MICHEI LOUTFALLAH 
 
 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 OF CALIFORNIA 
 
 LOS ANGELES
 
 fal
 
 OPHTHALMIC SURGERY 
 MELLER
 
 A Handbook of the Surgical Operations on the Eyeball 
 
 and Its Appendages as Practiced at the Clinic 
 
 of Prof. Hofrat Fuchs. 
 
 BY 
 
 DR. JOSEF MELLER 
 
 Privatdocent and First Assistant K. K. 77, University Eve Clinic. Vienna. 
 
 THE TRANSLATION REVIEWFD BY 
 
 WALTER L. PYLE, A. M., M. D. 
 
 Member of the American Ophthalmologica! Society. Ophthalmologist to Mount Sinai Hospital. 
 , Sometime Assistant Surgeon to Wills Eye Hospital, Philadelphia, etc. 
 
 WITH 11K ORIGINAL ILLUSTRATIONS 
 
 PHILADELPHIA 
 P. BLAKISTON'S SON & CO 
 
 1012 WALNUT STREET 
 1908 
 
 The Ktght of Translation js Reserved.
 
 COPYRIGHT, 1908, BY P. BLAKISTON'S SON & CO. 
 
 Registered at Stationers' Hall, London, England. 
 
 Printed by 
 
 The .\faple Press, 
 
 York, Pa.
 
 PREFACE 
 
 THE forelying volume is based on the lectures which for years I 
 have given during the courses in Ophthalmic Surgery at the Clinic 
 of Professor Fuchs, in Vienna. Among the numerous visiting 
 physicians who have attended these lectures, many have come from 
 English-speaking countries, and it is in pursuance of their oft- 
 expressed wish that this publication has been made. 
 
 In consecutive chapters there are described in detail and pictured 
 the most important ophthalmic operations, as they are performed 
 at the Clinic of my Chief, Hofrat Fuchs. Under his valuable 
 guidance, my clinical education and cultivation have been acquired, 
 and a large part of the operative procedures herein set forth I have 
 learned from him personally. Although presented under the 
 names of their originators, many of the operations are described 
 with the modifications and improvements which the very extensive 
 experience in our Clinic has gradually led us to adopt as the best 
 routine practice. Some of the methods, however, are essentially 
 my own: for example, the extirpation of the tear-sac. Had I not 
 been much pressed for time, these would have been published 
 years ago. As it is, I now for the first time publicly present them 
 in this book. 
 
 I take this opportunity of acknowledging my indebtedness to Dr. 
 M. Sachs, the former first assistant of the Clinic, to whose staff I 
 was attached as a beginner in ophthalmology. To him I offer 
 assurance of warmest thanks and sincere devotion. The drawings 
 for the illustrations are from the skillful hand of Wenzel, who gave 
 himself to his difficult labor with great earnestness and artistic 
 care. To Dr. William M. Sweet my thanks are due for his 
 friendly counsel and aid in effecting the publication of my work. 
 I also desire to record my appreciation of the faithful and scholarly 
 assistance of Dr. Walter L. Pyle, in reviewing the English transla- 
 tion of my manuscript. 
 
 JOSEF MELLER. 
 
 Vienna, June, 1908. 
 
 v
 
 CONTENTS 
 
 CHAPTER I. 
 
 EXTIRPATION OF THE LACHRYMAL SAC i 
 
 Topographical anatomy of the lachrymal-sac region; the anterior lach- 
 rymal crest and the internal canthal ligament; the most important 
 landmarks for the finding of the sac; incision through skin and super- 
 ficial fascia; insertion of Mueller's speculum; division of the muscle; 
 clearing of the deep fascia; incision of the deep fascia along side of the 
 crest; peeling of the sac from its capsule: first along the lateral wall 
 with division of the lachrymal canaliculi, then along the median wall, 
 and finally dissection of the apex and resection of the sac from the duct ; 
 curettement of the duct, suture and pressure -dressing; healing by first 
 intention; retention of secretion. 
 
 CHAPTER II. 
 
 EXTIRPATION OF THE LACHRYMAL SAC. (CONTINUED.) 15 
 
 Anesthesia and anemia of the field of operation; importance of deep 
 injections; the operation is bloodless and painless; difficulty of oper- 
 ation; direction of the dissection toward the bone; injury of the fascia; 
 fultility of curettement for removal of retained particles of the sac; for- 
 mation of fistula; necessity of a second dissection of the remnants of 
 the sac; dilatation of the sac; tuberculosis of the sac; treatment of 
 acute dacryocystitis; indications for extirpation of the lachrymal sac. 
 
 CHAPTER III. 
 
 EXCISION OF THE PALPEBRAL LACHRYMAL GLAND 22 
 
 Indications; section of the excretory ducts of the orbital gland; preserva- 
 tion of the tarso-orbital fascia; no danger of a drying of the conjunc- 
 tiva; probing; course of the lachrymal canaliculi; dilatation with the 
 conical probe; production of a false passage; slitting the canaliculus 
 for the purpose of passing probes is not to be recommended; indica- 
 tions for slitting; treatment of beginning ectropion; slitting with the 
 aid of Weber's knife; introduction of Bowman's probe; lavage of the 
 sac with fluids inducing anesthesia and anemia; Ariel's syringe; prob- 
 ing through the upper lachrymal duct; probing in newborn children; 
 indications for probing; causes of epiphora; hollow probes. 
 
 CHAPTER IV. 
 
 TRICHIASIS-OPERATIONS 32 
 
 Typical methods; method of Anagnostakis (Hotz); modifications of 
 this method; shaving of the tarsus; rolling forward of the thinned tar- 
 sus by the sutures; fixation of the suture at the upper edge of the tar- 
 
 vii
 
 viii CONTENTS. 
 
 sus; advantages and disadvantages of the operation; importance of 
 the incision in the intermarginal border; method of Panas; division of 
 tarsus and conjunctiva near the margin of the lid; fixation of the suture 
 in the tarsus near the margin of the wound; advantage of the opera- 
 tion: radical cure of the trichiasis; disadvantages: shortening of 
 the upper lid; danger of necrosis; operation of Spencer Watson 
 for partial trichiasis; atypical operations; transplantation of the mu- 
 cous membrane of the lip; the outer skin must not be employed for this, 
 electrolytic epilation. 
 
 CHAPTER V. 
 
 ECTROPION -OPERATIONS 42 
 
 Spastic ectropion: Snellen's suture; senile ectropion: combination 
 of the methods of Kuhnt and Szymanowski; shortening of the tarsus and 
 skin of the lid; the intermarginal incision; measurement of the piece 
 of tarsus to be excised; shape of the piece of skin to be excised; three 
 sutures through the tarsus; displacement of the skin outward with simul- 
 taneous slight elevation; necessity of a dressing over both eyes; ad- 
 vantages of the operation; paralytic ectropion: tarsorrhaphy; cica- 
 tricial ectropion; plastic operations; use of sutures; employment of flaps 
 with pedicles; advantage of flaps without pedicles; technic of trans- 
 plantation of flaps without pedicles; production of a wound-surface 
 of as great a size as possible; manner of preparation from the skin of 
 the arm; the most perfect adaptation possible; after-treatment. 
 
 CHAPTER VI. 
 
 OPERATIONS FOR SPASTIC ENTROPION 58 
 
 Gaillard's suture; excision of an obliquely oval piece of skin; shortening 
 of the skin in a perpendicular direction; Graefe's entropion -operation; 
 shortening of the skin in an oblique direction; canthoplasty; Ammon's 
 operation; provisional canthoplasty; indications; Kuhnt's canthoplasty: 
 formation of a skin -flap; tarsorrhaphy; indications; method of Fuchs; 
 advantage of the growing together of planes; tarsorrhaphy as a cosmetic 
 operation; total closure of the palpebral fissure; median tarsorrhaphy; 
 preservation of the lachrymal canaliculi and the internal canthus; 
 method of Arlt. 
 
 CHAPTER VII. 
 
 PlOSIS-OPERATIONS 71 
 
 Method of Hess; undermining of the skin of the lid; production of 
 a union with the tfrontalis muscle; moist chamber for two to three 
 weeks; good result; indications; Pagenstecher's suture; operation of 
 Everbusch; advancement of the levator palpebrae; topographical anat- 
 omy of the field of operation; preparation of the muscle; shortening 
 of the muscle ; indications ; advantages and disadvantages of the method ; 
 Panas's operation for ptosis is not to be recommended for cosmetic 
 reasons; Motais' method. 
 
 CHAPTER VIII. 
 
 STRABISMUS-OPERATIONS 84 
 
 The technic of tenotomy; grasping of the tendon-insertion with 
 forceps; the technic of advancement; application of loop-sutures; 
 shortening of the muscle; suturing of the muscle to the sclera 
 near the limbus; technic of the suture through the sclera; fixation
 
 CONTENTS. IX 
 
 of the muscle to the conjunctiva alone is insufficient; application of 
 the strabismus-operations; how much correction does tenotomy pro- 
 duce; the assisting suture; its indications; the counteracting suture; 
 its application; how much does advancement correct?; importance of 
 suturing forward to the limbus; allowance of the immediate result 
 of advancement; incalculable action of tenotomy and advancement, 
 when performed at the same time; the advancement is the physiologic- 
 ally more valuable operation; under-correction in convergent stra- 
 bismus; over-correction in divergent strabismus; operation of cases 
 of convergent strabismus of slight degree (to 15 degrees); medium 
 degree (to 30 degrees); high degree (over 30 degrees); difference in 
 the value of tenotomy and advancement of the internal rectus in pro- 
 portion to the same operation on the external rectus; simultaneous per- 
 formance of advancement of the internal rectus and tenotomy of the 
 external rectus in divergent strabismus; assisting suture for the opera- 
 tion of divergent strabismus; advancement of the internal rectus after 
 tenotomy; unpleasant results of tenotomy; operation in exophoria; op- 
 eration for paralytic strabismus; value of strabismus-operations almost 
 only cosmetic; time to perform the operation. 
 
 CHAPTER IX. 
 
 KMVI.EATIOX OF THE EYEBALL AND ALLIED OPERATIONS 103 
 
 Technic of enucleation; performance of the operation under cocain- 
 anesthesia; necessity of preserving the conjunctiva; resection of the 
 optic nerve; hemorrhage; indications for enucleation; procedure in 
 panophthalmitis; evisceration of the bulb; optico-ciliary neurotomy; 
 compensatory operation for enucleation; indications; immediate com- 
 pression after resection of the optic nerve; exenteratio orbits; indica- 
 tions and technic of the operation; subperiosteal preparation. 
 
 CHAPTER X. 
 
 PLASTIC OPERATIONS 115 
 
 Plastic lid -operations having a pedicle; method of Fricke; to prevent 
 recurrence of epitheliomas the operation must be performed at leas! '. 
 cm. beyond the visible margin of the tumor; disadvantage of Dieffen- 
 bach's method; Buedinger's ear-cartilage method; shaving down and 
 thinning of the ear-cartilage; attachment of the skin-ear-cartilage flap 
 to the lid-flaps; protection of cornea through the drawn-down upper 
 lid; difficulties in replacing an entire upper lid; operations for sym- 
 blepharon; sutures; pediculated flaps from the surrounding conjunctiva; 
 non-pediculated flaps from the conjunctival fornix; futility of grafting of 
 rabbit conjunctiva; both wound -surfaces should be covered; employ- 
 ment of skin-flaps from the surrounding tissue with pedicles; method 
 of Rogman; combination of it with a plastic operation of the con- 
 junctiva; employment of cutaneous flaps without pedicles; formation 
 of conjunctival sacs to enable the wearing of protheses. 
 
 CHAPTER XI. 
 
 OPERATION FOR SENILE CATARACT 124 
 
 Technic of the individual steps; fixation of the eye; use of the 
 right and left hand; avoidance of the slightest pressure on the eyeball 
 "with the forceps; grasping of the conjunctival fold in the vertical 
 meridian; technique of position; position of the incision; discussion
 
 X CONTENTS. 
 
 of the relative position of the limbus and the angle of the chamber; 
 after perforation of the anterior chamber the knife must neither be pulled 
 back nor checked in its advance; turning of the knife beneath the 
 conjunctiva; iridectomy; use of Wecker's scissors; opening of the anterior 
 lens-capsule; the capsule-forceps and its use; a large piece of the anterior 
 capsule must be pulled out; use of the cystotome; advantage of 
 the capsule-forceps; expression of the cataract; delivery of the cortical 
 substance; toilet of the eye; reposition of the iris; management of 
 the spatula; proper position of the conjunctival flap. 
 
 CHAPTER XII. 
 
 OPERATION FOR SENILE CATARACT. (CONTINUED.) 140 
 
 Discussion of complications and mistakes; other remarks; tearing out 
 of conjunctiva; fixation of the eye to a muscle -attachment; corneal in- 
 cision; scleral incision; disadvantage of both; length of the incision; 
 too short an incision; direction of the incision; intralamellar incision; 
 method of holding the knife; use of the right and left hand; hemorrhage 
 in iridectomy; the eye should be fixed only during the incision; produc- 
 tion of iridodyalisis; the iris falls against the knife; bridge-colo- 
 boma; indication for the use of the cystotome; procedure when the 
 anterior lens-capsule is markedly tense or is thickened; extraction of 
 the lens in the capsule; causes which prevent the delivery of the 
 lens: too short an incision; resistance of the sphincter; the anterior 
 capsule is not opened; dislocation of the lens; diminution in size of 
 the lens-nucleus; prolapse of vitreous; Weber's loop; Reisiger's hook; 
 symptoms of the approaching or beginning vitreous prolapse; pouring 
 out of fluid vitreous; luxation of the lens into the vitreous; corneal 
 collapse; expulsive hemorrhage; extraction without iridectomy; ad- 
 vantages and disadvantages; indications; excision of the prolapse. 
 
 CHAPTER XIII. 
 
 OPERATIONS ON THE SOFT, TRANSPARENT OR CATARACTOUS LENS 159 
 
 Discission per corneam; crucial incision into the anterior lens-capsule; 
 attention to prevent injuring the posterior capsule; discission of the 
 transparent lens in myopia operations; production of traumatic cata- 
 ract; puncture to remove the swollen lens-masses; procedure to pre- 
 vent increase in tension; indications for myopia -ope rations; their value; 
 discission of partial cataracts; procedure in perinuclear cataract; 
 viscual acuity by narrow and wide pupil; discission or optical iridec- 
 tomy; technique of the latter; pre-corneal iridotomy; other indications 
 for optical iridectomy; estimation of the probable value of an optical 
 iridectomy in corneal opacities; movable stenopaeic slit or fissure; 
 dilatation of the pupil for purposes of examination; provisional tattooing 
 of the cornea; successes of optical iridectomy; discission of completely 
 dimmed lenses; operation for complete congenital cataract; advantage 
 of discission as compared with linear extraction in small children. 
 
 CHAPTER XIV. 
 
 OPERATIONS FOR SOFT CATARACT AND SECONDARY CATARACTS 169 
 
 Discission per corneam in operation for secondary cataract; injury of 
 the vitreous; necessity of dilatation of the pupil by atropin; laceration 
 in the iris-attachment; transient depression of the membrane into 
 the vitreous; Bowman's discission; capsulotomy and iridotomy in com-
 
 CONTENTS. XI 
 
 plicated secondary cataract; scar-formation after extraction during 
 iridocylitis; use of Graefe's knife for the incision; importance of an 
 immediate pressure -dressing to prevent hemorrhage; direction of the 
 incision; advantages of this method of operation; discission per scleram; 
 technique of the operation; advantage as compared with discission 
 per corneam; unpleasant complications: glaucoma; cyclitis; linear 
 extraction; upper limit of age thirty-five years; technic of the operation; 
 extraction of the soft lens-masses by massage; enlargement of the in- 
 cision laterally in the presence of a large nucleus; careful treatment of 
 the iris; extraction of the lens with the capsule; prolapse of vitreous; 
 suture. 
 
 CHAPTER XV. 
 
 OPERATIONS FOR GLAUCOMA 180 
 
 Iridectomy in glaucoma; technic of the individual steps; incision; 
 relative position of angle of chamber and limbus; the incision with the 
 lancet; beginning of incision i mm. behind the limbus; fixation 
 of the eye in the vertical meridian; change of position of the lancet 
 into the plane of the iris; direction and length of incision; difficulty of 
 the lancet-incision; the lancet must be pulled out slowly; the incision 
 with Graefe's knife; indications; advantages of the incision with the 
 lancet; the incision with the knife is less dangerous; difference between 
 this iris-operation and the iridectomy in cataract-operations; difficulty 
 of reposition; indications for iridectomy; complications during the 
 operation; tearing out of the conjunctiva; intralamellar incision; im- 
 paling of the iris; production of iridodyalisis during the incision with 
 the lancet; injury of the lens; incorrect position of the incision; anes- 
 thesia of the iris before operation; caution during the use of the iris- 
 forceps because of possible injury of the lens-capsule; iridectomy at 
 the lower part of the iris; hemorrhage during the operation; im- 
 portance of reposition ; liberation of a part of the iris held into the wound ; 
 prolapse of the vitreous; expulsive hemorrhage. 
 
 CHAPTER XVI. 
 
 OPERATIONS FOR GLAUCOMA. (CONTINUED.) 193 
 
 Complications of iridectomy for glaucoma; subluxation of the lens;. for- 
 mation of a cataract; injury of the lens-capsule produced by the oper- 
 ator; spontaneous rupture of the lens-capsule; rupture of the capsule 
 at the lens-equator; spontaneous emersion of the lens from the eye; 
 technic of cyclodyalisis after Heine; liberation of the ciliary body from 
 the sclera; avoiding injury of the anterior ciliary veins and the ciliary 
 body; no danger of iridodyalisis after an injury to the canal of Schlemm; 
 pressure-dressing if hemorrhage is started; the operation certainly 
 does not act only because of the puncture; diminution of tension with- 
 in a few days; value of cyclodyalisis; operations for secondary glau- 
 coma; puncture of the cornea; technique of the operation; prevention 
 of the loss of aqueous humor during the incision; repetition of the punc- 
 ture; prolongation of the incision to remove masses of lens-matter; diffi- 
 culty of performing iridectomy in secondary glaucoma; procedure in 
 subluxation and luxation of the lens; transfixion; anterior sclerotomy; 
 incision of the angle of the chamber; iridodyalisis; results of the oper- 
 ation; indications; posterior sclerotomy; incision at the meridian; no 
 filtration -scar; results and indications.
 
 \ii CONTENTS. 
 
 CHAPTER XVII. 
 
 OPERATIONS FOR PROLAPSE OF THE IRIS AND ITS SEQUELA: ANTERIOR 
 SYNECHIA; ECTASIA OF THE SCAR, ETC., CORNEAL AND CONJUNCTIVAL 
 
 PLASTIC OPERATIONS 209 
 
 Every prolapse must be excised; technic of excision; removal of the 
 fibrous layer; liberation of the prolapse with the conical probe; draw- 
 ing the iris forward; amputation at the edge of wound; reposition of 
 the portion of the iris; resection in perforation of ulcers; difficulties of 
 the operation; healing of the perforation opening; if prolapse is too 
 large, it must not be excised; iridectomy when considerable of the 
 iris is healed in the wound; serpigineous ulcer in the stage of scarifica- 
 tion and in glaucoma; plastic operations on conjunctiva; development 
 of the operation through Kuhnt; flaps with a pedicle cover the defect; 
 de Wecker's procedure to cover corneal defects; prolapse of the ciliary 
 body or chorioid; application of the scleral suture; procedure by 
 prolapse existing for some time; iridectomy and pressure dressing to 
 flatten the recent scar; cutting off of the scar and excision of the iris. 
 
 CHAPTER XVIII. 
 
 CORNEAL OPERATIONS 216 
 
 Fuchs' corneal transplantation to replace ectatic and fistulous scar- 
 tissue in the cornea; technic of the operation; keratoplasty; v. Hippel's 
 partial keratoplasty; total keratoplasty; worthlessness of the operation 
 from the optic standpoint; Hippel's trephine; indications for the ker- 
 atoplastic restoration of corneal scars; general indications for operative 
 procedures, particularly in anterior synechia; Sach's temporary scar- 
 resection; technique of the operation; injury of the lens-capsule when 
 it heals in the corneal scar; liberation of a portion of the iris healed in 
 the scar; procedure for cystic scars after iridectomy for glaucoma., 
 
 CHAPTER XIX. 
 
 EXTRACTION OF FOREIGN BODIES FROM THE INTERIOR OF THE EYEBALL. 222 
 Difficulty of the operation; diagnosis of intra -ocular foreign bodies; 
 importance of examination of the posterior portion of the eyeball with 
 the ophthalmoscope; sideroscopic examination; Roentgen examination; 
 deference to small wounds or scars; technic of extraction with the 
 giant magnet; advancement of the foreign body from the vitreous to 
 the anterior chamber; extraction of a foreign body from the anterior 
 chamber; use of Hirschberg's magnet; extraction of an iron splinter 
 through the sclera; indications; prognosis of injuries from iron-splinters; 
 extraction of particles other than those of iron; opening of the eye- 
 ball through a long scleral incision; marked facilitation of the operation 
 through the lamp of Sachs; procedure in old injuries. 
 
 CHAPTER XX. 
 
 VARIOUS MINOR OPERATIONS. REMARKS CONCERNING ANESTHESIA AND 
 
 ASSISTANCE 230 
 
 Operative treatment of serpigineous ulcer; subconjunctival injections; 
 cauterization of an ulcer; puncture of the anterior chamber; Saemisch's 
 operation; frequent repetition of the incision; iridectomy to prevent 
 glaucoma; operations for pterygium; transplantation; Arlt's method; 
 tattooing of the cornea; indications; prickling with a multiple needle;
 
 CONTENTS. Xlll 
 
 use of the hollow needle; Froehlich's method of tattooing; operations 
 for corneal staphyloma; method of Beer; method of de Wecker; 
 possibility of sympathetic ophthalmia; squeezing trachoma-granules 
 from the conjunctiva; roller-forceps of Knapp; expression by Kuhnt's 
 method; concerning assistance; the lid-speculum is an instrument 
 which endangers the eyes; Mueller's lid-speculum; help rendered by 
 the assistant during the cataract -operation; Desmarres' spoon; down- 
 ward guiding of the upper lid with the assistance of inserted instru- 
 ments; operation without fixation-forceps; sponging; other aid which 
 the assistant may render; anesthesia; advantage of local anesthesia; dis- 
 advantage of general anesthesia; use of adrenalin; preference given 
 cocain over its various substitutes; dropping cocain on the bared iris; 
 scopolamin-morphin-narcosis; its advantages; Fuchs' wire-shield; 
 Snellen's cup-shield. 
 
 IXDEX 245
 
 OPHTHALMIC SURGERY. 
 
 CHAPTER I. 
 THE LACHRYMAL APPARATUS. 
 
 EXCISION OF THE LACHRYMAL SAC. 
 
 Anatomy. Before beginning the operation it is necessary to under- 
 stand the relative position of the internal palpebral ligament and 
 the anterior lachrymal crest. By placing the finger against the outer 
 canthus and stretching both lids slightly outward in a horizontal direc- 
 tion, the ligament is seen at the inner part of the eye as a slightly 
 circumscribed prominent cord immediately beneath the skin. This 
 ligament is Y-shaped, has a horizontal part, which takes its origin from 
 the bone, whereas the two branches of the Y are continuous with the 
 tarsal parts of the eyelids, in this way fastening them to the bone. The 
 lachrymal sac lies behind this so-called tendo oculi in such a manner 
 that the top of the sac is on the level of the horizontal portion of the 
 tendon, the sac itself extending downward from it for its entire length. 
 
 The anterior lachrymal crest is the most important landmark 
 throughout the operation. In thin individuals it may at times be 
 seen through the skin; in all other cases it may be found easily by per- 
 mitting the finger to glide along the lower orbital edge in a direction up- 
 ward and inward. In some instances it is prominent, forming a sharp 
 border; in others, it is flat and may then be felt much better by sliding 
 the closed forceps from the side of the nose to the inner wall of the orbit. 
 At times it is relatively superficial; at others, much deeper. At a 
 point where the crest forms a part of the lower bony orbital margin, it 
 is always very prominent; its upper half, however, is usually quite flat. 
 All these circumstances are of considerable importance in the perform- 
 ance of the operation. The more superficial the crest, the more 
 readily it is reached, and the easier is the extirpation of the sac; the 
 deeper the crest, the more difficult the operation. 
 
 The method recommended for the extirpation of the sac has proved
 
 2 OPHTHALMIC SURGERY. 
 
 eminently satisfactory. It requires an accurate knowledge of the topo- 
 graphic anatomy of this region, and this will be discussed as the various 
 stages of the operation are described. 
 
 In the dissection of the structures we commence the incision 
 through the skin, beginning at a point 2 mm. above the ligament of 
 the internal canthus and 3 mm. to the inner side of the canthus. The 
 direction of this incision is downward and in its lower half curved 
 slightly outward, whereas the upper half has to be perpendicular 
 (Fig. i). If, for instance, the upper half of the cut is not straight, but 
 
 FIG. i. With the thumb of the left hand (1. th.) the skin is fixed, but not pulled or 
 stretched. The cutting edge of the knife is directed vertically against the bone. The 
 incision is downward, slightly outward and somewhat curved; 3 to 4 mm. distant from 
 internal canthus. 
 
 curved towards the upper lid, an ugly fold of skin is frequently produced 
 at the upper angle of the incision during the healing process. While 
 making the incision, which, by the way, corresponds to the position 
 of the crest, we must not pull the lids outward with the idea of making 
 the skin tense. This would prevent the incision from being made at 
 the desired point. It is sufficient to press the upper inner part of the 
 skin backward against the bone with the thumb. If we use a sharp 
 knife, slight pressure against the skin will indicate the direction of the 
 incision, and then to deepen it more readily, the skin may still be 
 stretched. 
 
 The length of the incision is not of much importance. The be-
 
 THE LACHRYMAL APPARATUS. 3 
 
 ginner should make a long incision (about if cm.), as this facilitates 
 the dissection of the sac. The expert operator usually prefers a short 
 incision. The length of the cut varies, therefore, from i cm. to if cm. 
 The further from the external canthus the incision is made, the more 
 difficult becomes the dissection of the sac on account of the increasing 
 distance from it. 
 
 After completing the cut, the edges of the incision are lifted up and 
 dissected from the underlying tissue with the scalpel turned toward 
 the canthus, so the wound may be readily opened and the tearsac 
 speculum (Miiller's) introduced without difficulty. This instrument 
 is of great advantage, as it takes the place of an assistant and, by com- 
 pressing the surrounding tissues, aids materially in hemostasis. The 
 speculum is introduced closed, and to insert the hooks properly, the 
 wound edges must first be lifted gently with forceps. Its handle is 
 turned downward and slightly outward. The patient must keep his 
 eyelids closed throughout the entire operation. It is, of course, neces- 
 sary during the introduction of the instrument to fasten the hooks se- 
 curely into the wound edges, so that no injury of the cornea be produced 
 by any sudden jerking loose; since even an erosion might become dan- 
 gerous because of the great liability of infection. 
 
 In the wound, pulled open with the aid of the speculum, is laid bare 
 a delicate, thin, white membrane, the superficial fascia. Frequently 
 this is considerably thickened in the direction of the palpebral fissure 
 throwgh layers of connective-tissue fibers, some of which are connected 
 with the ligamentum canthi, and radiate from it. They must not be 
 confounded with the true ligament of the canthus, which belongs to a 
 deeper stratum. 
 
 In place of the scalpel, with which the main incision was made, we 
 now employ a small, slightly curved pair of scissors, both blades of 
 which are pointed and with these the operation is completed. With 
 tooth forceps we pick up a fold of the superficial fascia, transfix it 
 with one blade of the scissors and slit it throughout the entire length of 
 the wound, pushing it back toward both margins of the same. We 
 thus expose a layer of red fibers, the orbicularis muscle (palpebral 
 portion), the fibers of which, as is known, arise from the internal pal- 
 pebral ligament. 
 
 The muscle is slit up in the same manner as the superficial fascia 
 and the fibres pushed back toward both sides with the closed scissors. 
 We now expose to view in the floor of the operative wound a dense
 
 4 OPHTHALMIC SURGERY. 
 
 white membrane, the deep fascia, which covers the lachrymal sac 
 (Fig. 2). This extends from the anterior to the posterior lachrymal 
 crest and bridges over the fossa containing the lachrymal sac. Above, 
 below and at the inner side, the fascia becomes continuous with the 
 periosteum of the neighboring bones; but at the posterior lachrymal 
 crest it fuses with the orbital septum, thus completing the membrane 
 
 FIG. 2. The separation and pulling to either side of the muscle-fibers (m) exposes the 
 deep fascia (f. p.) in the wound; behind this the sac must be looked for. In the upper 
 angle of the wound are the transverse fibers of the ligament of the internal canthus (1. c.). 
 Through them the anterior lachrymal crest (cr. a.) can always be felt and can usually be 
 seen. 
 
 which separates the lachrymal fossa from the orbit. The specially thick- 
 ened median portions of this fascia form a prominent dense cord which 
 
 has already been referred to as internal canthal ligament. 
 
 i 
 
 The fibers visible at this point may also be referred to as the anterior branch of 
 the ligament. From it radiate bundles of fibers into the tarsus of the upper and 
 lower lid. In contradistinction to this the portion of the fascia attached to the 
 posterior lachrymal crest is spoken of as posterior branch of the ligament. This 
 arrangement, useful also because of the differences in insertion of the muscle-fibers,
 
 THE LACHRYMAL APPARATUS. 5 
 
 is understood without difficulty, when a horizontal section of the skull made 
 through the region of the canthal ligament is viewed. By pulling the lids outward 
 an angular folding of the deep fascia is produced, which bounds a triangular space 
 with the lachrymal fossa. Its floor is formed by the fossa itself, its branches 
 (anterior and posterior) by the corresponding portions of the internal canthal liga- 
 ments. In this triangle is to be found the cross-section of the lachrymal sac. 
 
