules's operation is so superior to that furnished by any other method that, if no contraindication exists, there should be no hesitancy in performing this operation ; for even if the accident of extrusion of the ball should take place, the remaining stump is far preferable to any that could be formed after an ordinary enucleation. The danger that the glass ball may be broken is remote, although this accident has happened.

Other Operations for Support of Artificial Eye. Claiborne and Belt advise sponge grafting in the orbit for the support of an artificial eye. After removal of the eve a globe of sponge, about three fourths the size of the eyeball, is inserted into the socket or Tenon's capsule. The recti muscles are then united over it and the conjunctiva over all. Suker prepares the stump for an artificial eye by suturing the recti muscles together with catgut and the conjunctiva with silk.

L. W. Fox describes an operation for implanting a glass ball in an orbit from which the globe has been enucleated at some previous date. A horizontal incision is made through the conjunctiva and tissues of the orbit, which should be slightly less than the diameter of the ball to be inserted. The upper lip of the conjunctival wound is raised and dissected away by sharp scissors until a pouch is made for the ball, which is inserted after bleeding is controlled, and the opening closed by sutures. This operation is practically identical with the suggestion ofFrost and Lang to introduce a Mules's sphere into Tenon's capsule after ordinary enueleation, and close the muscles and conjunctiva over it in the usual way.

Optico ciliary Neurectomy. Tbis Operation, like evisceration, was proposed as a substitute for enucleation, but has not, for two reasons, filled the place to which it was assigned : 1. It does not replace enucleation, because the danger of infection from such an eye is by no means prevented, as cases of sympathetic ophthalmia have occurred after its performance. 2. The operation is rather difficult to perform, and has been followed by softening and atrophy of the globe.

Operation. An opening is made between the superior and external recti muscles, and the scissors, pressed close to the ball, divide the tissues until the optic nerve is found. This is caught by a strabismus hook as far back as possible and divided. The optical end is then seized by forceps or hook and drawn to the Opening. The nerve and all surrounding tissues are then cut close to the ball. There is considerable hemorrhage, and it is difficult to replace the ball, There is some prominence of the ball for a time, but it usually resumes its normal position after a shorter or longer period.

After treatanent consists in cleanliness and bandaging the eye until healing is complete.

Complications. Abscess of the orbit and meningitis may follow from infection during the operation.

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