 At this stage of the dissection the operator sees neither the crest, 
 unless it is abnormally prominent, nor the lachrymal groove. To note 
 their exact positions, he must feel around with the forceps, gliding from 
 the side of the nose toward the orbit. The anterior lachrymal crest 
 must serve as landmark during the entire operation. By not dissecting 
 too near the median line he will, on the one hand, escape the mistake 
 of incising the periosteum of the dorsum of the nose, instead of freeing 
 the lachrymal sac; on the other hand keep from going in the wrong 
 direction from the sac toward the orbit. 
 
 The deep jascia has to be split now with the scissors, inserting (he 
 scissors to the outer side of the anterior lachrymal crest, 1-2 mm. 
 behind it. This is not easy, particularly on the cadaver, if we wish to 
 escape injuring the sac. One difficulty is that no fold of tissue can be 
 picked up for transfixion by the scissors, as the fascia is very tense. 
 We are, therefore, forced to perforate the layer with one of the points 
 of the scissors, holding the instrument almost parallel to the plane of 
 the fascia. It is our custom to make the cut through the fascia 1-2 mm. 
 behind the crest, and not, as done by others, right on the crest, 
 so as to make the following dissection of the lateral wall easier. 
 
 As the sac lies near the fascia, its anterior wall may be injured by 
 cutting too brusquely. This is particularly true on the cadaver, when 
 the sac is not diseased and the walls are therefore thin and made 
 friable through beginning decomposition. For purposes of demon- 
 stration (it may also be done with the best of success at operations), 
 it is as well to slit the fascia along its entire length with a narrow, pointed 
 knife (Graefe's linear knife), holding it obliquely with the cutting sur- 
 face forward. I myself prefer to use the scissors for this cut. The 
 danger of injuring the tearsac can be diminished by drawing away the 
 fascia from it, by taking the ligament with the forceps and pulling it 
 outward and forward. Moreover, the sac being thickened in the 
 patient, the danger of injuring it is reduced to a minimum. However, 
 the operator should begin with a very short cut through the fascia so 
 that even in case the sac is injured, its perforation need not be extensive.
 
 6 OPHTHALMIC SURGERY. 
 
 This cut must be completed through the whole length of the membrane, 
 and severs the ligament of the canthus at the same time. In the slit- 
 like opening thus produced may be seen the lachrymal sac, readily 
 distinguished because of its bluish color (Fig. 3). In operating 
 on living patients, it is not uncommon to have the anterior wall of the 
 sac bulge through the opened fascia in the form of a hernia. 
 
 The remainder of the operation consists in peeling the sac out of 
 
 FIG. 3. The deep fascia is incised throughout the entire length of the wound i mm. 
 behind (i.e., to the side of) the crest (cr. a.). This lays bare the bluish-red lachrymal sac 
 (sa.). The ligament of the internal canthus, which the figure shows to have been pre- 
 served, is cut through at the same time. 
 
 its coverings. From now on, the operator must constantly keep close 
 to the wall of the sac, but must not injure the fascia or cut it away 
 at the same time. There are no blood vessels of note in the loose tissue 
 connecting the sac with its fascial capsule, and, therefore, during the 
 dissecting there will be no annoying hemorrhage. 
 
 It is my usual custom first to separate the lateral wall of the sac from 
 the fascia. For this purpose I pick up the lateral margin of the fascial 
 wound with tooth-forceps and separate the delicate connective-tissue
 
 THE LACHRYMAL APPARATUS. 
 
 7 
 
 fibers which connect the sac with the lateral wall of the fascia, beginning 
 in the lower half of the wound and using for the purpose the edge of the 
 closed scissors (Fig. 4). With a few strokes the lateral wall is sepa- 
 rated back to the bone. 
 
 It is only when reaching the upper part that a disturbing factor is met. 
 There is seen a bluish cord going to the lid, the lachrymal ducts. 
 
 FK;. 4. The lateral margin of the fascial wound (f. 1.) is grasped with the forceps, and 
 the closed scissors made to separate the loose areolar tissue between sac (sa.) and fascia , 
 as far back as the bone. 
 
 These must be directly cut as close to the fascia as possible and not 
 dissected by the closed scissors or else a piece of the mucous membrane 
 will be left hanging to the fascia. Next, the median wall of the sac 
 is loosened. Should the portion of the fascia left behind at the crest 
 be too broad to free the crest easily, an incision must be made into it 
 (j in Fig. 6). Gliding along the upper flat half of the crest with the
 
 8 OPHTHALMIC SURGERY. 
 
 point of the closed scissors, it is an easy matter to separate the wall of 
 the sac from the bone (Fig. 5). On the cadaver it is often possible to 
 preserve the periosteum of the lachrymal bone, but on the living 
 subject adhesions nearly always compel the removal of the periosteum 
 with the wall of the sac. Because of this, the bone is denuded over the 
 lachrymal fossa, but no importance need be accorded the injury. We 
 
 FIG. 5. A short transverse cut (easily seen in Fig. 6 (i), while in this drawing it is 
 pulled to one side by the forceps) into the median margin of the fascial wound exposes the 
 anterior crest (cr. a.); this makes it easy to push the closed scissors between the bone and 
 sac (sa.) at the upper part of the crest and to loosen the sac. The point of the scissors 
 is directed toward the bone. 
 
 continue to proceed with the point of the closed scissors to the posterior 
 lachrymal crest. If the upper half of the median portion of the sac 
 had been freed, it will not be difficult to peel its lower half from behind 
 the prominently projecting crest without injuring the sac; but if the 
 preparation for excision has been begun at the lower steep portion of 
 the crest, the sac will usually be injured. This is a mistake frequently 
 committed by beginners.
 
 THE LACHRYMAL APPARATUS. 9 
 
 The sac has now been cleared from all sides, but at the upper pole 
 its apex is still fastened to the surrounding structures, while at the lower 
 point it is continuous with the mucous membrane of the duct. For 
 the first time since the operation began we can now grasp the entire 
 sac with the forceps without fearing the risk of tearing it, and dissect 
 
 FIG. 6. The sac, having been freed on both sides, is now for the first time grasped with 
 forceps near its apex (t) and separated from the surrounding structures with sharp cuts of 
 the scissors as near the sac wall as possible. The upper margin of the wound is lifted up 
 with a double tenaculum. (See Fig. 5 (i), transverse cut into fascia.) 
 
 it out of the surrounding fascia with which its top is intimately united, 
 making small nicks with the scissors as near as possible to the wall of 
 the sac (Fig. 6). 
 
 This freeing of the top is a difficult part of the operation. It may 
 readily happen if all the sac is not removed, that troublesome dis- 
 charge continues. We must also be careful not to cut too much tissue
 
 10 
 
 OPHTHALMIC SURGERY. 
 
 away with the apex, as in such case injury to larger blood-vessels is a 
 common occurrence. This, by setting up considerable bleeding, will 
 hide from view the field of operation lying beneath. In spite of the 
 greatest caution, we sometimes have profuse hemorrhage. Because 
 of this, I have recommended not to dissect the top until the entire sac 
 has been completely shelled out. Even should a considerable bleeding 
 
 FIG. 7. The sac, having been freed from the surrounding structures at all points except 
 at its lowest portion, is grasped with the forceps low down ; the vertically held scissors are 
 made to cut away all the tissue attached to its anterior wall as close to it as possible until 
 the naso-lachrymal duct is reached. 
 
 then occur, it need not cause much annoyance, as the entire sac is safely 
 held in the forceps. 
 
 As soon as the upper portion has been freed, the entire sac may be 
 pulled forward. Should its posterior surface still be attached to the 
 bone by a few connective-tissue fibers, a few strokes with the closed 
 scissors will suffice to separate them. 
 
 The next step is to dissect the sac downward as far as possible.
 
 THE LACHRYMAL APPARATUS. II 
 
 For this purpose I take hold of the sac with the forceps at as low a 
 point as possible (Fig. 7), and, holding the scissors vertically from 
 above downward near the wall of the sac, make several cuts in front 
 and to both sides. These incisions will at once free the path to the 
 beginning of the naso-lachrymal duct. Finally, the vertically held 
 scissors are pushed down into the bony portion of the duct from the 
 anterior or lateral surface, and in this manner the sac is cut through. 
 While the assistant -tampons the wound, I put the sac over a Bow- 
 man's probe to convince myself of the intactness of its wall, believed 
 
 FIG. 8. Operative Field after Completed Excision. The small portion of the deep fascia, 
 which has been left behind, is seen hanging to the anterior lachrymal crest; on it the trans- 
 verse incision (i) is still visible. The saccal fossa (f. s.) is quite empty. The outer border 
 is formed by the deep fascia (f. p.) where it is firmly attached to the posterior lachrymal 
 crest; it is of a white color and has a distinct luster. Behind the anterior crest is the probe, 
 which passes through the duct into the nose. 
 
 to be removed as a whole. If the stenosis present is complete, the sac 
 will have the appearance of a closed cyst. The mucous membrane 
 is brought to view only after the sac has been cut open. If we now 
 examine the wound cavity (Fig. 8), and this should never be omitted, 
 we will see as the median boundary the lachrymal crest and the bony 
 lachrymal fossa, deprived of its periosteum; and as the lateral wall the 
 dense, white, smooth, glistening deep fascia (the posterior branch of 
 the internal ligament of the canthus), which completely separates the 
 wound from the orbit. The sac does not properly lie within the orbital 
 cavity, but rather outside it.
 
 12 OPHTHALMIC SURGERY. 
 
 If during the operation, the surgeon loses his bearings and dissects 
 toward the orbit, the connective tissue septum is usually injured and 
 considerable disturbance is produced by the orbital fat entering the 
 wound. This fat prevents a good view of the operative field, and retards 
 the operation considerably by the hemorrhage which results when it is 
 cut away. 
 
 Finally, we must introduce a Bowman's probe into the naso- 
 lachrymal duct. To find its opening we place the instrument verti- 
 cally against the bone immediately behind the anterior lachrymal crest 
 and push it downward. Should the passage be closed, the instrument 
 must be forced through the cicatricial tissue. In every instance this 
 passage must be enlarged with a sharp curette, and all the mucous 
 membrane found in the duct scraped away. Curettment of the 
 cavity which contained the sac is not only unnecessary, if the sac has 
 been excised properly, but even superfluous. The naso-lachrymal 
 duct is opened with the probe in every case and made perfectly patulous 
 by curettment, not only to prevent any possible secretion from its 
 mucous membrane, but also to provide drainage for the wound. 
 Before closing the wound with sutures, it must be washed out with a 
 weak corrosive sublimate solution, care being taken that the fluid will 
 not enter the opened naso-lachrymal duct and through it reach the 
 mouth of the patient. 
 
 The sutures should receive especial attention. The skin of the 
 neighborhood is thin, often easily torn, and usually curled up at the 
 margins of the wound. If the edges of the skin are not perfectly 
 apposed, primary union is impossible, and the relatively large wound 
 must fill in by granulation. This means not only a retardation of the 
 healing process, but also a broader and more conspicuous scar, while 
 the delicate scar following a w^ell applied suture and healing by first 
 intention is often hardly visible. 
 
 Three sutures suffice, if the w r ound is of the usual length; if shorter 
 than usual, perhaps only two. Thin silk is the best material for the 
 purpose. Small hooks, sharp and somew r hat bent, are inserted into 
 both the upper and low r er wound-angle, and the wound somewhat 
 stretched; the thin, sharply curved needles containing the thread are 
 then pushed through near the margins of the w r ound. The assistant 
 must then adapt both margins, which are usually curled up consider- 
 ably, with two pairs of forceps, so that margin apposes margin. He 
 then turns the forceps to one side, so that the operator, who holds the
 
 THE LACHRYMAL APPARATUS. 13 
 
 looped threads parallel to the wound, can apply the knot readily at the 
 side of the wound. The knots should not be drawn too tightly, but 
 only enough to maintain perfect adaption, as the silk readily cuts 
 through the skin, which at this point is easily lacerated. The threads 
 must then be cut short. 
 
 Before applying the dressing, the intactness of the corneal surface 
 must be investigated. I have already called attention to the danger 
 of an accidentally produced corneal erosion. The application of 
 the dressing demands great care. The closed eye must first be covered 
 with a small pad of gauze. This prevents the threads from other 
 parts of the dressing passing through the palpebral fissure and eroding 
 the cornea. The wound is then covered with a tightly rolled pad of iodo- 
 form-gauze, which is pressed slowly and with gradually increasing 
 force against the wound, so that the wound-cavity is completely oblit- 
 erated. A second small pad made of sterile gauze is placed on top 
 of the iodoform gauze. This ensures permanent compression. The 
 entire eye is then covered with a few layers of white gauze, and the 
 entire dressing secured with a strip of adhesive plaster, which should 
 be drawn tightly. Lastly the bandage is applied. The other eye 
 remains open. 
 
 On the following day the dressing is removed for the purpose of 
 inspecting the cornea. The compression-pad, however, is not 
 removed from the wound, the outer angle of the palpebral fissure being 
 opened but slightly with the fingers. If the case progresses satisfactor- 
 ily, the second change in dressings is not made until the third day. 
 On the fourth day the dressing is taken off, the stitches removed, the 
 wound healing by first intention. Should the suture-openings bleed 
 slightly, it will suffice to dust them with xeroform or to close them for a 
 day with adhesive plaster. 
 
 If, however, blood has collected in the wound-cavity, the progress of 
 the healing of the wound is retarded. The cause of the accumulation 
 of blood is nearly always incomplete compression of the wound. In 
 this complication the patient complains of pain within a day or two 
 after the operation, and upon removal of the dressings the wound is 
 found to be bulging, and the skin dusky red and tender to the touch. 
 The best treatment is to remove the sutures, and to forcibly open the 
 wound with a sharp sound or probe, so as to afford free drainage for 
 the accumulated fluid. A small drain of iodoform gauze should be 
 inserted and a moist antiseptic dressing applied.
 
 14 OPHTHALMIC SURGERY. 
 
 Although this complication is annoying, it is usually found that 
 in the course of a few days the wound fills with granulations and cica- 
 trizes in a short time. 
 
 It is an entirely different matter, however, if the inflammation and 
 accumulation are due to retained particles of mucous membrane 
 of the sac in other words, if the excision has been incomplete. 
 This may happen occasionally to the most experienced operator; in the 
 case of beginners it is not at all a rare occurrence.
 
 CHAPTER II. 
 
 THE LACHRYMAL APPARATUS (Continued). 
 EXCISION OF THE LACHRYMAL SAC (Continued). 
 
 Before considering the complications which may arise in the perform- 
 ance of resection of the lachrymal sac it is necessary to discuss the 
 proper method of making the operative area anesthetic and anemic. 
 Practically all descriptions of this operation, refer to the extraordinarily 
 profuse bleeding, which obscures the field of operation and makes the 
 dissection more than ordinarily difficult. It is also generally noted 
 that cocain does not produce a sufficient analgesia, so that many opera- 
 tors prefer to remove the sac under general anesthesia. The employ- 
 ment of adrenalin, however, has produced a complete revolution in 
 this respect, and today the operation may be made almost bloodless 
 and painless. 
 
 The following preparatory measures are recommended: 
 
 After the conjunctival sac has been rendered anesthetic by a few 
 drops of 3 per cent, cocain-solution, the lower lachrymal duct is dilated 
 with a conical probe and a i per cent, solution of cocain is injected into 
 the sac by means of a lachrymal syringe. To prevent the fluid from 
 flowing into the nose and eventually into the mouth, the patient should 
 be placed in a sitting position with the head bent slightly forward. 
 In most instances the fluid will escape through the lachrymal ducts, par- 
 ticularly the upper. This preliminary procedure not only anesthetizes 
 but also cleanses the sac, which is of decided advantage, for, although 
 the sac itself is not injured during the operation, the lachrymal and naso- 
 lachrymal ducts are cut through, and the contained secretion may 
 escape and contaminate the wound. But even in such cases, in my 
 experience, infection of the wound is of rare occurrence, and should it 
 occur, it is nearly always of light character, never becoming serious. 
 
 The technic of the operation is as follows: The contents of a 
 Pravaz's syringe of i cc. capacity will be sufficient quantity for the 
 injection. The solution is mixed in the following manner: 8 to 9 parts 
 of the syringe are filled with the i per cent, cocain-solution, the 
 remainder, from i to 2 parts, filled with adrenalin or suprarenin solu- 
 
 15
 
 1 6 OPHTHALMIC SURGERY. 
 
 tion (i-iooo). One-third of the contents of the syringe is injected 
 beneath the skin, the needle entering slightly below the tarsal ligament. 
 This produces a slight bulging forward of the lachrymal-sac region, 
 but slight massage causes the immediate disappearance of this swelling. 
 The point of the needle is now inserted above the tarsal ligament and 
 pushed vertically against the bone. The syringe is then twisted for- 
 ward 90 so that the needle is turned in the direction of the orbit. Hold- 
 ing it in this direction the point is pushed forward to very near the peri- 
 osteum and the second third of the solution injected, so that the tissue 
 around the top of the lachrymal sac is made anesthetic and anemic from 
 this injection. With the remaining solution the region immediately 
 about the entrance into the naso-lachrymal duct is anesthetized. 
 The injection is made in a manner similar to that previously described. 
 The needle is inserted below the tarsal ligament in a direction vertical 
 to the lachrymal crest; the syringe is then turned in such a manner 
 that the needle lies parallel to the bone, when it is pushed slightly 
 backward. Should the point of the needle enter the lachrymal sac 
 itself, it must be pulled out somewhat and turned in a slightly different 
 direction. This complication is readily recognized by the escape of 
 fluid from the tear-ducts. 
 
 Immediately after completing the injection, the operation may be 
 commenced. In a large majority of cases, the bleeding is so slight that 
 layer after layer of tissue may be removed as in the dissection of a 
 cadaver. I have frequently resected lachrymal sacs in a few minutes 
 without any assistance. It is really only the incision through the skin 
 which may bleed more than expected, as occasionally the skin contains 
 abnormally large veins. The deeper parts are always absolutely 
 anemic. 
 
 The stated quantity of adrenalin (y 1 ^ to y 2 ^ cc.) suffices fully for the 
 production of this anemia. In my experience it has never been 
 followed by bad after-results, either local such as marked secondary 
 hemorrhage or necrosis of the tissue, or constitutional. Occasionally a 
 patient may complain of sudden distress, such as a sensation of oppres- 
 sion and palpitation of the heart, but these symptoms disappear shortly. 
 In elderly patients with advanced arteriosclerosis, not more than 
 T V cc. of the adrenalin should be injected, and this amount will be 
 sufficient. Dropping the adrenalin into the wound is unsatisfactory. 
 After the sac has been peeled out, and before the probe is inserted into 
 the nose, some cocain should be dropped into the wound. It will
 
 THE LACHRYMAL APPARATUS. 1 7 
 
 diffuse itself into the duct along the probe, and will make the curettment 
 with the sharp spoon almost painless. 
 
 Complications. The proper resection of the lachrymal sac is one of 
 the most difficult operations in ophthalmology. The difficulty, espe- 
 cially for the beginner, lies in finding the sac. Of course, this refers 
 only to cases in which the sac has not become so distended as to be 
 visible as a tumor through the skin. The anterior lachrymal crest 
 must always serve as a landmark throughout the entire operation; and 
 the operator should always keep as dose as possible to the bone. He 
 will then refrain from looking for the sac too near the nose in the per- 
 iosteum of the bone, and also avoid penetrating the orbital tissue with 
 H'hich he should never even come in contact. 
 
 The opening of the orbital cavity, through injury to the dividing 
 fascia, becomes dangerous at times, as it may terminate in infection of 
 the orbit and formation of an orbital abscess, though ordinarily it is 
 disadvantageous only because of the protrusion of fat and hemorrhage 
 from the orbital tissues. The beginner enters the orbit quite often, not 
 from injury to the fascia, but because he fails to work toward the crest, 
 and he dissects backward and penetrates the fat of the orbit on the 
 outer side of the fascia, without ever having cut into it. In so doing 
 he naturally does not find the lachrymal sac. 
 
 Should the sac be injured during the operation no importance need 
 be attached to the accident, provided the operator sees his mistake at 
 once and returns to dissect at the proper point. It may happen that 
 during the opening of the deep fascia (especially if done quickly) not 
 only the fascia but also the anterior wall of the sac, which lies imme- 
 diately beneath it, is slit open. If the operator is not aware of the 
 accident, he may dissect off only the anterior half of the wall, thinking 
 that he has the entire sac before him. If he is sufficiently careful, 
 however, and notes the injury, he can retrace his steps and without 
 much difficulty find the right spot for continuance of the dissection on 
 the outer side of the sac wall. The cleaner the dissection of the sac, i.e., 
 the closer to the wall of the sac the operator keeps, by constantly dis- 
 secting between it and the covering fascia, the more satisfactory will 
 be the course of the operation. It is remarkable with what perfect 
 freedom from hemorrhage and pain the operation may be performed. 
 The operator who lacks sufficient knowledge concerning the exact 
 position and surroundings of the sac, and resects it together with all 
 the attached tissues so as to be certain to have the sac in the excised
 
 1 8 OPHTHALMIC SURGERY. 
 
 portion, will be greatly annoyed by hemorrhage, and his patient will 
 suffer much pain. 
 
 Even the experienced operator may fail occasionally in extirpating the 
 sac in one piece and may remove it in several portions. This may be 
 considered as practically a failure, as small particles of the mucous 
 membrane are retained, which could cause continuance of the dis- 
 charge or, still more unpleasant for the patient, lead to formation of a 
 fistula. The causes of such a disappointing result may be an excep- 
 tionally profuse hemorrhage, preventing accurate dissection, tearing of 
 the sac during operation, or, finally, the partial destruction of the ante- 
 rior wall of the sac, the dacryocystitis having produced a rupture into the 
 surrounding tissue without having gone so far as perforation of the skin. 
 
 The beginner finds more difficulty in the resection of the lateral 
 than of the median wall, since in removing the latter he need only keep 
 close to the bone. It is also quite a common error to sever the sac some 
 distance below the apex, leaving this portion behind, since the top is 
 closely adherent to the fascia covering it and must, therefore, be 
 removed with the sharp edge of the scissors. The importance of inspect- 
 ing the wound carefully after an entire removal of the sac, to note 
 whether or not the bone is healthy, is especially great in instances in 
 which a part of the sac has been left behind. Curetting blindly with 
 the sharp spoon is not only a crude procedure, but entirely without 
 value. 
 
 If parts of the sac have been left behind, the wound should 
 be well packed, the best material being tannin-iodoform gauze, and 
 further operation deferred until the bleeding has been checked com- 
 pletely. The wound is then held widely open with the speculum, 
 and a careful examination made. In most instances it w r ill not be 
 difficult to see the parts of the wall which have been left behind and 
 these must be grasped with forceps and carefully separated from 
 underlying fascia and bone. It is only by removing all the remaining 
 mucous tissue that a cure and healing by first intention can be expected. 
 
 If the wound is sutured over retained particles of mucous membrane, 
 primary union is prevented. Within a short time the wound is dis- 
 tended by secretion, and the sutures rupture, or must be removed to 
 allow escape of the retained secretion, otherwise persistent suppura- 
 tion will be the inevitable result. In the event of suppuration the 
 wound must be loosely packed with iodoform-gauze and washed with 
 weak bichlorid solution or a 6 per cent, solution of hydrogen peroxid.
 
 THE LACHRYMAL APPARATUS. 19 
 
 To at once curette the wound is an error, as it is impossible during the 
 period of granulation to recognize all the details of the wound. Even 
 though the sharp curette is thoroughly employed, the discharge will not 
 cease. The mucous membrane attached to the bone may be removed 
 by the operator, but that of the lateral wall, not having firm tissues 
 beneath it, always escapes the sharp instrument. 
 
 The skillful operator will often have occasion to dissect the entire 
 lateral wall and top of the lachrymal sac of patients who were treated 
 without success by repeated curettings, and will have no difficulty in 
 effecting an instantaneous cure by primary union. 
 
 Under such circumstances the preparation for extirpation is more 
 difficult than in those cases in which the tissues are still untouched. 
 Even in such cases it should be the aim of the operator to remove layer 
 after layer, at least as far as possible in the scar-tissue, instead of fol- 
 lowing the usual practice of cutting down in the first incision to the 
 anterior lachrymal crest. 
 
 The anemia produced by the cocain-adrenalin infiltration in the 
 dense scar-tissue is here of decided advantage, as it permits the operator 
 to see every step of the operation very clearly. The bluish color of the 
 mucosa readily differentiates it from the white of the scar-tissue, and in 
 most instances it can be peeled off very easily. This is then followed 
 by a close scrutiny of the wound to be assured that all the lining has 
 been removed, and then, as in a completely performed excision of the 
 lachrymal sac, the wound is closed by sutures. 
 
 The operation becomes still much more difficult, if either after 
 attempted extirpation or after dacryocystitis a fistula has developed. 
 In such cases one has to perform a long incision (2 cm.) so that the 
 fossa may be conveniently reached. The fistula must be completely 
 excised. The incision, which at first is only through the skin, is at 
 once deepened to the crest after the wound-edges have been dissected 
 up and the wound well stretched with the speculum. The entire fossa 
 is now cleaned out, thus excising all of the exposed scar-tissue. Very 
 often the lateral fascial boundary can be found, so that after com 
 pleting the operation there is presented the usual picture of the 
 wound, i.e., the median border formed by the bone with its promi- 
 nent crest and the lateral border by the fascia. Even in these cases 
 it is not advisable to use the curette, but prove by close inspection of 
 the wound that none of the mucous membrane has been forgotten. 
 Suturing the wound is unfortunately often impossible, as the skin,
 
 20 OPHTHALMIC SURGERY. 
 
 particularly if several attacks of dacryocystitis have preceded the oper- 
 ation, is easily torn. By packing the wound loosely, the rapid devel- 
 opment of granulations is favored, and the cavity will soon fill up. 
 Even after such an operation the scar may be remarkably insignificant. 
 It is not uncommon for the repeated mistreatment of the tissues to 
 result in a ectropion through shrinking of the scar. In these cases 
 success in elevating the lid and retaining it permanently in its proper 
 position has been achieved by sutures going obliquely through the 
 wound-edges from without inward and from below upward. 
 
 If there is great dilatation of the lachrymal sac, which, acting like 
 a tumor, pushes the skin forward, the operation cannot be performed by 
 the rules laid down. The tissues covering the sac may be so atrophic 
 that immediately after cutting through the skin the wall of the sac 
 may be exposed. In other respects, however, the removal of the sac 
 does not differ in the slightest from that of other tumors in this 
 region. If proper care is taken not to injure the sac, successful oper- 
 ation is easy. 
 
 Tuberculous disease of the lachrymal sac, especially as seen in 
 children, makes a radical operation difficult, as the wall of the sac is 
 frequently destroyed through tuberculous infiltration which may 
 implicate the bone. The diseased tissue must then be cut away, the 
 diseased bone removed, and the wound packed with iodoform gauze 
 and permitted to heal by granulation. Recurrence is common in this 
 type of disease, and is usually accompanied by formation of fistuke, 
 which then make secondary operations necessary. 
 
 If an acute dacryocystitis exists, no incision is made unless 
 perforation seems unavoidable. Otherwise we must be satisfied 
 with applying moist antiseptic dressings and must w r ait patiently until 
 the inflammation has completely disappeared, a matter of several 
 weeks. Then the extirpation of the sac must take place to prevent 
 the inflammation recurring. Formerly in such cases, the blood vessels 
 being markedly dilated, profuse hemorrhage was the rule during the 
 operation; this can now be completely avoided by the method of injec- 
 tion already given. 
 
 The Indications for the Resection of the Lachrymal Sac. This 
 operation is absolutely indicated: i. In all cases of chronic blenor- 
 rhea of the lachrymal sac, which lead to marked thickening of its walls 
 and eventually to its dilatation, to total obstruction of the naso-lachry- 
 mal duct, or to the formation of a fistula. 2. When an operation
 
 THE LACHRYMAL APPARATUS. 21 
 
 (iridectomy, extraction of a cataract, etc.) is to be performed on the eye 
 of the corresponding side. 3. When a purulent infiltration of the 
 cornea has taken place (infected erosion, ulcus serpens, etc.). Cauteri- 
 zation of such an ulcer would not bring about the desired result as the 
 discharge from the diseased sac would constantly flow over the denuded 
 area and through its microorganism produce new infections. 4. In 
 all cases coming to the dispensary, as these patients have not the time 
 for a long course of treatments with sounds, and at best this method 
 usually promises but indifferent results. Particularly is resection 
 recommended if the treatment with probes has previously been carried 
 out withouc substantial improvement. 
 
 The ultimate result of the resection-operation is very satisfactory. 
 In a very short time the scar is hardly visible, the catarrh constantly 
 associated with the blenorrhea soon disappears, and with it also the 
 lachrymation, the latter probably through a nervous influence. Should 
 the catarrh and epiphora persist after the operation, a careful examina- 
 tion should be made of the canaliculi, and if a slight amount of mucopu- 
 rulent discharge can be squeezed from them, it is a sign that some 
 mucous membrane has been left behind. If there is no discharge and 
 the lachrymation continues for several months after the operation, 
 the lower lachrymal gland must be resected.
 
 CHAPTER III. 
 THE LACHRYMAL APPARATUS (Continued). 
 
 EXCISION OF THE PALPEBRAL LACHRYMAL GLAND. 
 
 This operation is performed in those occasional cases in which the 
 watering of the eyes does not disappear spontaneously. When patients 
 living at a distance require removal of the lachrymal sac, it is often best 
 to simultaneously resect the lachrymal gland; this may possibly save 
 the patient a second journey. Lachrymation from other causes may 
 also indicate the operation. 
 
 The palpebral portion of the lachrymal gland is understood to indi- 
 cate that lobule of gland-substance which surrounds the excretory ducts 
 of the orbital lachrymal gland, at the point where they pass toward 
 and through the superior conjunctival fornix. This so-called infe- 
 rior lachrymal gland may be seen in many individuals by lifting or evert- 
 ing the upper lid at its outer part, while the patient is looking downward 
 and inward; sometimes it bulges forward in the form of a small lobu- 
 lated tumor. To reach the gland conveniently, the lid must be 
 everted twice. This is done best by first everting the lid with the 
 finger in the usual manner, then inserting an opened lock-forceps at 
 the junction of the outer and middle thirds in such a manner that one 
 blade is pushed beneath the lid into the conjunctival fornix, the other 
 lies anteriorly on the tarsus. The lock is slowly closed and the lid 
 everted the second time by turning the forceps slowly upw-ard. 
 
 If the conjunctival sac has been well cocainized at the outset, the 
 resection, carefully performed, is not painful. One-third c.c. of a i 
 per cent, solution of cocain should be injected under the conjunctiva; 
 the injection is best made into the tissues between the point of the for- 
 ceps and the external canthus. The operation itself is not difficult, 
 but it must be performed carefully if the gland is to be resected in one 
 piece, and not cut away in a number of fragments. 
 
 The first step in the operation is to make an incision through the 
 conjunctiva with a small pair of curved scissors; this should extend 
 horizontally from the point of the forceps toward the external canthus 
 for a distance of about i cm. The lobules, which may be numerous 
 
 22
 
 THE LACHRYMAL APPARATUS. 
 
 2 3 
 
 and well developed, at other times few and small, protrude through 
 the wound as soon as the connective-tissue membrane which encap- 
 sulates the lachrymal gland is opened. (The cocain-injection may 
 obscure the outlines of the structures at this time.) The next step 
 is to carefully dissect the conjunctiva loose both in an upward and 
 downward direction, i.e., toward the tarsus and toward the ocular con- 
 junctiva. Of considerable aid is the retraction of both portions of the 
 conjunctiva by the assistant with a double tenaculum. The lachry- 
 mal gland will finally be seen as a small node in the center of the 
 
 FIG. 9. Extirpation of the lachrymal gland. The upper lid is turned upward twice 
 i.e., upon itself and is maintained in this position by a lock pincette held by an assistant 
 at the outer third of the lid. The conjunctiva (c) is freed on both sides of the gland. The 
 wound is held open with double tenacula. In it is seen lying perfectly free the lower 
 lachrymal gland (gl.)> appearing as a small nodule. 
 
 wound (Fig. 9). The gland is now grasped with forceps and 
 separated from the orbital lachrymal gland with cuts of the scissors, 
 beginning at the nasal end. It is not necessary to dissect high up into 
 the orbit, but it is important that the lobules are shelled out for their 
 entire length, as only then can all the excretory ducts of the large gland 
 be cut through. The amount of glandular substance removed during 
 this is of no moment whatever. The white membrane laid bare in the 
 floor of the wound is the tarso-orbital fascia. It must not be injured. 
 It lies in front of the gland and does not interfere with its extirpation.
 
 24 OPHTHALMIC SURGERY. 
 
 Its injury might have added unpleasant consequences on account of its 
 connection with the tendon of the levator palpebrae and the 
 possibility of resultant ptosis. Fastening of the forceps at the outer 
 third of the lid, as ordered above, will prevent such occurrence, even if 
 the dissection is carried too deep and the fascia cut into and injured. 
 An injury to the outer skin or the external rectus muscle can be produced 
 only by reckless cutting; this is clearly apparent if the position of 
 the gland is considered. The hemorrhage during the operation is 
 slight, although usually disturbing, and the assistant is kept busy spong- 
 ing up the blood. 
 
 One catgut suture, bringing the wound together from above down- 
 ward, suffices, and the dressing may be removed after twenty-four 
 hours. After the operation the eye is usually ecchymotic for some 
 days on account of the blood subsiding to the lower levels. Slight swell- 
 ing of the upper lid produces some ptosis, but this disappears soon. The 
 result of the operation is generally good, even though occasionally 
 lachrymation is but little diminished. In one such case, even though 
 the operation was performed according to every rule mentioned, 
 weeping persisted to such a degree that it became necessary to remove 
 the orbital lachrymal gland itself. This operation must be per- 
 formed through an incision from the skin. 
 
 Dryness of the conjunctiva or the cornea need not be feared either 
 after extirpation of the inferior or the entire lachrymal gland, as the 
 glandular secretion of the normal conjunctiva is sufficient to prevent 
 this. However, after extirpation of the lachrymal gland, an obstinate 
 and long-lasting catarrh of the conjunctiva associated with thick mucoid 
 discharge is occasionally to be seen. 
 
 LACHRYMAL PROBING. 
 
 Dilatation of the Canaliculus. Before attempting to pass a 
 Bowman's probe, the lachrymal canaliculus must be dilated. This is 
 done with a conical probe. Its first position is vertical to the inferior 
 lachrymal canaliculus (Fig. 10). Before placing it in this position the 
 patient is asked to look up and the lower lid is pulled outward and 
 slightly away from the bulb, thus making the lid tense. The lachry- 
 mal canaliculi at first pass for a short distance downward, then gradually 
 upward and finally describe an almost right angle to empty into the 
 lachrymal sac. To dilate the left canaliculus, the physician, sitting 
 in front of his patient, employs his right hand. For the right canalic-
 
 THE LACHRYMAL APPARATUS. 25 
 
 ulus the left hand is used, or the surgeon may stand behind the patient 
 to dilate the latter, and work with the right hand. 
 
 After the point of the vertically applied conical probe has entered the 
 first portion of the lachrymal canaliculus, the probe is depressed into a 
 horizontal position and then pushed slowly forward, employing a 
 slight twisting movement until the bone is reached (Fig. n). When 
 lightly drawing the probe to and fro does not cause retraction of the skin, 
 we know that its point has passed through the canaliculus into the 
 
 FIG. io. Introduction of the conical probe into the lower lachrymal canaliculus. The 
 lid is pulled outward with one finger, and the lachrymal punctum thus turned slightly 
 forward. The probe is inserted vertically. 
 
 lachrymal sac and has come in contact with its median wall. The 
 operator must be careful not to use force in dilating the lachrymal canal- 
 iculus, as the point of the probe penetrates the wall easily, and a false 
 passage is thus made that makes proper probing almost impossible. 
 Injury of the lachrymal canaliculus or the wall of the lachrymal sac 
 is also to be avoided, because during subsequent injection of cocain 
 for purposes of anesthesia or during a cleansing of the sac with any 
 antiseptic or astringent solution, the fluid diffuses itself through the
 
 26 
 
 OPHTHALMIC SURGERY. 
 
 subcutaneous tissues, producing marked swelling of the structures in 
 the neighborhood of the lachrymal sac, as well as of the lids. 
 
 Through the insertion of the conical probe, which increases in size 
 gradually, the mouth of the lachrymal canaliculus is so far enlarged 
 that every number of the blunt Bowman's probe enters easily. The 
 slitting of the lachrymal canaliculus for the purpose of passing 
 these probes is not necessary, and, therefore, not to be recommended. 
 The canaliculus is a good guide for Bowman's probe and with its aid 
 the sac is always easily entered. When the canaliculus has been slit 
 open, it may become very difficult to find the beginning of the portion 
 which has been left intact and which forms the point of entrance to the 
 
 FIG. ir. Second step in the dilatation of the lachrymal canaliculus with the conical 
 probe. The probe is' placed in the direction of the canaliculus, and is pushed forward 
 with short twisting movements to the median wall of the sac. 
 
 lachrymal sac. Bitter experience has shown how 7 fruitless in such 
 cases such efforts may be, as occasionally the probe cannot be passed 
 at all, the aperture after the slitting contracting secondarily through 
 the formation of delicate scar tissue around it. There is usually no 
 difficulty in passing a No. 5 probe through the intact lachrymal 
 canaliculus. 
 
 Slitting the Canaliculus. The canaliculus should be slit only if 
 through eversion of the inferior lachrymal punctum the course 
 of the tears has been diverted and they trickle down the cheek, or if 
 an ectropion of the lower lid has begun to develop. Slitting the lower 
 canaliculus converts it into a backwardly directed channel which com- 
 municates freely with the conjunctival sac; the tears are thus guided 
 into their normal path and one of the main causes of ectropion is
 
 THE LACHRYMAL APPARATUS. 27 
 
 removed. This operation is performed with a Weber's knife, which 
 is inserted into the dilated canaliculus and pushed in until the probe 
 point of the knife touches the bone. The cutting edge of the knife is 
 directed upward and slightly backward. The finger pulls the lid out- 
 ward, making it tense, and the knife, the probe point of which remains 
 against the bone, is turned up, thus cutting the lateral part of the 
 canaliculus. The hemorrhage is slight. To prevent healing together 
 of the edges of the wound, they must be separated occasionally during 
 the next few days with the conical probe, until the epithelium has grown 
 over them. 
 
 Probing the Duct. For purposes of probing we use Bowman's 
 probes, Xos. i to 6. The point of the probe is placed vertically into the 
 dilated lachrymal canaliculus, and, after it has passed the lachrymal 
 punctum, its direction is changed to the horizontal, the skin of the lid 
 being drawn outward at the same time. When the tip of the probe 
 strikes the bone, the lid is released and the instrument at the same time 
 returned to its vertical position. With a slight push forward the probe 
 glides readily into the naso-lachrymal duct, provided there are no 
 adhesions. The position of the probe in the upper part of the canal is 
 easily recognized; if it is in the canal it will remain standing when the 
 hand is taken away, it falls over if it is not in the canal. If the probe 
 is in the canal for a certainty, and resistance is met with in pushing it 
 forward, slight force may be used to push it through stenoses and 
 adhesions. 
 
 If, however, w r e are not certain that the probe is in the canal, force 
 should never be used. The wall of the lachrymal sac is easily perfor- 
 ated, and a false passage into the surrounding tissues established. It 
 is to be particularly emphasized that the re-establishment of the probe 
 in its vertical position and its gliding into the naso-lachrymal duct are 
 especially difficult for the beginner. The probe is frequently pulled out- 
 ward a little, its point leaves the bone and gets into a false direction. 
 The conditions are especially difficult when the lachrymal sac is almost 
 completely closed off by adhesions. If the beginner is not absolutely 
 certain of his ground, it is hard to decide whether force may be at- 
 tempted or whether a false passage is being made. If the probe has been 
 inserted properly, its plate will be on a level with the eyebrows (Fig. 12) 
 and it will have retained the slightly curved shape and position into 
 which it has been brought. If the probe has entered a false passage, 
 it can be recognized by the abnormal position in which it is found.
 
 28 OPHTHALMIC SURGERY. 
 
 Ordinarily the rough ends of the perforation in the bone, through 
 which the probe has been pushed, may also be felt. 
 
 Before commencing the probing, the naso-lachrymal duct should 
 be made anesthetic with an injection of a 3 per cent, solution of cocain. 
 The best instrument for this purpose is Ariel's syringe. The most 
 suitable model has a ring at each side; the second and third fingers are 
 placed in these, while the thumb presses the piston dow r n. The syringe- 
 point is placed upright into the lachrymal canaliculus, is then changed 
 to a horizontal direction and pushed into the lachrymal sac just as if it 
 were a probe. In this position the fluid flows in with the slightest 
 pressure. If the naso-lachrymal duct is patulous, a small amount of 
 
 FIG. 12. Bowman's probe is passed through the naso-lachrymal duct. 
 The small plate of the probe is on a level with the eyebrow. 
 
 fluid will slowly run from the nose as the patient bends the head forward. 
 If considerable resistance is felt, the fluid should not be forced out of 
 the syringe under too great pressure, as it will either escape through 
 the superior lachrymal canaliculus or it will be forced into the surround- 
 ing tissues from the lachrymal sac, setting up an unpleasant swelling 
 of the lids which persists for several days, and for which the patient 
 usually blames the physician. The douching of the lachrymal sac 
 should never be performed with the patient lying down, especially 
 if the fluid is a cocain or bichlorid solution; as, should the naso- 
 lachrymal duct be patulous, the fluid will flow into the pharynx. 
 
 The probing is begun with No. i, and is repeated every second or 
 third day, the size of the probe being gradually increased until No. 5 
 is reached. It is well to remember that a thick probe may at times
 
 THE LACHRYMAL APPARATUS. 29 
 
 pass by a fold easier than a thinner instrument. The passage of the 
 probe may be considerably facilitated by the addition of a small amount 
 of adrenalin-solution to the cocain. This contracts the blood-vessels 
 in the wall of the duct, thus increasing its lumen and with it the space 
 for the penetration of the instrument. The probes must be passed 
 slowly and carefully, and slight injuries avoided, as these give rise to 
 the formation of scar-tissue and through it to new stenoses. The 
 instrument should be permitted to remain in the naso-lachrymal duct 
 at least fifteen minutes each time. The probing must be continued 
 until the fluid from Anel's syringe flows easily through the channel. 
 Dilatation to probe No. 5 usually suffices. If the weeping continues 
 it may be considered a proof, that in spite of the normal permeability 
 of the lachrymal canaliculus, tear-conduction and possibly even tear- 
 secretion is disturbed. Tear-conduction as is well known, is not 
 dependent alone on the normal permeability of the nasal duct, but also, 
 and perhaps to a greater degree, on the normal activity of the sac. In 
 such cases it does not improve the patient to continue the ordinary 
 probing or to employ the larger instruments. 
 
 It may be impossible to pass probes through the inferior lachrymal 
 canaliculus in the manner described, owing to occlusion by scars 
 following burns or injuries. The probes must then be passed through 
 the superior canaliculus. Its course is analogous to that of the lower; 
 first vertically upward, followed by a curve toward the sac. After 
 dilating with the conical probe, cocain is injected into the sac with 
 Anel's syringe. Bowman's probe is inserted in the direction of the 
 naso-lachrymal duct, i.e., in vertical position. 
 
 The Passing of Probes in New-born Children. We occasionally 
 see cases in which the secretion is retained in the lachrymal sac, thus 
 leading to considerable dilatation. This is the result of a congenital, 
 but only epithelial, occlusion of the duct, and it is cured by one 
 passage of a small probe. The operation is not more difficult in the 
 new-born than in the adult, but it must be remembered that the 
 distance between lachrymal point and nose is much less than in the 
 adult, and therefore the probe does not penetrate as great a distance. 
 
 Indications for Probing. If the constant dripping of tears makes 
 the existence of a duct-stenosis probable, it is well for the physician 
 to cocainize the conjunctiva, dilate the canaliculus with the conical 
 probe and push Anel's syringe cautiously into the lachrymal sac to 
 make sure of the diagnosis. If the naso-lachrymal duct is patulous,
 
 30 OPHTHALMIC SURGERY. 
 
 very little pressure will carry the fluid through into the nose of the 
 patient, as he holds his head forward. If the passage is narrow, the 
 fluid will not flow through for a short time, and then only in small 
 quantities, while the greater part escapes through the superior lachry- 
 mal canaliculus. The latter occurs if the lachrymal sac and the 
 naso-larchymal duct are comlpetely occluded. Warning has already 
 been given against using too much pressure, so as not to force the 
 fluid into the surrounding tissues. After once making certain that 
 the passage is narrow or completely occluded, the probes should be 
 employed beginning with No. 2. If cocain cannot be injected before 
 passing even the small probe, the attempt will be rather painful; at 
 the second attempt, however, one can usually force a few drops of a 3 
 per cent, solution through, thus making the treatment less painful. 
 The treatment is continued until the cardinal symptom indicating 
 stenosis, persistent weeping, has disappeared, or at least a No. 5 probe 
 passes easily. 
 
 Chronic epiphora does not, however, always mean stenosis of the 
 naso-lachrymal duct, nor does this condition always rest on a mechani- 
 cal basis. It may be a reflex condition as the result of diseases of the 
 conjunctiva, the lachrymal passages, the nose, etc. ; in fact it may also 
 depend upon central disturbances. These are circumstances which 
 should always be considered in the treatment of the affection. 
 
 If a marked blenorrhea of the lachrymal sac exists, the examination, 
 as before, is preceded by testing the permeability of the lachrymal 
 passages. In nearly all the cases a stenosis will be found, and the 
 treatment as above described must be instituted. Conservative meas- 
 ures (passing of probes and lavage) are only employed in those cases of 
 blenorrhea, which are not yet too far advanced. If the walls of the 
 sac are already markedly thickened, if the sac is already dilated or 
 perforated after acute inflammation, conservative treatment is out of 
 the question. The blenorrhea itself is treated with a ^ per cent, silver 
 solution, in preference to all other agents. 
 
 To avoid the inconvenience of having to pass Anel's syringe into the 
 canal after the probe has been taken out, the operator may employ 
 hollow probes, to which Anel's syringe can be fastened, while the 
 probe lies in the naso-lachrymal duct. When such a probe is pulled 
 out, the solution washes the duct most thoroughly. A fistula in the 
 tissues about the sac forms a rare indication for the lavage of the sac. 
 To determine whether the fistula is connected with the sac, a blue
 
 THE LACHRYMAL APPARATUS. 31 
 
 douche solution should be used. If a tumor exists in this region, it 
 may be necessary to pass probes to determine whether or not the sac 
 is free. 
 
 Contraindications. Probes must not be passed in acute inflamma- 
 tory conditions. If the lachrymal-sac disease is associated with disease 
 of the bone (tuberculosis), the passage of probes is contraindicated; in 
 such cases extirpation of the diseased sac must be performed. As al- 
 ready mentioned, total stenosis of the naso-lachrymal duct is also an 
 indication for extirpation of the sac.
 
 CHAPTER IV. 
 TRICHIASIS. 
 
 Of the numerous operations employed for the relief of trichiasis, 
 two typical methods will suffice in the greater number of cases, viz.: 
 those of Anagnostakis and of Panas. 
 
 The Hotz-Anagnostakis method is preferable in the ordinary 
 cases of trachoma. It gives the best cosmetic results. The skin is 
 incised along the entire length of the lid, either with a scalpel or a 
 
 FIG. 13. Excision of the fibres of the orbicularis muscle (m) covering the tarsus (ta). 
 With forceps the fibres are grasped along their upper margin at the left angle of the incision ; 
 a small pair of curved scissors is applied close to the tarsus, and with short cuts the muscle 
 is separated along the entire length of the lid. 
 
 lancet, 2 mm. above and parallel to the free margin. As with every 
 incision into the lid, an ivory plate is placed beneath it, not only to pro- 
 tect the eyeball but also to provide a firm base, and by the compression 
 exerted to assist in checking hemorrhage. Lying exposed in the wound 
 are to be seen the reddish fibers of the orbicularis muscle, which run 
 parallel to the edge of the lid. After the skin has been freed down- 
 ward for a short distance, and upward to the upper border of the tarsus, 
 
 32
 
 TRICHIASIS. 33 
 
 the fibers of the muscle are excised in a breadth of about 4 mm. For 
 this purpose they are lifted up with a tissue-forceps at one end of the 
 lid (Fig. 13), and severed all the way to the other end of the lid with 
 one stroke of the scissors, applied flat. In this manner the entire 
 tarsus is dissected free. 
 
 In most cases of trachoma, the tarsus is usually several millimeters 
 thick, is of very firm texture and curved convexly forward. The 
 beautiful striations produced by the Meibomian glands, seen in the 
 tarsus of the cadaver, are not shown in the tarsus of a trachomatous 
 
 FIG. 14. With the knife applied flat against the convex anterior surface of the thickened 
 tarsus (ta), thin slices are cut. The upper border of the tarsus and the margin of the lid 
 are not disturbed. 
 
 patient. In the latter the glands have disappeared for the rnost part, 
 only some indistinct traces of them remaining. It is best to excise, 
 or rather to diminish the thickness of this useless scar-tissue, which is 
 the cause of the distortion of the lid. For this purpose a sharp scalpel 
 is entered (Fig. 14) somewhat below the upper margin of the tarsus and 
 parallel to its plane, and with a sawing movement downward thin slices 
 are cut away. In a normal tarsus of the cadaver, this procedure can- 
 not be demonstrated, as any attempt in this direction would im- 
 mediately perforate the tarsus. On the* other hand, in a trachoma- 
 tous patient there is little danger of cutting through the thickened
 
 34 OPHTHA'LMIC SURGERY. 
 
 tarsus. However, this perforation should be avoided. Only the 
 uppermost part of the tarsus retains its original thickness; the margin 
 of the lid also is left intact. 
 
 The Insertion of the Sutures. The purpose of the sutures is to 
 stretch and straighten the tarsus which has been bent backward by 
 the disease. This is effected by fastening the lower margin of the 
 skin-wound to the upper border of the tarsus. Because of thediffer- 
 
 7 
 
 FIG. 15. Two sutures are applied. They pass from above through the skin (u); then 
 through the upper border of the tarsus (ta), in which they are firmly fastened; and lastly 
 through the lower margin of the skin (1) above the cilia. Corresponding to the convex 
 form of the upper tarsal border, the tarsal point of insertion of the outer suture is nearer 
 the lower margin of the wound than that of the inner suture. 
 
 ence in the height of these two points, union is possible only if the 
 lower border of the tarsus bends forward on itself and carries the cilia 
 into the desired position. The sutures are therefore introduced in the 
 following manner (Fig. 15): 
 
 The skin is first transfixed above at a point corresponding to the 
 middle of the lid, and is then retracted somewhat by an assistant, so 
 that the upper border of the tarsus is exposed. Next, the needle with 
 the suture pierces the upper border of the tarsus. We penetrate in a
 
 TRICHIASIS. 
 
 35 
 
 horizontal direction, introducing the needle from the wound-surface 
 and bringing it out again immediately. In this manner perforation is 
 prevented, which accident, however, is harmless. The assistant 
 now permits the upper margin of the cutaneous wound to return to its 
 normal position, and the lower border of the skin-wound is pierced at a 
 point corresponding to the upper point of entrance. One suture is 
 inserted in exactly the same manner on either side of the first, making 
 three in all. Frequently four or five sutures are employed. The 
 central suture is tied first. The two margins of the skin-wound are 
 approximated with two tissue-forceps in the hands of the assistant. 
 As the suture is tightened, the tarsus with the free border of the lid 
 bends forward and somewhat upward (Fig. 
 1 6). It is better to induce slight over-correc- 
 tion at first, so that the margin of the lid is at 
 a slight distance from the eyeball. The re- 
 maining sutures are tied with the same care, 
 the ends being cut off at about the same length 
 as in other skin-wounds. 
 
 A simple dressing is then applied and kept 
 from adhering by the insertion of gutta- 
 percha tissue covered with ointment. The 
 other eye need not be bandaged. The dress- 
 
 - ta 
 
 ta 
 
 FIG. 1 6. Sagittal section 
 through the upper lid after 
 completion of the operation. 
 The margin of the lid, now 
 placed vertically to the plane 
 
 mg, as in every other lid-operation, should be O f the lid, is so adjusted to 
 
 The sutures 
 
 the tarsus (ta) that no part of 
 it projects into the palpebral 
 fissure ; in fact, only a small 
 portion of the wound-surface 
 (the cut edge (c) of the" 
 
 changed on the following day. 
 should be removed after four days. 
 
 Complications, etc. If performed in the 
 
 manner indicated the operation gives good tarsus ) remains exposed, 
 results. As the edge of the lid is not injured, 
 
 its normal outlines are preserved, which from a cosmetic standpoint 
 is of great importance. The main advantages of the operation are 
 that the pathologically heavy tarsus is rendered light by the excision, 
 and the lid returns to its normal position without becoming shortened 
 in the slightest. There are several disadvantages. The tarsus is 
 crescentic in shape, being broadest in the middle of the lid and taper- 
 ing off somewhat toward both angles. Therefore, the effect of the 
 ()])(. ration is better in the middle of the lid than at the ends. As it is 
 not necessary to turn up the ends so far in order to attach the cutaneous 
 wound-margin to the upper border of the tarsus, it is possible in certain 
 rare cases that the trichiasis at the margin of the lid is not completely
 
 36 OPHTHALMIC SURGERY. 
 
 overcome. However, by excising a small piece of skin, the lid can be 
 slightly shortened and raised. At the same time a small incision may 
 be made into the intermarginal border at a corresponding point, so 
 that the sutures raise the cutaneous layer of the lid with its cilia, away 
 from the eyeball. The small wound produced in the intermarginal 
 border is allowed to undergo cicatrization. 
 
 Beyond this provisional incision no cut is made into the inter- 
 marginal border; in fact, a primary intermarginal incision would make 
 the stretching of the tarsus impossible, for as soon as the anterior 
 cutaneous layer of the lid is separated from the tarsus by such an 
 incision, the rolling forward of the lower tarsal border can no longer 
 be accomplished by the suture. Correction of the position of the 
 tarsus is not intended in the secondary provisional intermarginal 
 incision, but rather a displacement of the layer of skin containing the 
 hair-roots, similar to that in v. Jaesche's operation. This latter 
 operation alone would allow the thickened and heavy tarsus to retain 
 its curvature toward the cornea, keeping up the irritation as before. 
 Again, it must be remembered that the wound produced in the inter- 
 marginal border must heal gradually by cicatrization, which would 
 interfere with the best cosmetic results. The lower suture must not be 
 carried through the intermarginal border. It should be kept in front 
 of the eyelashes; otherwise, it will eventually cut through the skin, and, 
 by injuring the hair-roots, cause the cilia to fall out and possibly give 
 rise to an ugly indentation in the edge of the lid. 
 
 The possibility of recurrence following this operation need not be 
 feared, if the tarsus has been treated as above described. The thinning 
 of the tarsus is an essential advantage, resembling in this respect, 
 Snellen's method. If the tarsus is permitted to remain intact, the 
 suture may be inadequate to straighten the rigid tarsus, and the slight 
 resultant improvement may be destroyed by subsequent progressive 
 contraction of the scar tissue. 
 
 Panas's method is a much more radical and serious operation, 
 The eyeball is protected by an ivory plate and the incision through 
 the skin of the upper lid is made as in the former operation. The 
 muscle bundle of the orbicularis, however, is divided with the same 
 stroke. The tarsus is freed as far as its upper margin. Excision of 
 the muscle-bundles is not necessary in this operation. With a sharp 
 scalpel a cut is now made through the tarsus immediately above and 
 parallel to the margin of the lid, dividing the conjunctiva and extending
 
 TRICHIASIS. 37 
 
 along the entire length of the lid. Thereby the free lid-margin is 
 converted into a movable flap, which is connected with the surrounding 
 tissues only at both lid-angles. This flap must be fastened to the 
 exposed tarsus in such a manner that union is effected in a position 
 with the eyelashes directed forward. To accomplish this, four sutures 
 are inserted. The sutures are doubly armed and the needles should 
 be thin and decidedly curved. First, we pierce with the one needle 
 the upper margin of the wound in the tarsus close to the cut. It must be 
 held parallel to the wound-margin, and is passed from the anterior 
 surface and brought out again close to this point. Perforation of the 
 
 FIG. 17. After cutting through the skin (s) and muscle (m), the tarsus (ta) and con- 
 junctiva are incised, over an ivory plate placed between lid and bulb, along the entire 
 length of the lid. The central suture has already been introduced. Above it is fastened 
 to the tarsus near the edge of the tarsal wound. Both ends of the suture pass downward 
 between tarsus and muscle and emerge in the intermarginal border behind the cilia. Over 
 one end of the suture a glass bead is drawn. 
 
 thickened tarsus is easily avoided. Should it occur, it is of little im- 
 portance, as the suture is drawn into the conjunctiva without injuring 
 the cornea. In this manner the suture is fixed to the upper part of the 
 tarsus, and both ends pass between the muscle and tarsus of the free 
 flap through the intermarginal border. The other sutures are intro- 
 duced in a similar manner (Fig. 17). 
 
 The assistant now turns the edge of the lid forward with forceps, 
 thus bringing it perpendicular to the plane of the tarsus, and the 
 operator ties the central suture, drawing a glass bead over it. He 
 should be careful not to tie the suture so tightly that the glass bead will
 
 38 OPHTHALMIC SURGERY. 
 
 exert pressure on the edge of the lid, as this might lead to circumscribed 
 necrosis and subsequent loss of eyelashes. It suffices to tighten the 
 knot just sufficiently to allow firm attachment of the flap. The other 
 sutures are treated in exactly the same manner. The ends of the 
 sutures are cut off short. The cutaneous wound must then be closed 
 with several sutures, and an ointment-dressing applied to the operated 
 eye. The sutures may be removed as early as the fourth to fifth day. 
 
 If the sutures are not firmly attached to the upper part of the tarsus, 
 the operation will result in an unsightly disfigurement; if fastened at 
 too high a point, the free edge of the lid is pulled up above the margin 
 of the tarsal wound, and the tarsus projects free into the palpebral 
 fissure. The wound-surface must then heal by granulation, which 
 requires a long time, and terminates finally in the formation of a scar. 
 As this rough cicatrix is directed toward the cornea, owing to the 
 pathological curve of the tarsus, irritation of the cornea follows. If 
 the sutures have been properly inserted, the flap fits in accurately 
 and without any disfigurement. The possibility of recurrence is 
 absolutely excluded by this method of operation. 
 
 There are several disadvantages which must not be under-rated. 
 The base, from which the flap derives its nourishment, is small in 
 proportion to the length of the flap, and is, therefore, in danger of under- 
 going necrosis. Should this unpleasant complication arise, the patient 
 has not only been disfigured by the operation, but is probably even 
 in worse condition than before, as now the upper lid is shorter by the 
 necrosed piece, and a resultant lagophthalmos may be produced. Even 
 if the operation passes off without complication, the upper lid has been 
 shortened by the width of the flap, inasmuch as the flap has been 
 turned out of the plane of the lid to one perpendicular to it. Short 
 lids in patients seeking surgical aid must, therefore, be considered 
 another contraindication, to the operation, as in such cases lagophthal- 
 mos may be produced. 
 
 The lower lid may be operated on after the methods of Hotz and 
 Panas in exactly the same manner as the upper lid. Because of the 
 small size of the tarsus, however, Hotz's operation is less favored. 
 
 Other methods of Operation. With the foregoing two operations 
 all cases of total trichiasis, that is, in which the disease extends along 
 the entire length of the lid, and which still have their cilia arranged in 
 regular order, can be successfully overcome. The method of Flarer, 
 resection of the layer containing the hair-roots, is not described because
 
 TRICHIASIS. 
 
 39 
 
 it is always disfiguring. The method of Jaesche-Arlt consists in a 
 displacement upward of the hair-root layer. Like all skin-transplan- 
 tations on the lid-margin, it sets up fresh irritation of the cornea 
 because of the fine lanugo hairs, always present in the skin. 
 
 FIG. 1 8. Position of the intermarginal and skin-incisions, (a). Base of the skin-flap 
 containing the eyelashes, (b). Base of the upper skin-flap. 
 
 Special consideration must be made of cases in which the trichiasis 
 is confined to only one end of the lid, and also of those in which the 
 cilia are no longer arranged in a regular row, but stand out from the 
 lid-margin in various directions, occasionally projecting obliquely 
 backward from the posterior edge of the lid. 
 
 IK;. 19. The flaps interchanged. 
 
 Partial trichiasis, at either end of the lid near the canthus, is 
 best treated by the operation of Spencer Watson. This may be 
 briefly described as follows (Fig. 18 and 19): An incision extending 
 along the entire length of the area affected is made in the intermarginal 
 border. The skin of the lid is incised 2 mm. distant from and parallel
 
 40 OPHTHALMIC SURGERY. 
 
 to the margin of the lid. By turning downward the lid-margin, the 
 cutaneous incision is made to terminate at the canthus and join the 
 intermarginal incision. In this way the cilia are contained in a flap, 
 the base of which lies on the side away from the canthus. By a 
 second skin-incision, 2 mm. above and parallel to the previous one, 
 another flap can be marked out, the base of which lies on the side of 
 the canthus. By undermining, the flaps are made movable so as to be 
 exchanged in such a way that the flap with the lashes comes above, 
 while the upper skin-flap is placed at the margin of the lid. The 
 flaps are held in the new positions by sutures passing through their 
 angles, and within a few days permanent union takes place. 
 
 If this method were applied to cases extending the whole length of 
 the lid, the flaps would have too small bases as compared to their length, 
 and in consequence could very easily break down. Like all skin- 
 transplantations, the operation has the drawback of inducing renewed 
 symptoms of irritation from the fine hairs in the skin-flap. However, 
 as the flaps in the cases just spoken of lie to one side of the cornea, this 
 is not a very important disturbing factor. 
 
 When the regularity of the arrangement of the cilia is gone, a 
 condition which exists in the more severe cases of trichiasis, and is 
 often associated with corneal complications, a plastic operation must 
 be resorted to. This is performed in the following manner: An 
 incision is made along the intermarginal border, and the skin, together 
 with the cilia, is dissected away from the tarsus to about its upper 
 border. As the skin is usually rather short, there is some retraction 
 at once. By means of a few fine silk sutures the skin-edge is attached 
 to the tarsus, a few mm. above the margin of the lid. The wound- 
 surface produced in this manner is then covered with a flap obtained 
 from the mucous membrane of the lower lip. After everting and 
 cocainizing the latter, a flap of the size and shape of the defect in the 
 lid is marked out and quickly separated from the underlying structures. 
 It is then placed upon a pad saturated with warm normal salt solution 
 with its mucous surface downward, and a pair of scissors applied flat 
 to the surface, is used to free it of all adhering shreds of fat, so that 
 only the delicate mucous membrane remains. This flap is then placed 
 upon the defect in the lid with its wound-surface down, and its edges 
 are brought into exact coaptation. Sutures are not necessary and not 
 even to be recommended. The operated eye is then bandaged, and 
 a piece of gutta-percha tissue covered with ointment is applied over the
 
 TRICHIASIS. 41 
 
 upper lid to prevent the dressing from sticking. The flap soon adheres 
 and heals firmly and in four to five days the dressing can be left off. 
 
 The results of the operation as regards the trichiasis leave nothing 
 to be desired, but from a cosmetic standpoint the operation is not 
 a success, as the conspicuous contrast between the white flap and the 
 surrounding skin is always in evidence. In these severe cases, however, 
 cosmetic appearance is not considered, as the danger of grave ocular 
 complications makes reliable operative interference absolutely com- 
 pulsory. Skin from the arm must not be used because of the fore- 
 going reasons. We have repeatedly been compelled to excise such a 
 transplanted flap from individuals in whom a plastic lid-operation for 
 trichiasis had been performed in other clinics, because the fine hairs 
 of the flap greatly irritated the eye. In such instances the skin-flap 
 should be replaced with mucous membrane. The patient suffers 
 more from the fine hairs of a skin-flap than from misdirected 
 eyelashes; the latter he can at least see sufficiently well to pull out 
 regularly himself with forceps, while the fine hairs of the skin are 
 almost invisible. 
 
 In trichiasis affecting individual lashes the best mode of treat- 
 ment is electrolytic epilation. At this is a rather painful procedure 
 the lid must be thoroughly cocainized. The point of a Pravaz syringe 
 is inserted into the skin near the margin of the lid and pushed forward 
 so that the point to be treated becomes completely white or anemic 
 during the injection (infiltration-anesthesia). The epilating 
 needle, corresponding to the negative pole of the battery (the other 
 pole, attached to a moistened flat electrode is placed over the forehead) 
 is then inserted close to the cilia and pushed into the sheath of the 
 hair-bulb; if the right spot is chosen, this can be done without diffi- 
 culty. If a current from one-half to one milliampere strong, is per- 
 mitted to act for 30 seconds, fine vesicles will be seen to rise from the 
 hair-bulb, and the hair can then be extracted with ease by the use of the 
 cilia-forceps. It is of advantage to employ a magnifying lens during 
 the introduction of the needle, so the exact point of exit of the hair 
 may be more readily observed. The epilating process must be per- 
 formed in several sittings, as occasionally cilia, which have not been 
 destroyed, grow again and cause fresh irritation.
 
 CHAPTER V. 
 ECTROPION. 
 
 SPASTIC ECTROPION. 
 
 The clinical picture of spastic ectropion is well-known, as the con- 
 dition is frequently seen, especially in children with scrofulous inflam- 
 mation of the conjunctiva. The lid appears as though replaced by a 
 tense, red mass the swollen, edematous, infiltrated conjunctiva. These 
 cases are easily relieved by Snellen's suture (Fig. 20). The thread 
 used has to be double-armed by long, flat, strong needles. One 
 
 FIG. 20. At the highest point of the inverted lid lies a suture 3 mm. long, the ends 
 of which are passed under the skin to the lower border of the orbit. 
 
 needle is inserted through the conjunctiva at the junction of the inner 
 and middle third of the highest point of the ectropion, i.e., usually 
 at the convex cartilage margin, and carried under the skin downward 
 until it is somewhat below the lower orbital margin where it is passed 
 out. A second stitch is made in the same manner with the other 
 end of the suture, 3 mm. to one side of it. By this procedure, a loop 
 
 42
 
 ECTROPIOX. 43 
 
 is formed which overlies the palpebral conjunctiva in the place where 
 the ectropion is most prominent, while below the two ends of the 
 suture hang free through the skin. A similar loop is placed at the 
 junction of the middle and outer thirds. Both ends of each suture 
 are now tied over a small pad of iodoform gauze and tightened 
 so as to bring the lid back to its normal position. The loops exert 
 their action on the highest point of the ected afflid (Fig. 21), which 
 is drawn down and brought back again to its proper position. 
 
 The same suture may be employed in the treatment of spastic 
 
 FIG. 21. Vertical section through the inverted lower lid with the suture inserted. The 
 tarsus has been bent forward during the closing of the skin-wound. The eyelashes are 
 directed forward and slightly upward. 
 
 ectropion of the upper lid, the threads being drawn through the skin 
 slightly above the upper orbital margin. 
 
 The stitches are allowed to remain in position for at least three or 
 four days, but may be left longer should the case demand it. We 
 must wait, however, until the edematous infiltration of the conjunctiva 
 has disappeared, as the swelling tends to push the lid away from the 
 eyeball. Spastic ectropion is most common in children with scrofulous 
 conjunctival inflammation and catarrhal secretion, in whom the 
 employment of a dressing would be an injury rather than a benefit. 
 It is sufficient to cover the place, at which the knots lie, with a strip 
 of plaster, leaving the eyeball itself free. 
 
 SENILE ECTROPION. 
 
 An entirely different method of operation must be performed in 
 treating senile ectropion. In spastic ectropion an otherwise normal 
 lid is brought into a false position by contraction of the orbicularis
 
 44 OPHTHALMIC SURGERY. 
 
 muscle, whereas senile ectropion is produced through marked changes 
 in the lid itself, which have originated in the course of a chronic inflam- 
 mation. The lid has become elongated, the tarsus thickened and 
 heavier, the skin flabby and not capable of offering resistance, and the 
 lid, therefore, sunken downward. The employment of Snellen's 
 sutures is of no value. Instead, we are compelled to shorten the lid. 
 
 The simplest method of operation, and in fact one of the first 
 methods devised, is excision of a triangular piece from the whole thick- 
 ness of the lid ; the base of this triangle corresponding to the palpebral 
 margin and of such length that the lid, after union of the wound by 
 several silk sutures, is of the desired length, and lies neatly applied 
 to the eye in its normal position. This simple operation had one 
 great drawback; namely, a coloboma of the lid was frequently pro- 
 duced. The tarsus being soft and easily rent, the sutures readily cut 
 through it, more particularly as the contraction of the orbicularis 
 muscle constantly exerts traction on the two edges of the wound. 
 The operation has, therefore, long since fallen into disuse, as either a 
 large coloboma or at least an unsightly indentation of the lid-margin 
 was the result. 
 
 Kuhnt tried to avoid this disadvantage by an operation, which con- 
 sists in division of the lid at the intermarginal border and subsequent 
 shortening by cutting out a triangular piece exclusively from the tarsus. 
 The surplus fold of skin which remains as an ugly prominence, Muller 
 attempts to remove by obliquely suturing it to the tarsus. 
 
 Another method is to shorten the lid by the excision of a piece of 
 skin, which is taken from the region of the external canthus; in this 
 manner an attempt is made to draw the lid outward and at the same 
 time to elevate it somewhat. The procedure has the disadvantage 
 that the relaxed skin will stretch again after a time, often allowing 
 recurrence of the ectropion. 
 
 A combination of the methods of Kuhnt and Szymanowski, i.e., 
 of the tarsal and cutaneous operation, yields perfect results, and should 
 be employed exclusively for the treatment of senile ectropion. 
 
 The First Step. The operation is begun by splitting the lower 
 lid in the intermarginal border. This procedure is not easy in 
 patients with senile ectropion, as the intermarginal border is usually 
 indistinct, the posterior border of the lid perfectly rounded, and the 
 conjunctiva thickened. It is desirable to make the incision with the 
 lancet, with its point resting on the intermarginal border, while its
 
 ECTROPION. 45 
 
 plane lies parallel to the surface of the lid. By so doing, we avoid 
 perforation of the tarsus or wounding of the skin with the point of 
 the lancet. A wound of the tarsus, when it lies in the region of the 
 piece to be excised, has no particular significance; but if it lies to the 
 side, the placing of the sutures in the tarsus may be made extremely 
 difficult. The incision in the intermarginal border usually bleeds 
 freely; it is, therefore, best when making the cut, to grasp the lid 
 between the thumb on the skin side and index finger on the con- 
 
 FIG. 22. The lid is fixed between the thumb and index finger of the left hand. The 
 lance pressed forward, its flat surface parallel to the surface of the lid, in the intermarginal 
 border, at first to the center of the lid. The incision is next continued outward to the 
 external canthus, as the line indicates. 
 
 junctival side (Fig. 22). The lid is thereby fixed and at the 
 same time rendered comparatively free from blood, so that the incision 
 may be made without annoying hemorrhage. Satisfactory anesthesia 
 and anemia of the whole field may be produced with the cocain and 
 adrenalin mixture described in an earlier chapter (p. 15). OIK 
 has to inject the fluid into the thickened substance of the tarsus itself. 
 Occasionally the solution spurts out of the openings of the Meibo- 
 mian glands. A Pravaz syringe (i cc.) is amply sufficient for this 
 procedure.
 
 46 OPHTHALMIC SURGERY. 
 
 The inter marginal incision is started slightly to the inner side of the 
 middle of the lid and goes exactly to the external canthus. The 
 greatest precaution must be observed not to wound the skin, as this 
 injury may produce a coloboma of the lid. In order to prevent falling 
 out of the eyelashes, it is also important that care be taken not to 
 injure their roots. When the point of the lancet, which is held parallel 
 to the lid-surface, enters the intermarginal border between the two 
 layers of the lid, it sinks without much resistance between them. The 
 lengthening of the incision to the external canthus by pushing the 
 lancet forward laterally is not to be recommended, as there is always 
 a risk of leaving the intermarginal border and either deviating for- 
 ward with the cutting edge of the knife injuring the skin, or, backward, 
 and penetrating the tarsus. It is decidedly safer, after an incision has 
 been made, corresponding in length to the breadth of the lancet, to 
 insert the point of the lancet in another place on the intermarginal 
 border and bury it in the tissue; and, when necessary, even to insert 
 it in a third place. Then one has simply to unite the separate incisions, 
 if they have not already been connected while being made, by cutting 
 through the separating fibers. In this manner the lid is divided with- 
 out injuring the anterior or posterior layers. 
 
 If the operator wants to perform the intermarginal incision in one 
 cut, a fine line must first be cautiously drawn with the point of the 
 lancet and gradually deepened by making short cuts. It is almost 
 impossible to draw this line if the intermarginal border cannot be 
 distinctly seen, as is the case when the whole lid-margin is rounded 
 by the ectropion. Therefore, we must be satisfied to keep behind 
 the lashes near the posterior margin of the lid. The intermarginal 
 incision is deepened until it is beneath the lower margin of the tarsus. 
 
 The Second Step is the Excision of a Triangular Piece from 
 the Tarsus. The length of this piece depends upon the degree of the 
 ectropion. If too little is excised, the ectropion is not corrected ; if too 
 much, the two edges of the tarsal wound cannot be re-united by sutures. 
 The operator must, therefore, carefully estimate in each case the neces- 
 sary length of the area of excision. This is best done by raising a 
 fold of the tarsus with two pairs of forceps, and determining exactly 
 how much must be removed to allow the shortened lid to lie properly 
 against the eyeball (Fig. 23). The forceps should be held in a vertical 
 position, near the eye, and the fold (/) allowed to protrude forward. 
 The length of the necessary excision may be only 5 mm., or even
 
 ECTROPIOX. 
 
 47 
 
 double or more. The piece of the tarsus is taken exactly from the 
 middle of the lid with a pair of short, straight scissors. A cut is first 
 made from the inner corner through the tarsus, and the piece limited 
 
 FIG. 23. Two vertically-held forceps raise a fold (f) of the tarsus, so that it projects 
 prominently forward. In this manner we determine how much must be excised from the 
 tarsus so that it can subsequently be properly attached to the bulbus. 
 
 by cutting from the other side obliquely downward from the edge of 
 the lid for a corresponding distance. The excision includes only 
 the tarsus and the overlying conjunctiva. The conjunctiva under 
 
 FIG. 24. The measured part of the tarsus has been excised. The triangle is drawn 
 in the region from which the skin is to be excised. 
 
 the tarsus must not be touched by the incision. The bleeding is con- 
 trolled by the previous injection of adrenalin, but, if severe, must be 
 checked by the application, for a short time, of two hemostatic forceps.
 
 48 OPHTHALMIC SURGERY. 
 
 The third step consists in the excision of a triangular piece of 
 skin from the region of the external canthus (Fig. 24). 
 
 The first incision is made with a scalpel or lancet from the canthus 
 outward and is carried a trifle upward (a b}. Its length equals, or 
 exceeds somewhat, that of the piece excised from the tarsus. 
 
 The second incision is carried from the canthus perpendicularly 
 from the first, i.e., downward and a trifle outward; this is easily twice 
 as long as the first, so that its lower point lies vertically below the outer 
 
 FIG. 25. The triangular piece of skin is excised, the skin of the lid undermined and 
 turned outward. The three sutures through the tarsus lie in their proper position. The 
 principal fixation suture of the flap (a b) is likewise drawn through. The cilia are excised 
 from the corresponding part. 
 
 end of the first incision. The ends of these two incisions are united 
 by a third, and the piece of skin so isolated is excised. The skin of the 
 lid is now completely undermined so that it may readily be drawn 
 outward to cover the defect produced. 
 
 The fourth step consists in uniting the open wounds (Fig. 25). 
 The first is the w r ound in the tarsus. Three sutures are employed 
 so as to be certain of the permanent union. Strongly curved, fine 
 needles with fine silk are used. The needle is inserted below, near the
 
 ECTROPION. 49 
 
 point of the triangle, pushed from the conjunctival side through the 
 tarsus out to the wound, and carried on the opposite edge from the 
 wound side through tarsus and conjunctiva. The needle must not be 
 passed through too close to the edge of the wound, because the tarsus, 
 as has already been mentioned, is easily torn, and, if the sutures have 
 once cut through, a second fixation is still more difficult. Both ends 
 of this suture are turned upward. The second suture is passed through 
 in a like manner. It is inserted through the middle of the tarsus, both 
 ends should be placed horizontally. Special care must be employed 
 to properly place the last suture, w r hich insures exact union of the 
 wound and must re-establish the margin of the lid. To accomplish 
 this, the needles have to be put through the tarsus close to the edge. 
 The threads are turned downward. 
 
 The pair of sutures turned upward are tied first. Nothing is more 
 unpleasant for the operator than to be compelled to search for the 
 threads belonging together by drawing one end to find its fellow; for 
 this reason, detail description of the arrangement of the suture ends is 
 dwelt on. As soon as the first suture is tied, and the edges of the wound 
 in the tarsus approximated, the lid begins to roll inward and we 
 must, therefore, in order not to work against this movement while 
 tying the threads, hold them perpendicularly upward and avoid 
 everything which might contribute to the separation of the lid from 
 the eyeball. After tying, the ends of the suture are cut off close to the 
 knot, then the second suture is tied and cut off close, and lastly the 
 third. 
 
 On the cadaver the union of the two margins of the wound is more 
 difficult than on the living, because the tarsus presents only as a thin 
 membrane. In living patients, the wound-surfaces lie in much 
 better apposition in consequence of the thickened tarsus presenting 
 a broad surface. Usually the help of an assistant is not necessary in 
 bringing the margins of the wound together. 
 
 If the two portions of the lid-margin do not fit, w'e can remove 
 from the longer, with a pair of scissors, the small superficial projecting 
 wedge. 
 
 The last step is the covering of the triangular defect in the 
 skin by means of skin from the lid. 
 
 From that part of the skin of the lower lid which is to lie beyond 
 the external canthus, we excise a small strip in order to remove the 
 eyelashes. The first suture fixes the apex of the flap (a) (Fig. 26)
 
 ^O OPHTHALMIC SURGERY. 
 
 to the outer angle of the defect (6); the suture is immediately tied. 
 As in every skin -suture accurate approximation of the edges of the 
 wound is absolutely necessary. Next follows a suture (e) along the 
 upper margin of the flap and the skin to the outer side of the upper 
 lid; in addition two skin-sutures, (c) and (d) are inserted. A suture 
 between the tarsus and the skin of the lid-margin must be made if 
 they are not already in good apposition. It occasionally occurs that 
 a gaping fissure is found between them, and in order to produce 
 primary union (otherwise, the lid-margin cannot be made to assume 
 its normal appearance) a suture is placed between the two in the 
 following manner : both needles of a doubly-armed suture are passed 
 
 FIG. 26. Appearance after the operation. The lower lid lies in its proper position; 
 4 (a, b, c, d, e) sutures sufficed for the fixation of the flap. One suture for the fixation of 
 the skin to the tarsus is tied over a bead (f). 
 
 from the conjunctival side out, at a distance of i mm. from the margin 
 of the lid and 2 mm. from each other, through the tarsus and forward 
 through the skin and tied over a small pad of gauze or a bead. An 
 ordinary suture would produce an unsightly indentation on the margin 
 of the lid. 
 
 The lower lid is now shortened, lies closely against the eyeball 
 and is at the same time slightly elevated. 
 
 Great care must be taken in applying the dressing. In order that 
 no space exists between the flap and the underlying structures, it must 
 be held down by a slight pressure-bandage. It is of the utmost im- 
 portance that both eyes should be bandaged for four days. If the 
 eyes are allowed to move, the knots in the tarsus greatly endanger the
 
 ECTROPION. 51 
 
 cornea by the constantly rubbing against this sensitive structure. If 
 both eyes are closed, the cornea rotates upward and lies behind the 
 upper lid and is not in contact with the knots. The orbicularis muscle 
 is kept quiet by the bilateral dressing, which also aids in the prompt 
 healing of the wound. After the operation, a small amount of iodo- 
 form ointment is placed in the conjunctival sac. The bandage should 
 be carefully lifted on the day following the operation to see that the 
 cornea is not eroded. After four days the sutures may be removed 
 from the tarsus, and a day later from the skin. Should one or more 
 of the sutures in the tarsal wound tear out prematurely, the tear must 
 be allowed to heal by granulation. Beyond delay in the course of 
 healing, this occurrence has no significance. 
 
 As already mentioned, the result of the operation is always brilliant 
 if the excised piece has been of a sufficient size, and the resultant scar 
 is scarcely visible. The existence of a corneal ulcer does not centra- 
 indicate the operation; on the contrary, it can readily be seen how 
 healing of such an ulcer might be effected without any further treat- 
 ment than replacing the protecting lid in its proper position. 
 
 On account of the softness of the tissues, the suture in the tarsus 
 may cut through at once, especially if there has been too much excision 
 and the tissues markedly stretched. For this reason, as has already 
 been mentioned, the needle must not be passed too close to the margin 
 of the wound, but kept away sufficiently to allow the suture to have 
 proper support. The greatest advantage of this method of operation 
 lies in the fact that even in -the cases in which the sutures in the tarsus 
 cut through, the danger of a coloboma does not exist, as the anterior 
 plate of the lid, the skin, remains uninjured. For this reason alone 
 care must be taken not to injure the skin in making the intermarginal 
 incision. As the skin itself is frequently highly friable and atrophic, 
 the skin-suture may also cause trouble. 
 
 In excising the triangular skin-flap, the upper incision must not be 
 carried straight upward, as Szymanowski, for other reasons, has 
 advised, but only with a slight inclination upward. Otherwise, the 
 skin of the lower lid will be drawn too far over the tarsus, and the union 
 made much more difficult. If the pressure-dressing is properly applied, 
 any stasis of secretion is prevented, and the attendant undesirable con- 
 sequence, such as rupture of the skin-sutures and their necessary 
 removal, is avoided. 
 
 I have recently seen a rare accident occurring after an ectropion
 
 52 OPHTHALMIC SURGERY. 
 
 operation. The lid was first in faultless position, and I was not a 
 little astonished to find, the day afterward, the lower lid again pre- 
 senting a marked ectropion. The operation appeared to have been a 
 failure, but the cause of the new ectropion was soon recognized. The 
 skin of the lower lid, which had been stretched outward, exerted its 
 greatest tension in the region of the lower margin of the tarsus; this 
 was pressed against the bulb and the free margin of the lid was turned 
 outward. The reposition of the under lid into its proper position did 
 not improve the result, and only after applying a Snellen's suture, 
 full recovery followed. 
 
 In cases of bilateral ectropion both eyes should be operated on at 
 the same time, as in all cases both eyes must be bandaged after the 
 operation; this spares the patient the prolonged closure of the eyes. 
 
 If the ectropion is not far advanced, the ordinary Kuhnt's method of 
 operation, with possibly Miiller's modification, will be sufficient. In 
 such cases the intermarginal incision is made from the middle outward 
 toward the canthus; the corresponding piece is excised from the tarsus; 
 the tarsal sutures are made as above described; and the skin is attached 
 to the tarsus by several sutures, which should be inserted obliquely, 
 to avoid the formation of one large fold of skin; instead the super- 
 fluous skin is divided into several small folds, which later become 
 entirely invisible. 
 
 PARALYTIC ECTROPION. 
 
 For correction of this deformity, resort must be had to the operation 
 of tarsorrhaphy, which is described on page 65. 
 
 CICATRICIAL ECTROPION. 
 
 As a typical method for cicatricial ectropion does not exist, the 
 delineation of the operative procedure is incomparably more difficult 
 than those from the other forms of ectropion, and a detailed descrip- 
 tion is essential. 
 
 In general, the following stages may be considered as necessary: 
 The first step is to divide the cicatrix which is holding the lid in an 
 abnormal position. An incision is made with a scalpel, parallel to and 
 usually quite close to the margin of the lid, throughout the whole length 
 and depth of the scar, so that the lid, entirely free and movable, can 
 be brought back to its normal position. As the cicatrix often extends 
 to the bone, after caries and deeply penetrating corrosions, the orbital
 
 ECTROPION. 53 
 
 margin, covered only with periosteum and cicatricial tissue, can become 
 exposed. 
 
 The next step is to fix the lid in its proper position, and to cover 
 the extensive area caused by the drawing away of the lid. This is 
 manifestly the most important part of the operation, as otherwise, 
 during the healing of the wound, the new cicatrix would draw the 
 lid back again to its former position. This may be remedied by 
 undermining and directly approximating its margins, or by a plastic 
 operation. 
 
 The defect can be closed by sutures only if the wound is relatively 
 small and the surrounding skin in a normal condition; for instance, 
 if an ectropion has been produced on the external portion of the upper 
 lid by a small scar following caries, and the lid-margin appears to be 
 fixed to the bony orbital margin. After thorough separation of the 
 scar and reposition of the lid in its normal position, the approximately 
 horizontal wound may be converted into a vertical one by sufficiently 
 undermining the surrounding skin and making traction on the middle 
 of the upper and lower edges of the incision with two blunt hooks. 
 Then by horizontal sutures the incision may be drawn into a vertical 
 line. 
 
 By approximation in a slanting direction, that is, vertical to the 
 earlier direction of contraction of the scar, the upper lid is placed 
 correspondingly deeper, and in slight cases actually remains per- 
 manently in its normal position. Such approximation is only possible 
 when the scar is small, so that the incision can be a short one, and 
 when the surrounding skin is in a normal state. But it is impracticable 
 in such conditions as the cicatricial changes following corrosives or 
 lupus, which have so affected the skin as to make it unyielding. 
 
 It is manifestly wrong to do the operation before the caries had been 
 cured. If a discharging fistula exists, the diseased bone has to be 
 laid bare first through an incision and curetted; eventually, the seques- 
 trum is removed. To protect the cornea from the danger of a subsequent 
 ectropion, a tarsorrhaphy is made. In this operation, by fixation of 
 the upper lid to the lower, the eversion of the upper lid is prevented. 
 Then the diseased process is allowed to run its course and, not until 
 it has completely healed, is the operation of dividing the scar and 
 obliquely suturing the wound performed. 
 
 The cases in which suturing suffices for the repair are quite few; 
 usually one has to cover the defect after separation of the cicatri*
 
 54 OPHTHALMIC SURGERY. 
 
 with a skin-flap by a plastic operation. In opposition to many opera- 
 tors we believe that it is better to use, whenever possible, flaps with- 
 out pedicles. Leaving out of the question the fact that in the greater 
 number of cases of cicatricial ectropion (corrosion, lupus), pedun- 
 culated flaps from the surrounding skin cannot be taken (the skin 
 itself being also contracted by the cicatrix), the cosmetic effect especi- 
 ally leads us to employ for covering the defect delicate flaps without 
 pedicles. Pedunculated flaps project from the surrounding skin as 
 thick irregular elevations and produce a marked disfigurement, whereas 
 the extremely thin non-pedunculated flaps apply themselves smoothly 
 against the denuded tissue and after some time present the same folds as 
 the healthy lid and are differentiated from their surroundings only 
 by their somewhat lighter color. The claim that non-pedunculated 
 flaps constantly contract so much as to destroy completely the results 
 of the operation is not true. We have formed new upper and lower 
 lids by means of non-pedunculated flaps, and they are still, after some 
 years, in a faultless position. The employment of the surrounding 
 skin was absolutely impossible in consequence of a marked cicatricial 
 contraction following corrosion with vitriol. 
 
 The results 'depend entirely on the manner of procedure in trans- 
 planting these flaps. The first condition necessary is a marked over- 
 correction of the defect. In the severe cases, which is the only type 
 considered here, the whole upper and lower lids are found turned out- 
 ward and usually lying in the region of the orbital margin, the upper 
 lid closely adherent to the eyebrow. Occasionally the margin of the 
 lid is relatively well preserved. The first step in the operation con- 
 sists (as already stated) in the division of the scar and the releasing 
 of the lid; an incision is, therefore, made with a scalpel, along the 
 whole length of the scar, i.e., of the lids. On the upper lid it is often 
 difficult to keep within the narrow zone between the eyebrow and 
 margin of the lid; so far up has the lid been drawn from its normal 
 position. If no lid-margin is present, the incision is made, if possible, 
 at a distance of 2 mm. from the margin of the conjunctiva. After 
 the scar is completely divided or, if the condition demands, excised, 
 the lid, which is now freely movable, is drawn well over the other lid 
 the upper down over lower, or the lower well up over the upper. 
 Three strong sutures are now passed through the margin of the freed 
 lid and are fastened, either on the cheek (if the upper lid) or on the 
 forehead (if the lower lid); both suture-ends must be passed through
 
 ECTROPION. 55 
 
 the skin and tied over a small pad of iodoform gauze; if this is done, 
 the defect will be covered by a flap, which considerably exceeds in 
 size the dimensions of the normal lid The hemorrhage may be 
 checked either by compression or by temporary clamping with hemos- 
 tatic forceps. The latter may be twisted off after a short time. Liga- 
 ture with catgut is only necessary for the larger vessels. The small 
 vessels in the scars soon stop bleeding without assistance. The wound, 
 produced in this manner, has naturally an irregular, obtuse, triangular 
 appearance, its surface showing as a depression below the orbital 
 margin and toward the side of the nose. It is now temporarily covered 
 with a tampon saturated with warm normal salt-solution. 
 
 The skin-graft flaps are prepared from the inner side of the upper 
 arm. In order to form an idea of the size and shape of the flap to be 
 excised, a piece of gutta-percha tissue, corresponding to the wound in 
 form and size, is employed. This is laid on the part from which the 
 skin is to be excised. After thorough disinfection, the skin of the 
 arm is well stretched in an oblique direction by the assistant. As the 
 skin retracts considerably in an oblique direction after being loosened, 
 the flaps must be made much broader in this direction and trifle 
 longer than the size of the paper-pattern. The flap should not be 
 wholly separated at once; first, an incision is made on one side with 
 lateral prolongations from each end of this for a short distance. The 
 flap is now ready to be dissected with the lancet. It should always 
 be the aim to remove only the superficial epithelial layers and those 
 in the form of a single flap, and for this, the lancet (keratome) serves 
 better than any other knife. If the surface of the lancet is placed 
 parallel and close to the skin, it is not difficult by a stroking motion 
 to separate the superficial epithelial layers. -This work always pro- 
 ceeds slowly, and requires the greatest attention on the part of the 
 operator. 
 
 When a small strip has been freed, it is rolled outward with a 
 pledget, from which the salt-solution has been well squeezed out, so 
 that the further dissection can be continued at the adhering point. 
 The flap is detached in such thin superficial sections, that bleeding 
 only occurs from the apices of the cut papillae, and appears in the form 
 of small dots. Care must be taken not to buttonhole the skin, as the 
 openings, although small at the outset, increase in size by retraction 
 of the margin of the sections, and are undesirable because their margins 
 roll up and later make the proper adaptation of the flap to the wound
 
 56 OPHTHALMIC SURGERY. 
 
 impossible. On the other hand, by rapid and careless working in 
 preparing the Map, one can cut too deep and the sections are then 
 thick and heavy and retract too much. When a section of the wished- 
 for size has been prepared, it is separated from the point at which it is 
 still attached to the skin, and is covered at once with two pledgets 
 saturated with warm salt-solution. Before transferring the flap, the 
 denuded surface of the wound should be stroked with the edge of the 
 lancet in different directions, in order that a small amount of blood 
 and serum may exude to ensure rapid adhesion of the flap to the wound. 
 We must manifestly guard against deep incisions, which through 
 more extensive bleeding, will lift the flap off. 
 
 Now follows the most delicate part of the operation, namely: The 
 adaptation of the flap to the surface of the wound. The flap, 
 which until now has been spread out on the pledget, is placed with its 
 wound-surface on the defect, at first as its shape and form seem to 
 indicate. The middle of the flap is then pressed well against the raw 
 surface, best by means of a pair of closed forceps, and the pressure 
 continued until it conforms to the surface of the wound; especial care 
 being taken not to allow hollow spaces to separate the various pits in 
 the wound from the flap, more particularly at the inner angle. After 
 this follows the exact adaptation of the margin of the flap to the margin 
 of the wound. To properly spread out the flap, as its margins roll up 
 in every instance, the latter must be drawn out with Carlsbad needles,* 
 and applied to the margin of the wound so that not even the slightest 
 interstice remains between the two. If the flap is somewhat too large 
 and the margins project over the edges of the wound, it must be reduced 
 to the proper length with a pair of scissors. This adaptation must, 
 naturally, be made along the whole periphery of the flap. Sutures are 
 not recommended. After completing the adaptation, the flap and its 
 surroundings are covered with an oiled gutta-percha paper and covered 
 loosely, but carefully, with sufficient dry gauze to cause slight com- 
 pression. The gauze is held in position by two broad strips of adhesive 
 plaster. The other eye is also included in the bandaging, in order 
 to prevent all movements of the lid. An outer starch-bandage makes 
 the dressing stiff within a short time. The operation is performed 
 under general anesthesia. The wound on the arm need not be sutured; 
 the skin regenerates within a short time from the islands of epithelium 
 remaining between the papillae. 
 
 *A kind of long hat pin, the end of which has the form of a small lancet.
 
 ECTROPION. 57 
 
 On the second day after the operation the dressing is changed for 
 the first time. It is always encouraging, when the bandage is taken 
 off, to find the flap in the desired position and already adherent. As 
 no wound-surface exists, there is naturally not the slightest secretion. 
 The flap is usually quite white, but occasionally the upper epithelial 
 layers are somewhat darker in color. Simply because of this, no 
 necrosis of the flap need be feared. Within a few days the delicate 
 normal young skin makes its appearance beneath. Two days later, 
 the bandage is again renewed. The fixation-sutures have by this 
 time usually cut through, and are now removed. The lid remains 
 at first still in the same position, and the flap has, by this time, healed 
 sufficiently, to prevent its being displaced during a change in the 
 position of the lid. Gradually and slowly the lid returns to its normal 
 position. As has already been stated, if the proper precaution and 
 care have been taken, the terminal results in most cases will be excellent. 
 The skin is gradually thrown into folds as is the normal skin of the 
 lid, and is differentiated from its surroundings only by its paler color. 
 
 Should an ectropion exist on both lids, the upper lid should be 
 operated on first, and some weeks later the lower lid may be corrected. 
 If the flap does not become adherent, it is found to be of a greenish- 
 black color at the first change of dressings, and separated by profuse 
 secretion from the granulations underlying the wound. Nothing 
 remains to be done in these cases but to wait until the cicatricial 
 process is concluded; then the original condition returns, and the same 
 operation may again be tried. But if the first operation is com- 
 pleted without error in technic, this undesirable occurrence will 
 be met with only exceptionally. 
 
 The plastic operation with pedicled flaps is described else- 
 where, (p. 115).
 
 CHAPTER VI. 
 ENTROPION. 
 
 SPASTIC ENTROPION. 
 
 Gaillard's Suture. Spastic entropion can readily be remedied by 
 Gaillard's suture. It acts in a manner similar to Snellen's suture 
 (Fig. 27). A long needle curved on the flat is introduced under the 
 skin at the highest point of the inverted lid and carried downward to 
 the lower border of the orbit, and the same process is repeated with 
 
 FIG. 27. Position of the sutures. A suture 3 mm. long overlying the conjunctiva 
 corresponding to the most marked anterior curvature. Under the skin the sutures extend 
 to the region of the lower orbital margin. 
 
 the other end of the suture. Both ends of the suture are then tied 
 over a small gauze compress. It is evident (Fig. 28) that by this 
 suture the highest part of the inverted lid is drawn downward, a fold 
 of the skin of the lower lid is tied off, and the edge of the lid is thereby 
 everted from its position and turned away from the eyeball. Two 
 sutures in all are introduced, one at the junction of the inner and 
 
 58
 
 ENTROPION. 59 
 
 middle thirds, the other at the junction of the middle and outer thirds 
 of the lid. The sutures are allowed to remain four or five days. 
 The sutures are then removed by cutting them over the gauze com- 
 press, close to one of the points of entrance into the skin, and then 
 drawing them through the wound. Occasionally a spastic entropion 
 is produced under the bandage after cataract-operation. To restore 
 the lid to its correct position, an attempt should first be made by means 
 of a strip of plaster. Adhesive plaster is to be avoided, as it frequently 
 produces an eczema. Zinc oxide plaster is much better, but often 
 does not stick well in this position, as the skin is moistened by over- 
 flowing tears. In applying this plaster it is, therefore, important to 
 dry the lid thoroughly first; then the strips of 
 plaster, i cm. wide, are slightly warmed and ap- 
 plied, by pressure, at one end accurately to the edge 
 of the lid. The other end of the strip, which 
 should be about 2 cm. long, is drawn downward, 
 pulling the eyelid with it into proper position and 
 fastened firmly. Disappearance of the entropion everted lower lid with 
 
 " , ., ., , . . the sutures in position. 
 
 may be effected more easily, if the patient s eye 
 is left open without a bandage. For protection against mechanical 
 injury, a Fuchs' lattice-frame should be applied, the wire-netting 
 being covered with black cloth. The bandage may with safety be 
 left off as early as the day after the operation, provided the wound is 
 closed, so that there is no danger of the upper lid springing it open 
 during the action of the palpebral reflex. 
 
 For senile entropion of the lower lid the best method consists in 
 excising horizontally an oval piece of the skin from the lid. By 
 picking up a fold of skin with the fingers, an approximation can first 
 be made of the amount of excision necessary to bring the lid into the 
 proper position. It is easy, then, with a scalpel or lancet to cut out on 
 a plate, placed between bulb and lid a corresponding piece of skin 
 of oval form which should be about f cm. wide at its middle diameter. 
 The wound, the upper edge of which should correspond with the 
 border of the lid, is then closed by several vertical sutures. The 
 resulting scar is hardly visible. 
 
 Graefe's operation consists in the excision of a triangular piece 
 from the skin of the lower lid (Fig. 29). The first incision runs 
 parallel to the edge of the lid at a distance of 3 mm., and is 3 cm. long. 
 From both ends (be) of the middle third of this cut, the two other
 
 60 OPHTHALMIC SURGERY. 
 
 incisions (be and ce) are made downward, which uniting, form with 
 be an equilateral triangle. The area of skin thus circumscribed is 
 excised. The edges of the wound at b and c are slightly undermined. 
 The first suture, which is now introduced, approximates the two 
 lateral angles (be) of the wound. The skin is, therefore, shortened and 
 stretched horizontally, exactly at the lower border of the tarsus; 
 for by this means the cartilage is pressed toward the eyeball, while 
 the free border of the lid is simultaneously rotated anteriorly away 
 from the globe. The rest of the wound is closed by two additional 
 horizontal sutures. 
 
 Immediately after the operation the lid is in a state of marked ectro- 
 
 FIG. 29. Horizontal incision (ad) through the skin 3 cm. long, parallel to and 3 mm. 
 from the edge of the lid. From the middle centimeter (b c) two incisions (b e and 
 c e), converging below. The circumscribed section of skin is excised. Suture of the 
 two lateral sides (b e c) of the lateral triangle. 
 
 pion, and to such an extent, indeed, that its middle portion forms a 
 protuberance. But this ugly position of the lid disappears within a 
 few days, during which the skin relaxes a little, and the lid slips back 
 into its normal position. If the first suture is too near the edge of the 
 lid, the stretched skin presses the free border of the lid backward 
 against the eyeball and thus increases the entropion. If the suture 
 is too low, below the tarsus, it naturally has little of no influence on 
 the position of the lid. It is, therefore, necessary to pay special attention 
 to the first incision, parallel to the edge of the lid, so that it corresponds 
 approximately with the lower border of the tarsus; i.e., 3 mm. from 
 the edge of the lid. Occasionally after the operation, the lid has a 
 tendency to slip back from the position of ectropion into that of entro-
 
 ENTROPION. 
 
 6l 
 
 pion; this may be prevented by means of a small gauze-compress, 
 which should be applied along the lower border of the tarsus, in order 
 to press it backward against the eyeball. In three or four days the 
 sutures may be removed. 
 
 CANTHOPLASTY. 
 
 The purpose of canthoplasty is to lengthen the palpebral fissure. 
 
 The operation is performed by thrusting the blunt end of a moderate- 
 sized, straight pair of scissors horizontally outward into the con- 
 junctival sac beneath the canthus, which is then cut in a horizontal 
 direction with one stroke of the scissors (Fig. 30). At the same time 
 the other hand stretches the skin in the region of the canthus by 
 
 FIG. 30. By means of two fingers the external canthus is separated and at the same 
 time pushed slightly toward the nose. A pair of straight scissors is introduced horizontally 
 with the blunt blade posterior. 
 
 means of the thumb and forefinger which are placed upon the outward 
 halves of the upper and lower lids, separating them and drawing them 
 toward the nose at the same time. If the cut of the scissors is to be 
 made on the left eye with the right hand of the operator, the hand 
 must be strongly flexed dorsally, in order to bring the scissors into the 
 right position, or the operation must be performed from behind the 
 patient. Bleeding is stopped by compression. In order to obtain 
 a satisfactory result, an additional cut should be made with a small 
 pair of scissors into the connective-tissue strands, which attach both 
 lids to the edge of the orbit, so that the lids are freely movable and 
 may readily be separated from each other.
 
 62 OPHTHALMIC SURGERY. 
 
 If only a temporary widening (canthotomy) of the palpebral fissure 
 is desired, no further operation is necessary. The wound closes in a 
 short time, without leaving a permanent increase of the width of the 
 palpebral fissure. Only the external horizontal scar remains as a 
 visible sign of the operation. 
 
 In order to obtain a permanent result (canthoplasty),it is neces- 
 sary to introduce sutures, which close the wound by uniting the con- 
 junctiva with the skin. After making the incision, a rhomboidal 
 wound is seen by drawing the lids apart (Fig. 31). If the con- 
 junctiva be undermined a little, it can readily be drawn outward so 
 
 FIG. 31. Form of the wound after incision. Position of the sutures for closure of the 
 \vound. The first suture unites the angle of the conjunctiva (a) with the angle of the 
 cutaneous wound (b). 
 
 that the angle of the conjunctival wound (a) may be connected with 
 the angle of the cutaneous wound (b). All that is then necessary is 
 to introduce one suture above and below, to unite the lateral sides of the 
 conjunctival and cutaneous wounds. To produce anesthesia, a 3 per 
 cent, cocain-solution is dropped into the conjunctival sac, and during 
 the second part of the operation a subcutaneous injection is made in 
 the neighborhood of the external canthus with a half syringeful of a 
 i per cent, cocain-solution. 
 
 Indications. Canthoplasty is indicated if there is a marked secre- 
 tion of the conjunctiva (blenorrhea, trachoma, etc.), with a relatively 
 narrow palpebral fissure, making it difficult to carry out the treatment 
 and to promote removal of the secretion. It is also performed in 
 children with blepharospasm and edema of the lids, and is an effectual
 
 ENTROPION. 63 
 
 operation for spastic entropion, as the cut of the scissors includes the 
 point of insertion of the orbicularis muscle; namely, the external 
 canthal ligament. 
 
 Finally, canthotomy is occasionally necessary to permit a larger 
 field in operations on the eye or in entering the orbit. It is some- 
 times indicated in iridectomy, especially in pathologically enlarged 
 eyes (buphthalmos) ; and in the operation of cataract upon patients 
 whose eyelids twitch considerably. It is done to assist in performance 
 of exenteratio orbits; also in ankyloblepharon, blepharophimosis, etc. 
 
 FIG. 32. The lidplate is inserted outward under the canthus. The direction of the 
 incision, to be made later through the canthus, is marked on the patient with ink-dots (i i')- 
 A flap of skin (f) is cut out of the lower lid, the base corresponding to the outer half of the 
 marked line. 
 
 Kuhnt's Method. In trachoma, if the conjunctiva is markedly 
 contracted it may be difficult or even impossible to unite the con- 
 junctiva with the skin. The sutures tear out either immediately or 
 shortly afterward, so that the wound closes up again and the palpebral 
 fissure returns to its former small size. These are usually urgent 
 cases, eyes in which trachoma has caused pronounced infiltration of 
 the cornea that has resisted all treatment. Such cases are better 
 for Kuhnt's modification of canthoplasty, which is performed as 
 follows : 
 
 By means of a few India-ink dots the line of incision for the cantho- 
 plasty is first drawn, this line being a straight prolongation of the 
 palpebral fissure from the external canthus to the outer border of the 
 orbit. A Jaeger's ivory plate is then inserted under the outer com- 
 missure, and while stretching the skin a little upward and toward 
 the temple, the operator cuts a flap of skin 2 mm. wide out of the
 
 64 OPHTHALMIC SURGERY. 
 
 lower lid, as indicated in Fig. 32. The base of the flap is situated so 
 that it shall be adherent to the upper edge of the wound after the 
 incision for canthoplasty is made (Fig. 33). The length of the flap 
 corresponds approximately to one-third the length of the lid, but must 
 be cut a little longer, as the skin always retracts after it is detached. 
 The orbicularis fibers, which appear in the lid after removal of the 
 flap, are excised. The horizontal external incision is then made 
 as in ordinary canthoplasty. The flap of skin mentioned above 
 now hangs free from the upper edge of the wound, and is so placed 
 that it remains several millimeters from the outer angle of the wound. 
 By means of a scissors, all adhesions of the lids to the edge of the 
 
 f 
 
 FIG. 33. The flap (f) is separated, and has shortened somewhat by contraction of the 
 tissue. The incision through the canthus is accomplished so that the same wound- 
 angles in the skin (b) and conjunctiva (a) are produced as in Fig. 31. But here the angle 
 (a) has receded towards the cornea, as a result of retraction of the contracted conjunctiva. 
 
 orbit, have to be thoroughly cut, so that the lids can be moved freely, 
 and the bulbar conjunctiva is undermined to the boundary of the 
 cornea. After arrest of hemorrhage the wounds are closed by sutures. 
 Three sutures are sufficient for the wound on the lower lid, and a 
 fourth fastens the temporal border of the lower lid obliquely outward 
 near the outer angle of the wound. The cutaneous flap itself is laid 
 in the wound, so that its apex is inserted either under the angle of the 
 conjunctival wound, or is fixed to the latter with a suture (Fig. 34). 
 
 As there is usually an entropion of the lower lid the removal of a 
 cutaneous flap also exerts a favorable influence on this anomaly of 
 position. If the upper lid should need correction, the flap could 
 be taken from it instead of the lower lid. 
 
 In severe cases of trachoma we have repeatedly observed a very
 
 ENTROPION. 65 
 
 favorable influence of this operation upon the condition and further 
 treatment of the disease. Certainly, from a cosmetic standpoint, the 
 operation cannot be recommended, but in such severe cases the 
 personal appearance no longer need be considered. By healing of 
 the cutaneous flap, which occurs promptly, the palpebral fissure 
 remains permanently and considerably widened. The sutures may be 
 removed in a few days. 
 
 TARSORRHAPHY. 
 
 The object of tarsorrhaphy is to shorten the palpebral fissure. 
 The operation is necessary, when, as a result of lagophthalmos, the 
 eye is in danger of being injured. It is indicated in cases of facial 
 
 FIG. 34. The wound on the lower lid is sutured, the flap of skin (f) being 
 fitted into the angle of the conjunctival wound (a). 
 
 paralysis that will presumably exist a long time or will never recover, 
 and in cases of marked exophthalmos resulting from Basedow's disease 
 or from tumors. Naturally, the cosmetic result is never pleasing, 
 but the operation is rendered necessary by existing circumstances, 
 and is unavoidable. 
 
 The method of Fuchs is almost exclusively employed by us. The 
 following is a description of external tarsorrhaphy: At the outset 
 it must be clearly determined how much the palpebral fissure it to be 
 shortened. This is best done by holding the two eyelids together, 
 with the fingers placed at the external canthus, and shortening the 
 palpebral fissure by advancing the fingers until the patient is able, 
 completely or almost completely, to close the eye. At most, a few 
 millimeters will be sufficient, but even in severe cases a distance of 8mm. 
 is never to be exceeded on account of the marked and very unsightly
 
 66 OPHTHALMIC SURGERY. 
 
 asymmetry of the palpebral fissure that would thus be produced. 
 In such a case we would be forced to do the same operation also at 
 the internal canthus, of which mention will be made later. 
 
 At the desired point a small vertical incision is made through the 
 skin of the upper and lower lids, not only to indicate how far the opera- 
 tion is to be conducted, but also to secure equal distances for both 
 lids. A subcutaneous cocain-injection is made in the upper and lower 
 lids, the point of the needle being directed towards the intermarginal 
 border, in order to make the incision of this edge painless. 
 
 Then an intermarginal incision is made on the lower lid, beginning 
 exactly at the external canthus, and extending to the indicated point. 
 
 FIG. 35. From the external part of the lower lid a flap of skin (f) is formed, and the 
 cilia removed. From the skin of the upper lid a corresponding long strip is excised. The 
 suture is already introduced : above near the edge of the lid, below near the base of the flap. 
 
 The eye is protected by the ivory plate. The incision is best made 
 with a lancet, which should be held parallel to the surface of the lid, 
 so that the point will perforate neither the skin not the tarsus posteri- 
 orly. While drawing the skin of the eyelid outward, the assistant 
 presses the obliquely-held ivory plate forward, so that the eyelid is 
 well stretched. By light pressure the operator himself holds the eyelid 
 against the plate and places the point of the lancet upon the inter- 
 marginal border. If the lancet is sharp, it will readily penetrate 
 between the two plates of the eyelid. At the same time a little under- 
 mining can be done. 
 
 A vertical cutaneous incision 3 mm. long is then made, beginning 
 at the point marked on the border of the lid. In this way a small
 
 ENTROPION. 67 
 
 cutaneous flap (Fig. 35 /) is formed from the lower lid, with the eye- 
 lashes still in position on the edge corresponding to the border of the 
 lid. The roots of these lashes are then injured by means of a scissors 
 applied flat against the raw side of the flap at the margin of the lid, 
 so that the cilia fall out later. 
 
 The Upper Lid is Now Prepared. The same intermarginal incision 
 is made as below, from the external canthus to the mark. Then a 
 cutaneous incision is made in the upper lid, parallel to its border at a 
 distance of about 2 mm. from it and of the same length as the inter- 
 marginal incision. The lancet undermines the bridge of skin thus 
 formed, and two cuts with the scissors sever its connections externally 
 and internally. In this way a raw surface is produced on the edge of 
 
 FIG. 36. Appearance of the palpebral fissure after the tying of the sutures. Both ends 
 of the first suture introduced are tied over a small gauze-compress. 
 
 the upper lid. The flap formed from the lower lid is now adjusted 
 so that it covers this raw surface and unites with it. The tarsi are 
 not injured in this operation. The tarsus of the lower lid slips in 
 beneath that of the upper lid. 
 
 The fixing suture is made with a double-armed thread. Both needles 
 are first passed through the upper lid near its border, proceeding from 
 the conjunctival surface outward. The two perforations are about 
 2 mm. apart. A short piece of thread, therefore, lies on the conjunct ival 
 surface side of the upper lid. This is of no consequence as it does 
 not come in contact with the cornea, which lies farther inward. Then 
 each end of the thread is passed through the base of the flap on the 
 lower lid from the raw surface outward to the cutaneous side, with 
 about the same distance between the perforations as before (Fig. 36).
 
 68 OPHTHALMIC SURGERY. 
 
 If both ends of the thread are then tied over a small compress of 
 iodoform gauze, the base of the flap will be drawn to the edge of the 
 upper lid, and the flap itself will lie over the raw surface of it. Several 
 fine cutaneous sutures are then introduced to unite accurately the edges 
 of the flap with those of the wound on the upper lid. A light dressing 
 is applied over the eye. The stitches may be removed on the third 
 day. As the interference has been slight, the other eye need not be 
 bandaged. 
 
 The advantage of the operation is that a surface union of the lids 
 is produced, and in this way a separation of the suture is avoided an 
 occurrence which is often encountered in other methods of operation. 
 The disadvantage of this method lies in the sacrifice of a part of the 
 normal cutaneous border of the lids. If at some future time it should 
 be desirable to re-open the palpebral fissure, it is not difficult to free 
 the upper and lower tarsal borders, as the tarsus has not been injured, 
 and a few sutures will unite the edge of the cutaneous wound with 
 this edge of the tarsus, but the border of the eyelid thus made would 
 naturally have no cilia. Therefore, tarsorrhaphy is performed only 
 in those cases, in which presumably no recovery is to be expected, e.g., 
 in many cases of facial paralysis. The operation may be accom- 
 panied by unpleasant results, caused by an inequality in the length 
 of the intermarginal incisions on the upper and lower lids. If, for 
 example, a longer piece is excised from the upper lid than will be 
 covered by the flap from the lower lid, the latter will, of necessity, be 
 pulled obliquely upward and inward, producing in this way an ugly 
 fold resembling an epicanthus. At the same time the cilia on the 
 neighboring part of the lower lid may also assume an oblique direction, 
 and in this way a trichiasis will be produced. Should this occur it 
 would become necessary to destroy additional eyelashes by electrolytic 
 depilation. 
 
 Indications. Tarsorrhaphy is well suited, not only to cases of 
 lagophthalmos caused by facial paralysis, but also when the con- 
 dition is caused by congenital shortening of the eyelids; further, it serves 
 to overcome paralytic ectropion, as it raises the ptosed eyelid. It is 
 also recommended as a preventive of cicatricial ectropion in persistent 
 carious fistula on the border of the orbit. Even though the operation 
 in itself is disfiguring, it may still be indicated for cosmetic reasons 
 in some rare cases, such as widening of the palpebral fissure after 
 strabismus operations, or unilateral enlargement of the eyeball (uni-
 
 ENTROPION. 69 
 
 lateral, high grade myopia) and its consequent widening of the palpebral 
 fissure. Tarsorrhaphy is also performed occasionally as a preliminary 
 to plastic operations. 
 
 Complete closure of the palpebral fissure is only undertaken in 
 rare cases. For example, after an extensive corrosion, in which the 
 skin of the upper and lower lid has been partially destroyed, and the 
 production of a cicatricial ectropion seems unavoidable. The latter 
 can be prevented by complete suture of the palpebral fissure. In 
 order not to destroy all the eyelashes, the operation may be performed 
 by denuding with the lancet the edges of the lids behind the cilia and 
 then suturing the lids together: Or, if it is possible, a narrow strip 
 may be cut out of the skin of both eyelids near their borders, and the 
 two raw surfaces united by sutures. If, however, the lid has been 
 completely destroyed, and the eye itself has not suffered much, it is 
 best to protect the eye by a moist chamber sufficiently long until 
 cicatrization has ceased, and it is possible to perform a plastic opera- 
 tion, such as described for cicatricial ectropion. 
 
 If tarsorrhaphy is performed for pronounced exophthalmos, after 
 the operation is completed, the rest of the palpebral fissure should be 
 temporarily closed by several sutures without denudation of the lid- 
 margin, in order that the flap may adhere firmly, and the sutures not 
 tear out prematurely, owing to the strong tension. 
 
 If indicated for paralytic ectropion, a triangular fold of skin may 
 be excised, as in senile ectropion, and the tarsorrhaphy combined with 
 this; an operation resembling the Szymanowski method. In this 
 manner the somewhat enlongated lid is shortened and brought to lie 
 more closely against the eyeball. 
 
 Internal Tarsorrhaphy. When Fuchs's tarsorrhaphy is performed 
 at the internal angle of the lids, two precautions must be observed: 
 
 (1) The internal canthus itself should not be touched by the operation. 
 
 (2) The lachrymal canaliculi must not be \vounded. The inter- 
 marginal incision is, therefore, made from the point (determined as 
 before) to the end of the tarsus, i.e., to the punctum lachrymale. If 
 the incision is made accurately in the intermarginal border and the 
 lancet penetrates between the two surfaces of the lid, there is no danger 
 of wounding the lachrymal canaliculus, as it is embedded in the tarsus 
 itself. The same is true of the upper lid. In other respects the 
 operation is the same as at the external angle. The horseshoe-shaped 
 excision is retained and appears as a shallow depression. In this
 
 70 OPHTHALMIC SURGERY. 
 
 way, if it should be desired to re-open the palpebral fissure in the 
 future, a normally formed internal palpebral angle can be obtained. 
 
 In marked cases of exophthalmos it may be absolutely necessary 
 to perform the operation simultaneously at the outer and inner 
 angles of the lids, in order to transform the palpebral fissure into a 
 short central aperture. 
 
 Median tarsorrhaphy may also be accomplished (v. Arlt) by 
 removing, by means of forceps and scissors, a strip of skin from the 
 
 FIG. 37. Horse shoe-shaped excision along the inner canthus 
 from the skin of the upper and lower lids. 
 
 upper and lower lids near the inner angle, in such a manner that the 
 wounds thus produced meet in a sharp angle at the internal canthus 
 of the eye (Fig. 37). Three sutures introduced vertically unite the 
 wounds and close the palpebral fissure from its inner side. This 
 operating has the advantage of not injuring the cilia, so that an 
 eventual re-opening finds the edges of the lids intact.
 
 CHAPTER VII. 
 
 PTOSIS. 
 HESS'S OPERATION. 
 
 After previous shaving of the eyebrow a horizontal incision is 
 made through the skin of the eyebrow along the entire length of the 
 palpebral fissure to avoid disfigurement. The incision should be 
 so placed that the short scar is completely covered by the eyebrow. 
 The section includes only the skin, as a deeper incision injures large 
 vessels, bleeding from which would disturb the further course of the 
 operation. After the incision has been made, the skin is undermined 
 downward with the knife beneath the convex border of the tarsus, 
 i.e., to a point near the edge of the lid. The beginning of the dis- 
 section is made slightly more difficult by the numerous muscle- 
 fibers which are inserted into the skin at this point. A little further 
 down, however, the subcutaneous tissue is loose and easily separated 
 with the knife. As the bleeding, even if present only slightly, inter- 
 feres with the operation by collecting in the pocket constituting the 
 field or operation, it is recommended to control the position and prog- 
 ress of the knife from without, through the skin. This may be 
 done by pushing the knife downward in a perpendicular position, 
 parallel with the skin, and fixing the skin at as low a point as possible 
 (Fig. 38). The skin is thus undermined in the whole length of the 
 incision with a few strokes, and a four-cornered pocket produced. 
 In this way we can more readily avoid a buttonholing of the skin, 
 than if we try to operate along the posterior surface of the skin with 
 an insufficient view into the pocket, a procedure that is difficult with a 
 small incision. 
 
 After the undermining is completed, the insertion of the sutures 
 is begun. The strong silk threads are doubly armed with long, flat 
 needles. In all, three sutures are employed, the first in the center of 
 the lid, the two others to the sides. Both needles of the first thread 
 are pushed through the lower part of the skin, at a distance of approx- 
 imately 4 to 8 mm. from the edge of the lid. To accomplish this 
 the skin must be fixed with the forceps, one blade of which remains
 
 72 OPHTHALMIC SURGERY. 
 
 in the pocket, and the other lies on the skin at the point of intended 
 transfixion, in order to prevent retraction of the lax skin and allow of 
 insertion of the sutures just at the place determined on (Fig. 39). The 
 needles with the thread are now brought out through the skin-wound 
 and directed upward. In like manner, the outer and the inner sutures 
 are inserted each about one centimeter from the middle stitch. Both 
 ends of the middle thread are then pushed upward behind the upper 
 edge of the wound near the periosteum, therefore, behind the muscle, 
 and are brought out through the skin close to one another at about a 
 
 FIG. 38. Hess's operation for ptosis. Method of undermining the flap. The 
 forceps grasps the skin at as low a point as the progress of the undermining permits. The 
 knife held vertically presses downward behind the skin and is observed by the operator 
 from the front through the skin, (c), Section through the skin. 
 
 distance of i-^ to 2 cm. from the incision. The outer threads are 
 treated in the same way. The ends of the inner thread are not inserted 
 directly perpendicularly, but should be inclined a little inward toward 
 the median line. 
 
 The three threads are next tied over iodoform pads. This raises 
 the lid and at the same time forms a fold in the skin corresponding to 
 the point of entrance of the threads, similar to the normal fold of the 
 lid. The above mentioned distance, as the insertion of the thread, 
 varying from 4 to 8 mm. must, therefore, be adjusted according to the 
 position of the fold of the lid on the other side. A fold lying too high 
 is just as disfiguring as one too near the edge of the lid.
 
 PTOSIS. 
 
 73 
 
 Slight traction on the threads raises the lids so that the palpebral 
 fissure readily attains its normal width, but in tying the threads, they 
 must be drawn up sufficiently to lift the lid higher than normally, i.e., 
 to cause an over-correction. However, the threads should not be drawn 
 too tightly, as this will make them cut through quickly, without materi- 
 ally elevating the lid more than with threads drawn moderately tight. 
 The skin-wound is closed with several silk sutures. 
 
 The Dressing. Immediately after the sutures are tied, a condition 
 
 FIG. 39. Application of the sutures. The forceps, one blade of which should be in 
 front of, the other in the wound, grasps the skin just where the needle is to be inserted. 
 One end of the thread has already been drawn through, the needle mounted on the other 
 end has only just been inserted. 
 
 of total lagophthalmos is naturally produced. Because of this, the 
 eye is covered with a celluloid shield, so as to produce a comparatively 
 air-tight covering (Fig. 40). It suffices to fasten the shield along its 
 border with adhesive strips, and, if extensive spaces exist between 
 shield and underlying parts, they should be filled in with absorbent 
 cotton. Within a few minutes the shield becomes moist, and under 
 this dressing the eye may remain for weeks without the slightest sign 
 of irritation. As the celluloid shield is sufficiently transparent to
 
 74 OPHTHALMIC SURGERY. 
 
 permit a view of the eye, the dressing is changed only when secretion 
 is present, and the eye must be cleansed. 
 
 After-treatment. The sutures closing the skin-wound may be 
 removed in from three to four days, but the sutures retaining the 
 lid in its elevated position should remain undisturbed as long as pos- 
 
 FIG. 40. After treatment. The skin-wound has been closed by several sutures. The 
 three fixation threads, of which the inner inclines a little toward the median line, are tied 
 over pads. The lid, strongly elevated, stands off a little from the bulb, the new fold of the 
 lid corresponding to the puncture points of the threads. For the protection of the eye, 
 which cannot now be covered by the upper lid, a celluloid shield is employed; it is fastened 
 at its circumference by strips of zinc oxide plaster, only a few pieces of which show. 
 
 sible at the least, fourteen days; if they have not become loosened by 
 this time, even longer three weeks. By this time they are usually 
 so loose as to have lost their hold and may be easily withdrawn after 
 being cut through. The object of leaving the stitches so long is the 
 formation of strands of scar-tissue along the threads, which not only 
 unite the lid with the frontalis muscle, through which the threads have
 
 PTOSIS. 75 
 
 been brought, but also serve as tendons by means of which this muscle 
 elevates the lid. 
 
 The one indication for the operation is a case of ptosis in which 
 the patient absolutely shows distinct contraction of the frontalis muscle. 
 This most patients with ptosis are actually able to accomplish. The 
 forehead lies in constant folds, and the skin of the eyebrow is con- 
 stantly pulled far up over the upper border of the orbit, which would 
 correspond to its normal position. In those who make no attempt 
 to improve their ptosis by contraction of the frontalis muscle, the 
 operation promises very little. 
 
 If the threads are drawn tightly and produce an over-correction it is 
 not necessary to form a loop and tighten this frequently in order to 
 maintain the lid in its normal position. The chances and results of 
 the operation are always improved if the threads are pulled tightly at 
 the outset. As the lid is not shortened by excision, but only by the 
 pushed-up anterior (skin) flap of the split lid which unites at a higher 
 point with the posterior flap and raises the lid, lagophthalmos need not 
 to be feared. Of the many cases of Hess's ptosis-operation that I 
 have performed personally or have seen at the clinic, this result has 
 not occurred. This is certainly a strong point in favor of this method 
 of operation. It is, however, to the disadvantage of the operation 
 that we are not certain at the beginning of the terminal results. But 
 this is not possible in any one of the many operations for ptosis which 
 have been recommended. As yet, there is no method to enable us 
 with certainty to make the palpebral fissure of the affected side exactly 
 the same width as that of its normal fellow. 
 
 The results of Hess's ptosis-operation are in the great majority 
 of cases very good; occasionally they are excellent, and but rarely 
 unsatisfactory. Permanent over-correction need never be feared. 
 In bilateral ptosis especially, it should be the operation of choice. 
 It is easy of performance and the cosmetic results are excellent. The 
 scar at the point of incision is later covered by the eyebrow, and if the 
 sutures are properly inserted, a good position of the fold of the lid is 
 obtained. 
 
 Anesthesia. The operation may be most satisfactorily performed 
 under cocain-anesthesia. Onesyringefulof a i percent, solution (i c.c.) 
 suffices as injection into the skin of the eyebrow and lid. Before the 
 threads are brought out at the upper point, a second syringeful must 
 be injected into the tissues about the periosteum of this region.
 
 70 OPHTHALMIC SURGERY. 
 
 Contraindications. Apart from insufficient contraction of the 
 frontalis muscle, the operation is contraindicated in those cases in 
 which, in addition to the ptosis, there is paralysis of the superior 
 rectus muscle or, as in some cases, a total ophthalmoplegia. If the 
 eye, during sleep, is not drawn upward under the conjunctiva of the 
 upper lid, there is danger of resultant disease of the cornea. This 
 result may also be brought about by the occasional swelling of the skin 
 of the upper lid after the operation, through an effusion or other 
 edema projecting downward over the border of the lid. This coming 
 into direct contact with the cornea may produce erosions and ulcer- 
 ations, as has been my personal experience in two cases. 
 
 In this as in every other operation for ptosis, we must always con- 
 sider the possible occurrence of diplopia, as the result of existing 
 paralysis of the ocular muscles, after the correction of the ptosis. This 
 would furnish just as important a contraindication to the operation for 
 ptosis, as an abnormal position of the affected eye, for example, by sec- 
 ondary contractures after paralysis. 
 
 PAGENSTECHER'S SUTURES. 
 
 The stitches in Hess's method of operation are essentially the same 
 as those recommended by Pagenstecher. The great efficacy of Hess's 
 operation is due to the change in position of the anterior layer of the 
 
 FIG. 41. Pagenstecher's suture. 
 
 lid brought about by the sutures. Pagenstecher's sutures should be 
 used only in the slightest forms of ptosis. As the stitches are allowed 
 to remain in place for a long time, it is best to employ a wire suture,
 
 PTOSIS. 77 
 
 the upper end of which is shortened by twisting, producing a sufficient 
 elevation of the lid. In order to avoid scarification of the skin, the 
 sutures are introduced subcutaneously (Fig. 41). From the point of 
 entrance at the one end, the suture is carried up and brought out 
 above the eyebrow through c. The other end of the suture is carried 
 outward subcutaneously for 2 mm. from a, and then withdrawn at b. 
 The needle is re-inserted at the same point b and brought out above, 
 either at c or at d. It is then twisted over a gauze pad. The one 
 suture is inserted at the inner third, the second suture at the outer 
 third of the lid. 
 
 EVERBUSCH'S OPERATION. 
 
 Indication. The advancement of the levator palpebrae is an 
 operation intended to overcome ptosis brought about by a paresis of 
 this muscle. The object of the operation is to make the weakened 
 muscle stronger by shortening and suturing its point of attachment 
 further forward. The first part of the procedure is to lay the muscle 
 bare. This is not so easy in living patients. Anesthesia is pro- 
 duced at the beginning by cocainizing the conjunctiva, and later by 
 injecting i cc. of a i per cent, cocain-solution under the skin and 
 into the deeper parts of the lid. 
 
 The Dissection. A longitudinal incision through the skin of the 
 lid and the orbicularis muscle, is made midway between the arch of 
 the eyebrow and the border of the lid. The eye is protected by a 
 horn-plate placed between it and the lid. By undermining to some 
 extent both borders of the lid- wound, it is easy to expose below the 
 upper border of the tarsus, and above, the thin tarso-orbital fascia. 
 In order that the preparation of this part of the operation may be 
 readily understood, it is well to briefly recall the topographical rela- 
 tions in this region. 
 
 If a sagittal section is made through the orbit near its middle, 
 the appearances seen are approximately as follows (Fig. 42). 
 
 The border of the orbit, b; attached to this is the fascia tarso- 
 orbitalis (/. 0.), which hangs down like a curtain and becomes thickened 
 below at the tarsus (to); in front of it, the fibers of the orbicularis 
 (m.o.) and the skin with the lashes at the free border of the lid; behind 
 it and passing forward on the roof of the orbit, the levator palpebrae 
 (m.l.), which spreads out at the orbital opening like a fan; its apo- 
 neurosis joins the fascia tarso-orbitalis, so that immediately above the
 
 78 OPHTHALMIC SURGERY. 
 
 upper border of the tarsus no more than a membrane is visible the 
 tarso-orbital fascia, which has united with the aponeurosis of the 
 levator palpebrte. A cut through the fascia at this point, would come 
 directly upon the conjunctival fornix (c) and would not touch the 
 muscle. 
 
 If, however, the cut is made slightly higher, carefully piercing the 
 
 &~\- 
 
 r.s. 
 
 II 
 
 FIG. 42. Sagittal section through the lids and the anterior portion of the orbit, 
 b. Upper border of the orbit; f. o., The tarso-orbital fascia, which is attached to the 
 bone, hangs down and blends with the tarsus (ta.). The levator muscle (m. 1.) passes 
 forward above the superior rectus (r. s.), changes here into a fan-like tendon, which, 
 joined by the tarso-orbital fascia, is inserted into the upper part of the tarsus. Behind the 
 tarsus is seen the conjunctiva (c), in front of it the orbicularis muscle (m. o.). 1. 1., repre- 
 sents the transverse section through the lower lid. 
 
 fascia, which at this point is thin, there will readily be seen the radiating 
 red bundles of the muscle which may be traced upward into its com- 
 pact body. Therefore, the fascia must be incised at from 5 to 6 mm. 
 above the tarsus; at this point the muscle-bundles of the levator 
 palpebrae will be exposed (Fig. 43). 
 
 Three sutures must now be inserted through the muscle in the 
 same manner in which they were inserted in the advancement of the
 
 PTOSIS. 
 
 79 
 
 recti muscle first through the middle. With a fairly strong curved 
 needle the middle of the muscle is transfixed in its entire thickness, 
 the horn-plate remaining in place, at as high a point as possible; the 
 same stitch is repeated with the same needle. In this manner a loop 
 is produced by the drawing together of which the middle fibers of the 
 muscle are constricted. A second loop is placed to its inner side 
 (Fig. 44), and a third loop to its outer, both at the same height. Now 
 the muscle is cut through, 2 mm. below the threads, along the entire 
 
 FIG. 43. Everbusch's operation for ptosis. The incision made midway between 
 eyebrow and border of the lid through the skin (s) and orbicularis muscle (m. o.) is held 
 open by tenacula. The tarso-orbital fascia is also cut near the upper margin of the wound 
 (the border of the wound (c) is visible as a white line) and turned down in such a way that 
 the transition of the levator palpebrae muscle into its tendon is plainly visible in the wound ; 
 at m, it blends with the tarso-orbital fascia. 
 
 length of the lid, and a piece excised 3 to 5 mm. or more broad, that is, 
 downward to the upper border of the tarsus or even including a small 
 piece of the tarsus itself. The conjunctiva as far as it comes within 
 the reach of the piece to be excised, need not be saved, but may be 
 removed with the muscle. However, with slight care, it is not difficult 
 to excise the piece of muscle without injuring the conjunctiva; but 
 when a strip of the tarsus is included, the conjunctival covering cannot 
 be preserved, as it is too intimately adherent.
 
 8o 
 
 OPHTHALMIC SURGERY. 
 
 The gaping wound is closed either by bringing all six ends of the 
 threads between the tarsus and the orbicularis muscle, through the 
 intermarginal space and tying them over rubber tubes; or, as I prefer, 
 by sewing the ends of the catgut threads to the anterior surface of the 
 tarsus so that the upper cut-edge of the muscle is drawn over the cut- 
 edge of the tarsus to its anterior surface, to which it heals (Fig. 45). 
 
 The skin-wound is closed over these sutures with several stitches 
 (Fig. 46). This method of operation has the advantage that the margin 
 of the lid is in no way disfigured. If the threads are drawn through 
 
 FIG. 44. The middle thread has already been inserted. The second stitch is just 
 being inserted; to do this the operator lifts the lateral part of the muscle with forceps in the 
 form of a fold and pushes the needle through the entire thickness of the tissue. 
 
 the intermarginal space and tied there, the underlying materials, 
 glass-beads, gauze-pads or rubber-tubes, almost invariably induce a 
 circumscribed and superficial necrosis of the margin of the eyelid, as 
 the stitches must remain a number of days. The lashes fall out in 
 the necrotic area, and occasionally the scarification may bring about 
 a high grade deformity of the lid-margin, even to incurving of the 
 lashes trichiasis. Because of this, the margin of the lid should, if 
 possible, be spared. 
 
 The result of the operation is in most cases good, although it is
 
 PTOSIS. 
 
 s, 
 
 difficult, and even impossible, to determine exactly just how much 
 muscle should be excised to attain the desired result. Caution must 
 be exercised during the operation to limit the excision of the lid suffi- 
 ciently to prevent resultant lagophthalmos. On this account the 
 piece to be incised should never be broader than 5 mm. 
 
 Contraindications. This operation is, however, only suitable 
 when the levator is not completely paralyzed. This is ascertained by 
 
 FIG. 45. After excising a strip of muscle (and conjunctiva) 5 mm. broad, the middle 
 pair of threads is first fastened on to the anterior surface of the tarsus (ta); during the tying 
 the end of the cut muscle is pulled onto the anterior surface of the tarsus and heals thereon. 
 
 asking the patient to close both eyes as in sleep, so that the super- 
 ciliary ridge may be brought in its normal position immediately on 
 the upper border of the orbit. The skin of the superciliary region 
 must then be fixed in its position on both sides by firm pressure with 
 the thumbs. If now, the patient at command can open the eye 
 even though only to a limited extent, there is proof of some action of 
 the levator, and the muscle is not completely paralyzed. We may 
 then expect success from the operation of Everbusch. 
 6
 
 82 
 
 OPHTHALMIC SURGERY. 
 
 SUMMARY. 
 
 Hess's operation yields good results only when the patient is able 
 to raise the lid through contraction of the frontalis muscle ; otherwise, 
 not much improvement can be expected. Occasionally after per- 
 forming Hess's operation, it is noticed that the patient, having the same 
 degree of ptosis as before, lifts the operated lid, even to the normal 
 breadth of the lid-fissure, only in the moment when the sound eye 
 is closed. The explanation for this may be found in the fact that, 
 not until the sound eye is closed, can the patient contract his frontalis 
 in order to elevate his palsied lid. When contraction of the frontalis 
 on the operated side, while the sound eye remains open, does not 
 
 FIG. 46. Appearance of the lid after the operation. The skin-wound is exactly approx- 
 imated by several sutures. The edge of the lid remains perfectly intact. 
 
 seem possible to the patient, it is not attempted. Likewise, after a 
 Hess's operation has been performed on one side, the patient can open 
 this eye to its normal width, but only with great elevation of the lid 
 the other eye through excessive simultaneous contraction of the 
 frontalis. The bilateral innervation of the frontalis muscle brings 
 about in such individuals an excessive widening of the palpebral 
 fissure on the sound side, while effecting only the normal opening on 
 the affected side. Only in bilateral ptosis can we expect, with cer- 
 tainty, good results from Hess's operation; and, no matter what oper- 
 ation is performed it is impossible in unilateral ptosis to restore and 
 maintain the palpebral fissure to exactly the same width as on the 
 normal side. In any case, the operation should be performed whenever 
 possible under local anesthesia, as in narcosis even a superficial com- 
 parison of the new fissure w r ith that of the sound side is impossible.
 
 PTOSIS. 83 
 
 On the other hand, it must be remembered, that in local anesthesia 
 the swelling of the tissues through the subcutaneous injection makes 
 it also rather difficult to correctly estimate the width of the palpebral 
 fissure. 
 
 The method of Panas, performed considerably at one time, for 
 cosmetic reasons alone is inadvisable and need not be described. 
 
 The method of Motais, recommended recently by several French 
 operators, depends upon the suturing of the superior rectus to the 
 upper margin of the tarsus. It has the great disadvantage of inter- 
 fering with the function of this muscle; and a permanent diplopia may 
 follow its performance.
 
 CHAPTER VIII. 
 THE EYE-MUSCLES. 
 
 TENOTOMY. 
 
 In tenotomy of the rectus interims, the left hand, holding a 
 pair of toothed forceps, raises a fold of the bulbar conjunctiva at a 
 distance of 3 mm. from the limbus. A short vertical incision, about 
 5-7 mm. long, is made with a small, slightly curved scissors. The 
 nasal border of the wound is then lifted up with the forceps and the 
 subconjunctival tissue severed and undermined by short cuts with the 
 scissors. The closed forceps, held parallel to the sclera, are now 
 introduced into the wound, the internal margin of which is slightly 
 raised by the assistant to facilitate this introduction, till they reach the 
 insertion of the muscle (5 mm. from the limbus). They are then 
 opened, pressed against the sclera, and through shutting them the 
 tendon is grasped. The forceps are now rotated into a position per- 
 pendicular to the sclera, and the tendon divided close to its insertion 
 by the scissors held in the right hand. In making this division, one 
 blade of the scissors is pushed behind the tendon, as shown in the 
 illustration (Fig. 47). 
 
 Not a particle of the tendon should remain adherent to the sclera, 
 and after its separation only a slight ridge should mark its point of 
 insertion. The muscle is immediately released, as pulling with the 
 forceps is painful. The scissors are laid aside, and a curved strabis- 
 mus hook, taken in the left hand, is pushed into the wound, close to 
 the sclera, and moved upward and downward in order to determine 
 whether all of the tendon-fibers have been severed. Any fibers which 
 have not been divided will offer a tense resistance to the hook, when 
 the latter is drawn forward. These fibers must also be separated 
 close to the sclera. If the hook becomes caught in the capsule of 
 Tenon, it pulls out a delicate membranous fold, which must not be 
 mistaken for tendon-fibers. Incisions of Tenon's capsule are likely to 
 produce undesirable results. After all the fibers are separated, the 
 wound is closed with one or two catgut-sutures, which are introduced 
 in a direction from above downward. While the needle is being passed 
 
 84
 
 THE EYE-MUSCLES. 
 
 through 
 
 the conjunctiva, the membrane should be firmly fixed with 
 the toothed forceps and the needle held close against it, as pulling on 
 the conjunctiva will cause the patient unnecessary pain. 
 
 The execution of the tenotomy itself is the work of an instant. The 
 operation is best performed under cocain-anesthesia. The experi- 
 enced operator may anesthetize the conjunctiva alone, by dropping 
 
 FIG. 47. Tenotomy of the rectus internus. The eye is placed in the position of 
 abduction. A small incision is made in the conjunctiva (c). The forceps, after seizing 
 the muscle, are held perpendicular to the curvature of the eyeball. One blade of the open 
 scissors is introduced immediately behind the muscle at its insertion, the other bladejies 
 in front of it. A single snip with the scissors severs the tendon (t) at its insertion. 
 
 the cocain-solution into the eye. In sensitive patients, or if the operator 
 is inexperienced, it will be advisable to make a subconjunctival injec- 
 tion of a i per cent, solution of cocain immediately over the tendon of 
 the muscle, employing a quantity of ^ cc. The manner of holding the 
 instruments is the same whether the tenotomy is performed on the 
 right eye or the left eye. After the operation a slight dressing is
 
 86 OPHTHALMIC SURGERY. 
 
 applied which may be removed the following day, or at most two or 
 three days later. 
 
 In tenotomy of the external rectus the incision through the con- 
 junctiva is made slightly further from the limbus, on account of the 
 more remote insertion of the tendon of this muscle (7 mm. instead of 
 5 mm.). Otherwise, the technique of the operation is exactly the 
 same. 
 
 ADVANCEMENT. 
 
 In the operation of advancement the conjunctival sac is first cocain- 
 ized, followed in every case by a subconjunctival injection of a 3 per 
 cent, solution of cocain (^ cc.). A fold of conjunctiva is lifted up 
 over the tendon of the muscle, and the needle of the syringe introduced 
 against the sclera and directed along the axis of the muscle toward the 
 canthus. While this injection is being made, the needle must be pushed 
 farther in, in order to better anesthetize the deeper parts. The 
 resultant swelling may be dispersed by slight massage. 
 
 Sufficient space for the performance of the operation is obtained 
 by a short vertical incision through the conjunctiva, as in tenotomy, 
 in addition to which a long horizontal incision is made, beginning 
 at the middle of the first cut, and running perpendicular to it toward 
 the canthus. The wound is thoroughly undermined by small cuts 
 with the scissors, after which the muscle is seized with the forceps in 
 the manner previously described. 
 
 The tendon is now held with the forceps, and the eye is rotated in 
 the direction opposite to the action of the muscle, while the latter is 
 loosened from its bed by a few strokes with the point of the closed 
 scissors, which is made to glide along its upper and lower margins. A 
 straight strabismus hook is then passed beneath the muscle, either from 
 above or below. If the point of the hook is covered by the conjunctiva 
 or the capsule of Tenon, it must be freed, and the second strabismus 
 hook is thereupon introduced in the opposite direction. Muscle- 
 fibers will frequently be caught by this hook which escaped the first 
 one. If the muscle is not yet cleanly dissected, the overlying tissue 
 must be separated with the scissors, the cutting always following the 
 direction of the muscle. If it is done transversely, that is, vertical to 
 the muscle-fibers, it may happen that a considerable part and some- 
 times even the entire muscle is severed, thus making the operation 
 much more complicated. It is important for the assistant to remember
 
 THE EYE-MUSCLES. 87 
 
 that he should stretch the muscle by means of the two strabismus-hooks 
 only when desired by the operator, as tension on the muscle always 
 causes pain. 
 
 The suturing is now done. While the sutures are being inserted, 
 the assistant must stretch the muscle. This is effected by the anterior 
 strabismus hook drawing the eye in a direction opposite to the action 
 of the muscle, while the other strabismus hook is moved in the direc- 
 tion of the musclar contraction. A moderately thick silk thread, 
 
 FIG. 48. The eye is placed in the position of adduction. The freed muscle is stretched 
 over two strabismus-hooks. The upper suture has already been pulled through; the lower 
 suture is being introduced. 
 
 upon the strength of which we can rely with certainty, is used. The 
 threaded needle is passed from within outward through the muscle 
 near its middle close to the posterior strabismus-hook. Half of the 
 suture is drawn through, and the needle is again passed in the same 
 manner at the same point. The loop thus formed is made to firmly 
 grasp the muscle-fibers. It makes no difference whether the needle 
 is first passed through the upper or lower half of the muscle. The 
 other half of the muscle is then included in a loop of thread intro- 
 duced at the same distance from the insertion of the tendon (Fig. 48)
 
 88 OPHTHALMIC SURGERY. 
 
 and laced up in the same manner. The ends of the suture containing 
 the upper half of the muscle are laid upward, and those of the lower 
 half downward, or a white and a black suture may be used in order 
 that the wrong ends of the threads may not be tied, when this stage 
 of the operation is reached. After the sutures are introduced, the 
 operator divides the muscle with one snip of the scissors, about 2 mm. 
 in front of the threads; closer than this, the loops are liable to slip off. 
 The stump of the muscle still adhering to the sclera, is now removed 
 close to the scleral surface, leaving only a short piece at one end of the 
 insertion, to allow fixation of the eye with the forceps. 
 
 By the foregoing procedures, it is seen that the muscle is shortened 
 to a certain extent, and it must now be not only re-attached to the 
 bulb, but fastened so that its influence is more strongly felt, i.e., its 
 insertion must be brought nearer to the limbus, hence the term: 
 advancement. For this purpose, the needle of either suture is passed 
 near the limbus through the superficial layers of the sclera, the thread 
 of the upper loop corresponding to the upper half of the original 
 insertion, and vice -versa. The sclera in front of the insertion must 
 first be laid bare by separation of the conjunctiva, as the muscle 
 naturally can only unite with a raw surface. For this suture, it is 
 best, to employ a thin flat needle, not the thick and triangular needles, 
 as these would have to be introduced deeply to prevent cutting through. 
 
 With a normally thick sclera there is no danger of perforating 
 the bulb, if the needle is held parallel to the curvature of the sclera, 
 so that only the most superficial layers are taken up. The needle 
 point must not be placed vertically against the sclera in order to pene- 
 trate its fibers. The only unpleasant feature is that the needle may be 
 passed too superficially and soon cuts through. If this happens, a 
 fresh attempt must be made to catch some of the adjacent scleral 
 fibers, a few of which are sufficiently strong to allow the operator to 
 draw the eye, by means of the suture, in the direction of the muscle 
 and to fasten the latter firmly to the globe. In making this suture, 
 the needle is inserted in the direction of the muscle, i.e., horizontally, 
 and the thread fastened to the sclera in front of either the upper or 
 the lower half of the tendon-insertion, according to which suture is 
 being tied. The attachment is made as close as possible to the limbus, 
 but care should be taken that the knotted thread does not injure the 
 cornea by pressure. The position of the knot should, therefore, be at 
 least i mm. from the limbus, so that it does not press upon the
 
 THE EYE-MUSCLES. 
 
 8 9 
 
 cornea. For this reason, it is advisable, and for the less skillful 
 operator easier, to pass the needle through the sclera parallel to the 
 limbus, i.e., perpendicular to the axis of the muscle. The needle of 
 the superior suture must, therefore, be brought from the horizontal 
 meridian upward, while that of the inferior suture goes from the 
 same point downward. Such a direction of the sutures has also the 
 
 FIG. 49. Advancement of the rectus externus. The muscle is divided; a piece 
 excised; the eye is held fast by forceps applied to the stump of the tendon, which has been 
 allowed to remain. The upper suture has already been drawn through the sclera near 
 the limbus and also through the conjunctiva. The needle, which has been applied flat 
 against the sclera, has already penetrated slightly the superficial lamellae. 
 
 advantage of lying perpendicular to the direction of the scleral fibers 
 
 (Fig- 49)- 
 
 After the needle has been fixed into the sclera, it is passed a little 
 further upward or downward through the conjunctiva. This affords 
 not only an additional hold for the suture, if the attachment to the 
 sclera is not sufficiently firm, but closes simultaneously the wound in
 
 9 o 
 
 OPHTHALMIC SURGERY. 
 
 the conjunctiva. Only one end of each suture is passed through the 
 sclera. 
 
 Now a surgical sling is prepared in both the upper and the lower su- 
 tures. Then, while the assistant seizes with the forceps the eyeball at 
 the opposite limbus and rotates the bulb in the direction of the operated 
 muscle, each suture is drawn as tight as possible, and a second knot 
 is made over the first (Fig. 50). The sutures must be dra\vn firmly 
 in order to be certain that the muscle has actually been brought for- 
 
 FIG. 50. The operation is almost completed. The eye is rotated outward by the 
 forceps, which are fastened at the inner side. The lower suture has already been tied; 
 the upper has still to be pulled together. The conjunctiva covers the wound spontaneously . 
 
 ward to the limbus and fastened there. If the sutures have not been 
 brought together properly, the muscle will be weakened rather than 
 strengthened by the advancement. 
 
 A suture of the conjunctiva is usually unnecessary as the w T ound has 
 already been closed perfectly by the advancement-sutures. If this, in an 
 isolated instance, should not be the case, there is no objection to a con- 
 junctival suture. The operation is the same for either the rectus inter- 
 nus or externus. The threads are cut off short, and care exercised that
 
 THE EYE-MUSCLES. 91 
 
 they do not come in contact with the cornea. After the operation a 
 dressing is applied to both eyes, as the prevention of all ocular motion 
 will protect the recently sutured muscle in its new position and make 
 secure its attachment to the limbus. 
 
 After-treatment. When possible, as in hospital-cases, both eyes 
 should be kept closed for three days, but the dressing is changed on the 
 day following the operation, in order to ascertain whether or not the 
 cornea is uninjured. The sutures may be removed on the fifth or 
 sixth day after the operation, but if a pronounced swelling of the con- 
 junctiva prevents ready access to the knots, there is no objection to 
 allowing the sutures to remain longer, as they can be removed later 
 with much greater facility. On the whole, the reaction of the conjunc- 
 tiva to this operation is usually slight. The eye exhibits no irritation 
 or pain, and in a short time there is only a slight thickening of the con- 
 junctiva to mark the point of operative interference. 
 
 If the patient's sound eye cannot be bandaged (as in the case of 
 ambulant patients, who must go home alone), it is advisable to keep the 
 muscle at rest by introducing a suture through the conjunctiva close to 
 the limbus, and carrying the ends through the canthus to the external 
 skin, where they are tied. In this way it becomes impossible to rotate 
 the eye toward the side opposite to that of the advanced muscle. 
 
 The Fixation of the Muscle to the Limbus. While it is our custom 
 to suture the muscle directly to the sclera, by passing the needle 
 through its most superficial layers, as has been described, it is proper 
 to discuss here another common method. This consists in passing 
 one end of the upper suture upward beneath the conjunctiva along 
 the limbus, going almost as far as the upper end of the vertical meridian, 
 and, in a similar manner, one end of the inferior suture is passed be- 
 neath the conjunctiva as far as the lower end of the vertical meridian. 
 In this way an attempt is made to obtain sufficient hold for the muscle 
 in the conjunctiva. When the sutures are tied, the muscle is, of course, 
 drawn forward to the limbus, and must naturally split. On the 
 other hand, the ocular conjunctiva also yields to the tension, and is 
 stretched in the direction of the tendon, obliquely across the cornea. 
 Quite apart from the fact that this attachment is not dependable, on 
 account of occasional friability of the conjunctiva, the method has still 
 a greater drawback namely, that the conjunctiva lies from above- 
 downward in a tensely drawn fold across the cornea. Again, it can 
 easily happen that the suture will come to lie upon the cornea, especially
 
 92 OPHTHALMIC SURGERY. 
 
 if it is not drawn sufficiently tight, a fact which may pass unnoticed by 
 the operator, as the knot is covered by the conjunctiva. A corneal 
 ulcer may thus be produced, which will make the prognosis bad, as 
 these ulcers show little tendency to heal. The operator is then forced 
 to remove the sutures at once sacrificing the entire success of the 
 advancement. Therefore, preference should be given absolutely 
 to the direct suturing to the sclera. The only contraindication to this 
 would be a pathologically thinned sclera (ectasia) . 
 
 APPLICABILITY OF STRABISMUS-OPERATIONS. 
 
 Before performing a strabismus operation, two conditions should be 
 investigated the degree of deviation of the affected eye, and the 
 mobility of the eyes. It may be incidentally mentioned at this time that 
 a preliminary accurate determination of the ocular refraction 
 under the influence of atropin is an absolute necessity. The same 
 degree of strabismus may in one case call for a tenotomy, and in another 
 make an advancement of the muscle desirable. Furthermore, it must be 
 clearly understood how much effect is likely to be produced by a tenotomy 
 or an advancement. For example, how many degrees of the squint in 
 an eye with convergent strabismus may be overcome by a correctly per- 
 formed tenotomy of the rectus internus, and how many by an advance- 
 ment of the rectus externus ? The exact determination of this is not 
 possible. It is commonly believed that tenotomy of the rectus internus 
 corrects to the extent of 15 degrees, but very often there is produced 
 decidedly less correction, sometimes even very much less. And, while 
 at times the final result of a tenotomy after the lapse of some time shows 
 little change in the degree of squint, in other cases the effect is unex- 
 pectedly great, so that the commonly given figures are far exceeded. 
 As stated clearly above, this applies only to a correctly performed 
 tenotomy. It would not be surprising to find an enormous change in 
 the position of the eye after extensive incisions of the conjunctiva, the 
 subconjunctival tissue and Tenon's capsule, or to get no result at all 
 when some of the muscle-fibers were overlooked. But even in per- 
 forming the operation in the most approved manner, the effect may 
 be decidedly influenced, not only by preexisting physiologic variations 
 in the distance of the muscular insertion from the limbus, in the 
 strength of the muscle, and in the relations of Tenon's capsule, but 
 also, and sometimes to a considerable degree, by definite even though 
 only slight variations in the degree of separation of the subconjunctival
 
 THE EYE-MUSCLES. 93 
 
 tissue and capsule resulting from, the operation. It must also be 
 remembered that the immediate result of an operation may differ 
 greatly from the more remote, permanent result. 
 
 From the foregoing it is readily understood that the degree of cor- 
 rection after tenotomy of the rectus internus cannot be foretold with 
 certainty. But even if the effect of a tenotomy were definitely 
 known in advance, there would still remain many perplexing problems 
 for the operator. It would naturally be most uncommon for the degree 
 of a strabismus to correspond exactly with the degree of change in 
 position produced by severance of the tendon. Therefore, the neces- 
 sity for some means of regulating the effect of a strabismus operation 
 is at once recognized. With such means at hand one does not need to 
 know accurately in advance how much effect the operation will have. 
 Hence, for altering the effect of a tenotmoy there are introduced what 
 are termed supporting and counteracting sutures. 
 
 The supporting suture is inserted by means of a short, moderately 
 curved needle, into the conjunctive close to the external limbus in the 
 horizontal meridian. In this situation the conjunctiva is firmly attached 
 to the coats of the eye. If the suture is placed more externally only a fold 
 of conjunctiva will be pulled forward by it, and it will be impossible 
 for it to exert an appreciable influence upon the position of the eye. 
 The suture is introduced in the horizontal meridian, because the eye 
 should be rotated outward accurately on its vertical axis; if the fixation 
 is made above or below the horizontal meridian, the rotating of the eye 
 will occur on other axes, which would produce undesirable results. 
 In order to fasten the suture firmly, it is advisable to introduce the 
 needle twice, once immediately above and once just below the horizon- 
 tal meridian. In those occasional cases in which the conjunctiva is 
 easily lacerated, there should be no hesitation in penetrating somewhat 
 deeper with the needle in order to fasten the suture in the episcleral 
 tissue beneath the conjunctiva. Both ends of the silk-suture are then 
 passed in the horizontal meridian through the external canthus out 
 to the skin. In doing this, the needle is made to penetrate the can- 
 thus rapidly, while the outer angle of the eye is stretched between two 
 fingers. By tying both ends of the suture finally over a small gauze 
 compress, the operator is in a position to rotate the eye outward 
 at will. 
 
 The problems now confronting the operator are the following: 
 How far outward should the eye be rotated ? How great is the effect
 
 94 OPHTHALMIC SURGERY. 
 
 of this supporting suture, and when should it be applied ? The appli- 
 cation of the suture is naturally limited to those cases in which con- 
 vergent strabismus still exists after the tenotomy but in which at the 
 same time the loosened muscle is not too much limited in its efficiency. 
 It follows, as a matter, of course, and this is an important rule after 
 every strabismus-operation, that the position of the eye should be con- 
 trolled immediately after completion of the operation. This is best 
 done by having the patient, while still lying on the operating table, fix 
 his gaze with both eyes open upon a point on the ceiling of the room. 
 It can then be readily determined how much improvement in position 
 has been accomplished by the operative interference. Then, by having 
 the patient fix upon the operator's finger, while it is moved toward him 
 in the sagittal plane, the convergence-ability of the eye can be deter- 
 mined, and, by laterally conducted movements, also the adduction- 
 power of the severed muscle. The suture should not be used in those 
 cases in which the muscle appears considerably weakened, even though 
 there still remains some strabismus. As the suture rotates the eye 
 outward, the insertion of the muscle will come to lie still further from 
 the limbus than after a simple tenotomy, and through this the muscle 
 will lose still more in efficiency. If there is pronounced weakness of 
 the muscle, a divergent squint will soon develop, owing to the marked 
 preponderance in strength of the intact rectus externus. 
 
 In accordance with the rule always to be satisfied with a slight 
 undercorrection in the operation for convergent squint, the eye should 
 not be rotated outward to its greatest extent by means of the suture, 
 although it is known that the eye rolls inward again after removal of 
 the suture. At the most, therefore, it is permissible to pull the suture 
 sufficiently tight to produce a slightly divergent position. It is not 
 necessary to allow the suture to remain over twenty-four hours. The 
 final effect of the suture cannot be estimated accurately in degrees. 
 As already mentioned, the eye usually rolls inward again to a slight 
 extent. The influence of the supporting suture is closely related to 
 the size of the incision into Tenon's capsule. Lateral incisions in 
 the capsule of Tenon, which are also recommended to increase the 
 effect of tenotomy, must certainly be made to some extent in the 
 performance of every tenotomy. 
 
 A great advantage lies in the possibility of introducing this suture 
 one, two, or even three days after the tenotomy. It happens occasion- 
 ally that the correction produced by a tenotomy is entirely satisfactory
 
 THE EYE-MUSCLES. 
 
 95 
 
 immediately after the operation, but in the next few days, to the great 
 astonishment of the operator, the effect diminishes considerably and the 
 degree of strabismus increases correspondingly. The suture is, there- 
 fore, the most acceptable means of reproducing the original result. 
 After cocainizing and re-opening the conjunctival wound, a strabismus 
 hook is employed to separate the fresh adhesions that have formed 
 since the operation, after which the suture may usually be introduced 
 with gratifying results. 
 
 The counteracting suture is applied as follows: A suture is intro- 
 duced through the conjunctiva close to the internal limbus, in the same 
 manner as previously described for the supporting suture at the external 
 limbus. The inner border of the wound is then raised by means of 
 toothed forceps, and if a pronounced effect is desired, an attempt is 
 made to grasp the muscle itself with the forceps. The needle is then 
 pushed deeply into the subconjunctival tissue and is brought out near 
 the internal canthus about the point of the caruncle. The whole region 
 must previously be anesthetized by a cocain-injection. The other 
 end of the suture is passed in the same way, and the two ends are 
 tied firmly. The eye is thereby rotated inward, so that the recently 
 divided muscle with its tendon is again brought closer to the limbus, 
 and thus gains in power. The fixation of the silk-thread in the con- 
 junctiva at the limbus is sometimes difficult, particularly if the con- 
 junctival incision has been made close to the limbus. If the con- 
 junctiva is easily torn, and does not offer sufficient hold for the suture, 
 no other course is left open but to fasten the suture in the superficial 
 layers of the sclera. 
 
 This suture must invariably be employed if an over-correction has 
 resulted from the tenotomy. If the eye shows a tendency to become 
 divergent immediately after the division of the tendon, and if the powers 
 of adduction and convergence of the eye have been greatly interfered 
 with by the operation, the omission of this suture would constitute a 
 serious mistake. The highest grades of divergent squint may follow 
 such unfortunate tenotomies. As in the case of the supporting suture, 
 this counteracting suture may also be introduced one to three days after 
 the tenotomy. It is only necessary first to break any existing adhesions 
 by means of the strabismus hook. The suture is always tied firmly so 
 that it produces a decided convergent position of the eye. In over- 
 correction of the eye, it is not likely that too much counteraction will be 
 produced. The suture should be allowed to remain several days.
 
 96 OPHTHALMIC SURGERY. 
 
 As mentioned before, all of the methods described here refer to tenotomy 
 of the rectus internus. 
 
 Tenotomy of the external rectus plays a much less important part 
 in the operation for divergent strabismus, than does tenotomy of the 
 internal rectus in the operation for convergent strabismus. This 
 subject will be considered later, and in the meantime the discussion 
 will be continued regarding the operation for convergent strabismus. 
 
 The Extent of the Effect Produced by Advancement of the 
 Rectus Externus. Still less accurate figures can be given here than 
 in the case of tenotomy. The variations in the extent of the results 
 should not occasion surprise, and it would be extremely naive, if we 
 could believe that each millimeter of excised muscle will produce ex- 
 actly the same degree of correction in every case, or that a certain degree 
 of strabismus will be overcome by the excision of so many millimeters 
 of muscle in accordance with an inflexible rule. A change of 30 
 degrees in the position of the eye is the most that can be expected 
 from an advancement; usually it is much less, and may be put down 
 at 20 degrees at an average in an operation with normal course. 
 
 In the method which has been described, there are two means of 
 influencing the effect of advancement the excision of a piece of 
 muscle, and the suture of the insertion in front of the original point of 
 attachment. The last plays a more important part than the excision. 
 If the operation is limited merely to the excision of part of the muscle, 
 and the muscle again sutured to the original point of insertion, the 
 effect of the operation will be slight. Of decided importance is the 
 approaching of the new point of insertion of the muscle toward the 
 limbus. 
 
 There is no danger of producing an over-correction by performance 
 of advancement alone. Even in a convergent strabismus of no more 
 than 20 degrees one may safely excise the longest possible piece of the 
 muscle and suture the remainder in an advanced position without 
 producing thereby a divergent strabismus. It must also be taken into 
 consideration that the result evident immediately after the operation 
 is at its maximum, and that the effect usually diminishes somewhat 
 in the near future. Therein lies an important contrast with the effect 
 of a tenotomy. While an over-correction must be strictly avoided in the 
 performance of tenotomy, on account of the increasing degree of diver- 
 gent strabismus that is inevitably produced, any over-correction that 
 may occur during the performance of an advancement need not worry
 
 THE EYE-MUSCLES. 97 
 
 the operator. No increase in the divergence is to be expected; on the 
 contrary, a retrogression is certain to occur. 
 
 Incalculable results may follow simultaneous advancement of the 
 rectus externus and tenotomy of the rectus internus of one eye. 
 Even though a considerable degree of convergent squint with good 
 adduction-power of the eye remains after a tenotomy of the internal 
 rectus, an immediate advancement of the rectus externus is a risky 
 procedure. The effect accomplished is often enormous, and a high 
 degree of divergent strabismus may be the immediate result. As a 
 result of the preliminary tenotomy, the advancement not only produces 
 changes in the region of the external rectus, but also weakens the action 
 of the internal rectus. Through advancement of the rectus externus 
 the eye is rotated outward, and owing to the lack of resistance on the 
 part of the divided rectus internus, this rotation is greater than it would 
 be with a normal internal rectus. The result is necessarily the same 
 as that produced by a supporting suture. The rectus internus is drawn 
 further away from its original point of insertion toward the equator of 
 the eye, and loses correspondingly in its influence. 
 
 The simultaneous performance of tenotomy and advancement can 
 be recommended only for the highest grades of convergent strabismus. 
 Even in these cases the operation has to be limited to a resection of the 
 muscle, and the suture made through the original point of insertion. 
 If an over-correction is produced, it should by no means be allowed 
 to remain, as the resulting divergent strabismus will rapidly increase 
 in degree. It is necessary to introduce immediately a counteracting 
 suture, which must be well buried in the superficial layers of the sclera 
 at the internal limbus, to prevent the thread from tearing out. Should 
 this not be sufficient, the operator must remove the sutures of the 
 advancement and fasten the muscle further backward. The removal of 
 these sutures after an interval of two or three days will no longer have 
 any effect on the result of the operation. 
 
 From a physiologic standpoint, advancement must be given the 
 preference. It increases the motility of the eye, while tenotomy causes 
 a diminution or loss in motility. Therefore, although the pathogene- 
 sis of strabismus may indicate tenotomy as the operation of choice for 
 the correction of convergent squint, advancement must be recognized 
 as of greater value physiologically. This should not be understood, 
 however, as meaning that an advancement must be performed under 
 7
 
 98 OPHTHALMIC SURGERY. 
 
 all circumstances; in fact, it cannot be denied that in many cases tenot- 
 omy is an indispensable operation. 
 
 In order to give some general indications for procedure 
 in overcoming convergent strabismus, the following rules may 
 be formulated, based upon the preceding considerations: 
 
 If the squinting eye is amblyopic, the operations are preferably 
 performed upon this eye, so far as the consideration for its mobility 
 will allow; however, an interference with the other eye is usually allow- 
 able. 
 
 In convergent strabismus of slight degree (maximum 15 degrees) 
 tenotomy of the rectus internus of the affected eye is the first con- 
 sideration. An examination of the new position of the eye must be 
 made immediately after the operation and in accordance with the 
 points of view previously pointed out, in order to determine whether 
 or not a suture, and which suture, is necessary to change the effect. 
 Only rarely will it be found that the tenotomy has produced exactly 
 the result desired. If the tenotomy is succeeded by a marked diminu- 
 tion in the motive power of the rectus internus, all thought of immediate 
 further interference must be abandoned, even though a convergent 
 squint still remains. 
 
 Tenotomy is the operation of choice in cases with normal motility 
 of the squinting eye, while advancement is preferable if the abductive 
 power of the eye is materially limited. An advancement of the rectus 
 externus on both sides may be advisable if a unilateral operation does 
 not produce sufficient correction, or if abduction is weak on both sides, 
 as happens not infrequently in alternating convergent strabismus. 
 The extent of the second advancement depends naturally upon the 
 degree of convergent squint remaining. That an over-correction is 
 not to be feared, has already been mentioned. 
 
 With strabismus of higher degree, in which it is foreseen that neither 
 tenotomy alone nor advancement alone will suffice, warning must again 
 be given against a simultaneous performance of both operations. 
 In such cases the patient should be told in advance that two operative 
 procedures will be necessary to overcome the squint. The tenotomy 
 is first performed, with supporting suture if necessary. The patient 
 is then allowed to go about wearing fully correcting lenses for several 
 weeks, by which time the final result of the operation will be manifest. 
 The advancement may then be performed, the amount of advance 
 varying with the degree of strabismus still existing. If, after the tenot-
 
 THE EYE-MUSCLES. 99 
 
 omy, it is seen that the rectus interims may not be further weakened 
 directly or indirectly by a strengthening of the antagonist, then the 
 operation should be performed on the other eye. It would be worth 
 the attempt to determine how far an advancement of the rectus exter- 
 nus could be influenced in a strengthening sense by a simultaneous 
 partial tenotomy of the rectus internus, thus avoiding the danger of over- 
 correction which accompanies tenotomy. The simultaneous per- 
 formance of tenotomy and advancement should be reserved for the 
 highest grades of convergent strabismus only, the advancement being 
 performed with the foregoing precautions. This has also to be done 
 in those cases of medium degrees in which we are compelled to correct 
 the strabismus in one sitting, either through the request of the patien 
 or for some other reason. 
 
 The advice relative to the operation for divergent strabis- 
 mus is much simpler. The precept, which applies chiefly here, is 
 to produce an over-correction; but this desideratum is not so easily 
 attained. It must be remembered that advancement of the rectus 
 internus is the only procedure, \vhich has any material influence on a 
 divergent strabismus. But in itself an advancement oj the rectus 
 internus has not as much influence on the position oj the eye as an 
 advancement of the rectus externus. 
 
 Two circumstances are responsible for this: 
 
 (i) On account of the local obstruction it is not possible to pre- 
 pare and free as large a part of this muscle as in the case of the 
 external rectus, and consequently the suture cannot be introduced as 
 far back; (2) There is less room to advance the muscle, as the inser- 
 tion of the tendon is normally near the limbus and cannot be brought 
 much closer to it. In a similar way a division of the external rectus 
 has much less influence on the position of the eye than a tenotomy of 
 the internal rectus. As the tendon insertion of the rectus externus is 
 already further removed from the limbus, its shifting by means of a 
 tenotomy will cause relatively much less loss in the influence of the 
 muscle on the motility of the eye, than is the case with the rectus 
 internus. The value of the point of insertion grows in a rapidly 
 increasing ratio as this point approaches the limbus. 
 
 From these observations it follows that, even in slight grades of diver- 
 gent squint, both operations are usually performed simultaneously, in 
 order to obtain immediately after the operation an over-correction 
 a slight degree of convergent strabismus as experience has shown, that
 
 100 OPHTHALMIC SURGERY. 
 
 there is always a tendency toward a return to the divergent position. 
 A tenotomy alone of the rectus externus has hardly any influence. In 
 higher grades of divergent strabismus even the simultaneous perform- 
 ance of both operations is not sufficient. 
 
 In such cases a supporting suture may be employed. This is 
 introduced in a manner similar to that described for the counteracting 
 suture in tenotomy of the rectus internus. Or a suture may be passed 
 externally through the bulbar conjunctiva, not too close to the limbus, 
 carrying both ends out through the palpebral fissure toward the median 
 line. By drawing upon both ends firmly at the same time, the eye is 
 brought into a pronounced convergent position, one end being drawn 
 upward to the median line of the forehead, and the other over the bridge 
 of the nose to the other side of that organ, in which positions both ends 
 are fastened with several strips of plaster. A small piece of absor- 
 bent cotton is placed beneath the lower thread, so that it does not cut 
 into the bridge of the nose. As the eye cannot be completely closed, 
 it should be covered with a piece of oiled gutta-percha paper. The 
 suture may be removed on the following day. The cornea will not 
 be injured by the suture, especially if it has been introduced a short 
 distance externally to the limbus, so that it raises a small fold of the 
 conjunctiva. 
 
 If the divergent position is not yet corrected in spite of the supporting 
 suture, then the analogous operation on the other eye is indicated. 
 
 If the divergent strabismus is the result of a tenotomy of the 
 rectus internus that has been performed for convergent strabismus, 
 then an advancement of the rectus internus usually produces an 
 excellent result. The preparation of the muscle, however, is somewhat 
 more difficult, as it is often inserted surprisingly far back from the 
 limbus. It is scarcely possible, in such cases, to excise a part of the 
 muscle, as there is only sufficient room to introduce the sutures. Never- 
 theless, the result is good, as the point of insertion can be brought 
 forward a considerable distance. After an over-correction of convergent 
 strabismus by tenotomy of the rectus internus, the operator must be 
 warned against undertaking an advancement of this muscle within a 
 few days after the tenotomy. The only course that can be pursued is i;o 
 introduce the counteracting suture. An advancement according 
 to exact rules is extraordinarily difficult, as the muscle can often be 
 scarcely found in the congested and somewhat swollen tissue, and the 
 procedure in addition is painful to the patient in spite of the cocain-
 
 THE EYE-MUSCLES. IOI 
 
 injection. Under these circumstances if the suture has not had the 
 desired effect, it is much better to wait until the eye has recovered from 
 its congested condition, and several weeks later undertake the advance- 
 ment. An unsuccessful attempt at advancement may render the con- 
 dition even worse. 
 
 Among the unpleasant sequelae that may follow a tenotomy are 
 widening of the palpebral fissure, protrusion of the eye and 
 retraction of the caruncle. The last may occasionally be observed 
 immediately after the performance of the tenotomy, and is due to 
 fibers which pass from the rectus internus to the caruncle; these fibers 
 become stretched through retraction of the muscle, thus exerting a 
 traction on the caruncle, and causing its depression. Under these 
 circumstances, the fibers should be divided by undermining the con- 
 junctiva toward the caruncle with small clips of the scissors. This can 
 also be done some time after the tenotomy, through a freshly made 
 opening in the conjunctiva. An abnormal widening of the palpebral 
 fissure should be remedied by tarsorrhaphy. 
 
 The principal indication for advancement of the rectus internus 
 is manifest divergent squint, but it must also be performed in exophoria, 
 in which asthenopic symptoms, such as fatigue and variable diplopia, 
 arise even during use of the eyes at distance, provided, of course, that 
 these symptoms cannot be remedied by the use of prisms. As the 
 extreme correction possible from an advancement of the rectus internus 
 is about 12 degrees, the operator must be governed in using this opera- 
 tion by the degree of exophoria. If the heterophoria is slight, the 
 operation should be confined to a simple advancement without excision, 
 or with excision of a short piece of the muscle. It is desirable that the 
 patient should show immediately after the operation a slight conver- 
 gence when looking into the distance. If binocular vision existed before 
 the operation, the convergence will soon disappear under the influence 
 of the fusion-tendency. When a carefully performed advancement of 
 one internus does not relieve the patient of the exophoria and its 
 accompanying symptoms, a similar advancement of the rectus internus 
 of the other eye may be undertaken after the lapse of a few weeks. 
 
 In paralytic squint, operative interference should be resorted to 
 only if it is decided that the paralysis is permanent and has been 
 present for at least nine to twelve months. An effect upon the 
 mobility of the eye can be promised from the advancement only in 
 cases of partial paralysis of the muscle. In total paralysis no influence
 
 102 OPHTHALMIC SURGERY. 
 
 can be exerted on the motility, and the operation is performed rather 
 with the idea of returning the paralyzed eye 'to its normal position. 
 
 In general, all strabismus-operations have only a cosmetic value. 
 It is only in rare cases that the operation for associated strabismus, 
 restores binocular vision. 
 
 To secure a sufficiently good cosmetic result, the co-operation of the 
 patient is needed not only during the operation (by remaining quiet, 
 etc.), but also immediately afterward, when a rapid examination of 
 the eye must be made in order to alter the effect if necessary, by means 
 of supplementary procedures (sutures, etc.). It is better, therefore, to 
 undertake the operation only in those patients who possess the neces- 
 sary average intelligence for the different tasks assigned to them. 
 Therefore, in our clinic we operate only on children who have 
 passed their twelfth or thirteenth year. Before this period we 
 confine ourselves to an accurate correction of refraction with the aid of 
 atropin, to the constant use of glasses, and to the continuous exercise 
 of the squinting eye by systematic bandaging of the healthy eye. When 
 indicated, resort is made to regulated stereoscopic practice.
 
 CHAPTER IX. 
 
 ENUCLEATION OF THE EYEBALL AND ITS SUB- 
 STITUTES. 
 
 ENUCLEATION. 
 
 The greater number of the enucleations of the eyeball are made under 
 general anesthesia. If, however, the eye is not markedly injected or 
 tender to pressure, the operation may be performed under cocain- 
 anesthesia. In the latter case one first thoroughly anesthetizes the 
 conjunctival sac by instilling a 3 per cent, solution of cocain. The 
 anesthesia may be better completed by adding several drops of adrena- 
 lin solution, which produces pallor of the eye and anemia of the 
 conjunctiva. 
 
 The first step of the operation is to separate the conjunctiva from 
 the eyeball. A fold of the bulbar conjunctiva is picked up with a pair 
 of toothed forceps in the horizontal meridian near the limbus, and a 
 small incision is made into it close to the limbus. Not a particle of 
 conjunctiva should remain on the bulb, as every millimeter is of the 
 greatest importance for the wearing of a prothesis. 
 
 The detachment of the conjunctiva is best performed in the 
 following manner (Fig. 51): The blunt blade of the small, slightly 
 curved scissors is inserted into the opening made near the limbus, and 
 pushed forward beneath the neighboring conjunctiva, while the other 
 blade remains in front of the cornea. The blades must be held parallel 
 to the limbus. The scissors are then closed, thus separating the con- 
 junctiva from its attachment at the limbus. This is continued, the 
 conjunctiva being picked up with forceps at the end of the incision and 
 the scissors being pushed forward until the conjunctiva is loosened 
 completely at the limbus. As a right-handed operator always cuts from 
 right to left, the detachment of the conjunctiva in the case of the right 
 eye should begin on the inner side; in the case of the left eye, 'on the 
 outer side of the corneal limbus. The lower periphery is separated 
 first, and then the upper, so as not to be disturbed by the blood con- 
 stantly running down. After the conjunctiva has been cut all the way 
 around, it is undermined with closed scissors on all sides, in order to 
 completely detach it from the eyeball.
 
 104 
 
 OPHTHALMIC SURGERY. 
 
 The division of the straight eye-muscles is then made. The 
 tendon of the internal rectus is the first muscle to be divided on the right 
 eye; the tendon of the external rectus, on the left eye. The tendon is 
 picked up with the toothed forceps in exactly the same manner as 
 described under tenotomy (p. 84). While the assistant slightly lifts 
 the conjunctiva in front of the muscle, the operator, having scissors 
 ready in his right hand, puslies the shut forceps held in his left hand, 
 along the sclera back, close to the attachment of the muscle, where 
 
 FIG. 51. Enucleation of the right eye. Division of the conjunctiva has advanced 
 to the vertical meridian. Note the position of the scissors: one of its blades is pushed 
 forward beneath the conjunctiva, the forceps at the same time lifting the margin of the 
 conjunctival wound somewhat; the other blade of the opened scissors is placed in front of 
 the cornea in such a manner that by shutting the instrument the conjunctiva is separated 
 close to the limbus. 
 
 he opens it and grasps the muscle by pressing the forceps against the 
 sclera. The final detachment of the tendon from the sclera is not com- 
 pleted as in tenotomy; but the muscle is cut through at the side of the 
 forceps, away from the eyeball, by pushing the blunt blade of the 
 scissors under the muscle-tendon from beneath and cutting through it 
 obliquely, so that a short piece remains attached to the eye, by which 
 the globe is held during the subsequent stages of the operation (Fig. 52). 
 By the tenotomy, Tenon's capsule is laid open, completely exposing 
 the sclera. The small, slightly curved scissors, employed for the
 
 EXUCLEATION OF THE EYEBALL. 105 
 
 division of the conjunctiva and the tendon, are now replaced by a some- 
 what larger and stronger pair, which may be either straight or slightly 
 curved, the enucleation-scissors. 
 
 The eyeball, which is held throughout by the stump of the muscle- 
 tendon, is rotated in a horizontal direction toward the side opposite 
 the cut muscle (i. e. the right eye outward, and the left eye inward i, 
 and the scissors inserted into the opening in Tenon's capsule, 
 which is found best by pressing the blunt blade of the opened scissors 
 
 !'!<;. ;2. The- forceps have grasped ilu 1 internal rc< iu> at its attachment, and have turned 
 
 the eve outward; one blade of the scissors is pushed under the niu-cle to the inner side ol 
 
 ut through it verticallv to the tin 
 
 against the bared sclera and pushing it from here upward under the 
 capsule. In this way the blade glides under the tendon of the superior 
 rectus (Fig. 53). The muscle i- recogni/ed by the marked resis- 
 tance which it offers the scissors. The eyeball i- next pressed forward 
 with the aid of the scissors, so that the tendon of the muscle is exposed, 
 when it is cut off close to its in.-crlion with one snip of the scissors. 
 The tendon of the inferior rectus is next severed by similar fixation 
 and position of the eyeball, excepting that the operating hand must be
 
 io6 
 
 OPHTHALMIC SURGERY. 
 
 held perpendicularly. In the same manner as before, the blunt blade 
 of the scissors glides beneath the capsule of Tenon, lifts up the tendon 
 of the inferior rectus, so it can be seen on the scissors, and cuts through 
 it. 
 
 The tendon of the fourth straight eye-muscle is not divided until 
 after the severance of the optic nerve. While the eyeball is held 
 rotated to the right, the closed enucleation-scissors are pushed along 
 the sclera slowly to the posterior pole of the eye (Fig. 54). Inasmuch 
 as the optic nerve of the right eye is approached from the inner side, it 
 is more easily reached than the left eye, where the advance is made 
 
 FIG. 53. The forceps pull the eye downward with the tendinous stump of the rectus 
 internus, while the blunt blade of the enucleation-scissors is pushed from the inner side 
 under Tenon's capsule, until it reaches the superior rectus, which it now cut off close to its 
 insertion. 
 
 from the outer side, and consequently the posterior pole must be passed 
 before the nasal side of the bulb is reached. The beginner often has 
 difficulty in locating the optic nerve. If the eyeball is rotated about 
 its vertical axis to the right, and the closed scissors held to the horizon- 
 tal meridian against the sclera, and moved from above downward, the 
 optic nerve can be made out as a tightly stretched cord. The finding 
 of the optic nerve may be facilitated by drawing the eye slightly out of 
 the orbit in order to stretch the nerve. Ordinarily the nerve should 
 be severed close to the bulb. After having ascertained its position, the 
 scissors are opened, the operator feels around once more to make sure 
 that the nerve is between the two blades, and then divides it with one
 
 ENUCLEATIOX OF THE EYEBALL. 
 
 IOJ 
 
 cut. The loosened bulb is immediately pressed forward with the closed 
 scissors, and turned out from the orbit so that the assistant may check 
 the bleeding with a tampon and prevent any suffusion into the orbit. 
 Nothing remains now except to free the bulb from its remaining 
 attachments, which consist of the tendons of both oblique muscles 
 and of the fourth rectus, and these are cut through with the scissors 
 close to the bulb. If the enucleation has been properly performed, no 
 large tissue-remnants should remain on the eyeball with the exception 
 of the stump, by which the bulb is held. The wound in the conjunctiva 
 
 FIG. =54. The eye, which is still held fast at the same point, is strongly turned outward 
 exactly around its vertical meridian. The opened enucleation-scissors have the optic 
 nerve between their blades ready to cut through it. 
 
 may be closed either with a purse-string suture or with several vertical 
 sutures. If the latter are employed, it is important to draw both, 
 threads through near the border of the wound, so that no shortening 
 of the conjunctival sac may be produced by the central margin of the 
 conjunctiva projecting inward in the form of a roll. It is, however, 
 not at all necessary to close the conjunctiva with sutures. It 
 will, of itself, assume the best and most suitable position, and the 
 wound will heal in a few days. Moderate compression should be 
 employed in the dressing in order to prevent secondary hemorrhage. 
 On the day after the operation the bandage is changed and a light pad 
 worn for several days. The conjuntival sac is cleansed with a weak 
 bichlorid solution. 
 
 If the operation is performed under cocain-anesthesia, the .s per 
 cent, solution is instilled into the conjunctival sac, and a i per cent.
 
 I08 OPHTHALMIC SURGERY. 
 
 solution (i c.c.) injected beneath the conjunctiva by means of a syringe. 
 The latter is inserted four times at the outer, inner, upper and lower 
 portions. The conjunctiva is thus raised up in the form of a large 
 bleb. The cutting may then be made without pain. Next follows a 
 thorough undermining of the conjunctiva, in order that it may not inter- 
 fere later during the removal of the eye. The muscle-tendons are then 
 anesthetized by injecting ^ c.c. of a i per cent, cocain-solution beneath 
 the capsule of Tenon, immediately above each tendon. The point of 
 the needle is placed in the direction of the muscle, and pressed close 
 against the sclera. This produces a bleb-like bulging forward of Ten- 
 on's capsule, similar to that previously noticed in the conjunctiva. 
 After lightly massaging the tissues, the division of the muscles should 
 be proceeded with. To further lessen the possibility of pain, the mus- 
 cle-tendons may be picked up with a strabismus-hook before parting 
 them, and it is advisable at this time to cut off the fourth rectus so that 
 the eye may be absolutely free as soon as the optic nerve has been severed. 
 
 The third injection is made into the neighborhood of the optic nerve 
 after the division of the muscle-tendons. The syringe, containing a i 
 per cent, solution of cocain, to which y 1 ^- c.c. adrenalin has been added, 
 is again used, and the solution slowly injected into the tissues about the 
 nerve. After waiting for about one minute the optic nerve may be 
 divided in the usual manner. It is not necessary that the syringe have a 
 curved needle, as the nerve can be approached with a straight needle 
 just as well. 
 
 Complications. The enucleation does not always proceed as 
 smoothly as described, and especially for the beginner is it no easy 
 operation. Difficulties may be encountered even during the incision 
 into the conjunctiva. If the eye had been inflammed for a long time, 
 adhesions frequently exist between the conjunctiva and the sclera, 
 and the separation may be troublesome. This is particularly the case 
 if subconjunctival injections of solutions of mercuric chlorid or 
 sodium chlorid have been repeatedly made, or, after injuries, destruc- 
 tive processes have led to cicatricial fusion between conjunctiva and 
 sclera. The loosening of the conjunctiva becomes most difficult, 
 sometimes even impossible, after the action of corrosives when, in place 
 of a membrane, only a small layer of scar-tissue is found, which is thin 
 and easily perforated. In any case the first consideration is to pre- 
 serve the conjunctiva as much as possible, and not to tear it by unneces- 
 sary handling with the toothed forceps. The severing of the muscles
 
 ENUCLEATION OF THE EYEBALL. 1 09 
 
 is made easier for the beginner if he searches for them with the strabis- 
 mus-hook. The operator, however, who pushes the scissors beneath 
 Tenon's capsule, after the manner described, finds that this method 
 has the advantage of greater rapidity, but he must be careful while 
 cutting the tendons of the superior and inferior recti not to injure the 
 lid by a snip of the scissors. During the entire operation the lids 
 must be held apart by a lid-speculum. By using Desmarres' lid- 
 retractors an assistant is spared. 
 
 Should the muscle-stump, by means of which the eyeball is handled, 
 break or tear off from repeated seizures with forceps new difficulties 
 arise. If such an eye is soft, it is best to simply pick up a fold of the 
 sclera in this neighborhood and in this way hold the eyeball or, when 
 possible, grasp it by the remnants of the tendon of another muscle. 
 When, however, they have been cut off perfectly smooth, the index and 
 middle fingers of the left hand must be used to hold the bulb in the 
 desired position in order to cut through the nerve. The closer to the 
 eyeball the tendon is grasped and the less frequently the forceps are 
 applied, the more firmly will the tendon hold. 
 
 The most difficult part of the operation for the beginner is the 
 division of the optic nerve. If the knowledge of its position is 
 acquired by slow groping about with the closed scissors, it will be 
 almost impossible to miss it, but should the eye be incl,ned in an oblique 
 direction, and the operator hastily make a cut anywhere backward in 
 the orbit, he will not succeed in dividing the nerve. This blind cutting 
 leads to a profuse hemorrhage into the orbit, which cannot be stopped 
 by inserting a tampon, as long as the bulb remains in place. The infil- 
 tration may become so extensive that the tissue of the orbit is bulged 
 forward like a tumor, and weeks may elapse before the blood will 
 become absorbed. An attempt should be made to cut the optic nerve 
 with the first stroke. Injury to the levator palpebrse can only occur, 
 if the position in which the eyeball is held or the direction of the cutting, 
 are extremely faulty. Cases of total ptosis, however, have been reported 
 after enucleation. 
 
 After division of the optic nerve the eyeball must at once be displaced 
 forward, so that the tampon may be inserted. It is unpleasant if 
 the operator, instead of severing the nerve, cuts into the posterior part 
 of the bulb itself. This may happen, if the eyeball is soft, following 
 severe injuries which have induced a complete collapse of the bulb, or 
 if the globe has ruptured when the muscles were severed. It is then
 
 110 OPHTHALMIC SURGERY. 
 
 necessary to search for the nerve, while still holding the stump of the 
 bulb, and resect it. As the surrounding orbital tissue becomes much 
 swollen from effusion of blood, it is difficult to dissect and free the optic 
 nerve so as to divide it further back. The bearings to its position are 
 lost, and the profuse bleeding prevents a clear view. 
 
 Resection of the optic nerve must also be done, if, during 
 enucleation because of a malignant growth, the stump of the nerve is 
 found involved by the tumor. The nerve should be cut as far back of 
 the bulb as possible; but if it is assuredly affected, exenteration of 
 the orbit (p. 113) is a safer procedure than resection of the nerve. In 
 iridocyclitis following injuries, in which sympathetic inflammation 
 threatens, as much of the nerve as possible should be resected. 
 
 A rare complication after division of the optic nerve is severe, almost 
 uncontrollable hemorrhage (arteriosclerosis, hemophilia). If ener- 
 getic compression does not suffice to check the bleeding, ligation of 
 the blood-vessels must be resorted to, or even the Paquelin cautery. 
 
 The main indications for enucleation are: 
 
 1. When the visual power of the eye is irretrievably lost, and the eye 
 itself gives the patient pain. 
 
 2. When the sound eye is seriously endangered by a sympathetic 
 affection. 
 
 3. Malignant intraocular tumors. 
 
 Therefore, every painful amaurotic eye may be enucleated. Enuclea- 
 tion of still functionating eyes must also be resorted to, as for example, 
 when there is an intraocular tumor. If after an injury, an iridocyclitis 
 develops and the outbreak of a sympathetic inflammation is feared, we 
 do not have recourse to enucleation, so long as the eye retains good 
 light-perception at six meters and has the proper light-projection. How- 
 ever, if both light-perception and projection have become greatly 
 reduced, the enucleation must not be delayed, as we now have proof 
 positive that the structures of the eye upon which the sight depends are 
 becoming involved in the inflammatory process, and that the visual 
 power is being destroyed for ever. After recent injuries, enucleation 
 should not be deferred when there is no doubt that vision is lost. 
 Extensive ruptures of the cornea and sclera with prolapse of the iris 
 and crystalline lens justify immediate removal of the globe. Prompt 
 action spares the patient weeks and months of suffering. After great 
 injuries one may suture the gaping wound before the enucleation, so 
 as to make a squeezing-out of the ocular contents impossible.
 
 ENUCLEATION OF THE EYEBALL. Ill 
 
 Ruptures of the sdera furnish the indication forenucleation much less 
 frequently. Even though the visual power is usually either entirely ruined 
 or returns only to a minimum extent, still such eyes can later become 
 absolutely quiescent, and often do not seem to be materially disfigured. 
 Not until the rupture of the sclera is followed by a shrinking of the 
 globe, and this being eventually associated with pain and injection, 
 should enucleation be performed, but then, however, without delay. 
 Justification for enucleation must not be considered as existing simply 
 because the light-perception of the eye is completely destroyed after a 
 trauma. Not infrequently it happens, that immediately after a blunt 
 trauma the light-perception is completely lost, but both perception and 
 projection return gradually and within a certain time may even reach 
 normal. We have seen such eyes, which, from a condition of absolute 
 amaurosis, (rupture of the sclera, with hemorrhage and obscuration 
 of the lens) have regained partial visual acuity. 
 
 Enucleation is practised on eyeballs with a high degree of ectasia 
 (total staphyloma of the cornea, and staphyloma of the sclera), which are 
 disfiguring because of their size, and are in danger of rupture, resulting 
 in serious hemorrhage. Enucleation is indicated when panophthalmi- 
 tis is developing. For example, if, after an injury which in itself was 
 not considered sufficient indication to perform an enucleation, the eyeball 
 becomes infected, and this infection is rapidly progressive and through 
 its intensity makes a panophthalmitis probable, we check the process 
 by enucleation of the eyeball. Enucleation is also demanded if the eye 
 becomes seriously infected after operative interference, as, for instance, 
 a cataract-operation. If, however, the panophthalmitis has already 
 developed, that is, if exophthalmos, marked edema of the lids, limita- 
 tions of the movements of the eyeball, chemosis, etc., are already 
 present, enucleation is contraindicated, as experience has shown repeat- 
 edly that meningitis may follow the operation. The proper procedure 
 in such cases is to open the anterior portion of the eyeball to permit the 
 free drainage of the pus and thus furnish the patient relief. 
 
 EVISCERATION OF THE EYEBALL. 
 
 Evisceration of the bulb with sewing in of glass balls or gold balls, 
 etc. (Mules's operation) is not performed at our clinic. Cases of 
 sympathetic inflammation have repeatedly been observed after this 
 operation, not only by us, but also by others. The expulsion of the 
 sewed-in balls occurs frequently, and sometimes even after years have
 
 112 OPHTHALMIC SURGERY. 
 
 passed. This may be accompanied by symptoms of inflammation, 
 which may require operative interference, such as the shelling out of 
 the balls; in fact, subsequent enucleation of the stump may be necessary. 
 
 OPTICO-CILIARY NEUROTOMY. 
 
 Optico-ciliary neurotomy is a substiute operation for enucleation 
 of the bulb. If an eye blinded by glaucoma has become painful, a 
 certain indication for enucleation exists. But in case this eye is not 
 disfiguring, it is more desirable that the owner retain it than replace it 
 with an artificial eye, the use of which is associated with many incon- 
 veniences. Such eyes, therefore, furnish the suitable indication for 
 optico-ciliary neurotomy. Rarely do we use it if the eye has become 
 blind through a spontaneous irido-cyclitis one not induced by injury 
 and causing the patient pain. In these cases the eyes for the most part 
 are shrunken and disfiguring, so that enucleation must be recommended 
 on cosmetic grounds alone. If an injury has preceded, enucleation 
 must of necessity be performed, as an optico-ciliary neurotomy would 
 not prevent a sympathetic inflammation. When the slightest suspicion 
 of an intraocular tumor exists, that enucleation is peremptory in every 
 case, needs no further explanation. 
 
 The operation is done under general anesthesia. It is begun by 
 freeing the rectus internus if in the right eye and the rectus externus if in 
 the left eye, as in an operation for advancement. A suture is passed 
 through the muscle at a distance of about f cm. from its attachment, 
 then tied, and given to the assistant to hold, after which the muscle is 
 divided between its insertion and the knot. The assistant now pulls 
 the muscle away from the eye by means of the suture, the operator 
 using the stump, which remains attached to the eye, to fix the bulb. 
 As in enucleation, we now pass slowly backward along the sclera with 
 the enucleation-scissors, and feel around for the optic nerve, take it 
 between the two blades of the scissors and glide backward along it for 
 a short distance. With one vigorous snip it is divided. The scissors 
 are withdrawn at once and strong pressure maintained on the bulb 
 through the closed lids for five minutes to prevent a hemorrhage into 
 the orbit. Without this compression it may happen, that the loose eye is 
 pushed through the palpebral fissure at once, or it may be found out of 
 the orbit on the next day. As a reposition is impossible, nothing 
 remains but enucleation. But this complication may also occur in 
 spite of a perfect compression, as in the aged, who chiefly undergo this
 
 ENUCLEATION OF THE EYEBALL. 113 
 
 operation, arteriosclerosis may be the cause of such an extensive 
 hemorrhage. 
 
 As it is obvious that we have not divided all the ciliary nerves 
 (transmitters of the pain) with the one cut, we now turn the eye about 
 its vertical axis in such a manner, that the posterior surface of the 
 eyeball lies free in the palpebral fissure, and are thus enabled to readily 
 cut the ciliary nerves that pass through the sclera in the neighborhood 
 of the optic nerve, the greater number of which have already been 
 torn during the turning of the eyeball. If a long piece of the optic 
 nerve remains attached on the eyeball, a part of it may be resected 
 (neurectomy). After this the eyeball is replaced in its normal position, 
 and the muscle carefully sutured to the stump to insure its normal mo- 
 tility. After sewing the conjunctiva, a firm pressure-bandage is 
 applied over the closed lids. Usually, healing progresses without inci- 
 dent. The slight amount of exophthalmos after the operation, because 
 of the hemorrhage, disappears within a short time. 
 
 If the operation has been performed according to these directions, the 
 cornea is perfectly anesthetic and the eyeball free from pain. The 
 sensitiveness of the cornea returns very slowly. A neuroparalytic 
 keratitis is not to be feared. Over the fundus the blood-vessels are seen 
 to be absolutely empty, appearing as white lines, and the papilla is a 
 pure white. The tension of the bulb remains normal, sometimes even 
 greater than normal. Atrophy of the eyeball does not develop. 
 
 EXENTERATION OF THE ORBITAL CAVITY. 
 
 Exenteratio orbitce, the removal of all the contents of the orbit for the 
 extirpation of malignant neoplasms, whether of the orbit itself or 
 of the eyeball after they have broken through the sclera, is performed 
 as follows: 
 
 If the lids are to be preserved, the palpebral fissure must first be 
 widened by canthotomy ; this exposes the outer border of the orbit. 
 Next, the conjunctiva of the lower fornix is cut through with a sharp 
 scalpel to the bony low r er border of the orbit, which is thus completely 
 bared. The assistant draws the lid away with a dull tenaculum. 
 The upper conjunctival fornix is then cut through in the same manner, 
 along the upper orbital margin. To the inner side both incisions meet 
 at the front part of the lachrymal bone. Both lids can now be easily 
 drawn away from each other with tenacula, so that the entire orbital 
 border is exposed. The periosteum is incised along the bony margin
 
 114 OPHTHALMIC SURGERY. 
 
 of the orbit, and by means of a periosteal elevator or a closed, somewhat 
 curved, scissors, pushed between bone and periosteum, the entire 
 contents of the orbit are shelled out with great rapidity on all sides to 
 the posterior end of the orbit. Only at the inferior orbital fissure and at 
 the posterior crest need we make use of the scissors to divide the fascial 
 strands. With proper care we can easily avoid injuring the thin bones 
 of the orbit. Finally the entire mass is divided as far back as possible 
 by several snips of the scissors. Energetic tamponing prevents serious 
 hemorrhage, for the checking of which we are rarely forced to use the 
 cautery. The orbital cavity is now tightly packed, gauze is pushed 
 beneath the lids so that they will not fall into the orbit, and a pressure- 
 dressing applied. At the outset a long time ensues before the wound 
 of the orbit begins to be covered with granulations, and several weeks 
 pass before the entire cavity has become filled with granulations. 
 During this time it must be kept loosely packed. 
 
 In the end, however, the lid is always drawn far back by scar-tissue, 
 and the use of an artificial eye is not possible. The palpebral conjunc- 
 tiva may even become a burden to the patient on account of its secretion 
 and, therefore, nothing is lost, if in the exenteration of the orbit the 
 lids are also cut out. Such an operation is easier, and the large wound 
 in the skin can be so diminished by a few vertical sutures that only 
 the normal width of the palpebral fissure remains.
 
 CHAPTER X. 
 
 PLASTIC OPERATIONS WITH PEDICLED FLAPS 
 ON THE EYELIDS. 
 
 Plastic operations with pedicled flaps are particularly adapted to 
 those cases in which a lid affected with a neoplasm must be excised. 
 
 As long as a new-growth in the lids has merely involved the skin, and 
 the tarsus is wholly preserved, the plastic operation with a pedicled flap 
 from the surrounding tissue differs in no respect from the identical 
 operation in other regions of the body. 
 
 The method of Fricke is used in case of an extensive skin-defect 
 (d) in either the upper or lower lid. A flap is taken from the neighbor- 
 ing skin, as is shown in the illustration (Fig. 55) and the base joined to 
 the defect in the tissue. Because of possible retraction of the skin 
 after it has been dissected free, the flap (/) must be cut about one-third 
 larger than the area to be covered, and the base wide enough to insure 
 perfect nutrition. For the same purpose, rotation of the flap should 
 be made as easy as possible by an adequate undermining of the under- 
 lying tissues. The flap, which now covers the excised area, is held in 
 its new position by sutures. The opening, caused by the removal of 
 the flap, is dissected sufficiently back of the margins, and the skin- 
 edges brought together, at least in part, by sutures, the remainder being 
 left to heal by granulation; or the wound is covered by transplanting 
 epidermis, according to the method of Thiersch, or by a small non- 
 pedicled flap. The bulging at the base of the flap produced by the 
 necessary rotation soon disappears, so that no subsequent disfigurement 
 exists. 
 
 If, however, the margin of the lid has already been involved, as is 
 usually the case, since new-growths spring more particularly from the 
 lid-margin, the restoration of the lid becomes a more difficult matter. 
 
 The method of Dieffenbach is the typical one for the lower lid. 
 As a recurrence of a lid-neoplasm is only prevented by cutting at least a 
 full half-centimeter away from the growth, a large part of the lid must 
 be sacrificed even if the tumor is not extensive, and, if large,the whole 
 lid must be excised. There is very little advantage in retaining the
 
 u6 
 
 OPHTHALMIC SURGERY. 
 
 small remnants of the lid left at either end of the incision, and the oper- 
 ation is not rendered more difficult by a total extirpation of the lid. 
 The tear-ducts are to be spared only if they lie beyond the field of 
 operation. 
 
 In Dieffenbach's method, the wound has to be brought in a trian- 
 gular form. The base of the triangle corresponds to the lid-border 
 (be) (Fig. 56). In the direction of the base an incision (ab) is per- 
 formed outward toward the temple, somewhat larger than the defect 
 
 FIG. 55. Restoration of a skin-defect in the upper and lower lid (after Fricke). d, de- 
 fect ; g, pattern of guttapercha paper, cut the same size as the defect, and laid on the place 
 selected before excision of the flap, in order to estimate more readily the size of the latter; 
 f , flap to be cut out. 
 
 to be repaired, as the flap contracts after it is freed. From the outer 
 end of this incision, another cut is carried downward, parallel to the 
 outer side of the triangle. A flap can now be dissected off, the 
 base of which lies below. Sufficient freeing from the underlying 
 tissue affords easy rotation inward upon the defect. The upper edge 
 of the flap is sutured to the remains of the conjunctiva, and corresponds 
 to the lid-margin, w r hile the inner edge is secured to the neighboring 
 skin by strong sutures. The surface from which the flap was taken 
 is closed in as much as possible by sutures after a thorough under-
 
 PLASTIC OPERATIONS ON THE EYELIDS. 
 
 117 
 
 mining of its edges. The remainder of the exposed area is left to 
 heal by granulation. 
 
 The results produced by this method of operation are only moder- 
 ately satisfactory. The diseased area is, it is true, covered in by 
 healthy skin, but as the flap, lacking a cartilaginous substratum, is 
 yielding, it sinks downward continuously, and becomes drawn against 
 the eyeball and attached directly to it by the cicatrix. The conjunctiva 
 is also materially shortened, the movability of the eyeball is usually 
 considerably lessened, and besides, the hairs continuing to grow from 
 the skin of the flap, in a short time cause a clouding of the lower half 
 of the cornea. 
 
 FIG. 56. Restoration of a lower lid after Dieffenbach. The lower lid is excised in 
 triangular fashion; that is, a pre-existing defect is brought into this form. Formation of a 
 quadrangular skin flap (a b), which is freed from its underlying tissues. 
 
 The combination of Diefifenbach's method with the plastic 
 operation making use of the ear-cartilage, as first recommended 
 by Buediner, represents an extraordinary advance in the treatment 
 of such cases. 
 
 After the skin-flap has been freed as in the foregoing description, a 
 flap, including not only the skin but also the cartilage, is excised from 
 the posterior surface of the ear. It should be as long as the lower 
 lid, have a straight edge corresponding to the lid-margin, and a second 
 somewhat convex edge corresponding to the lower border of the tarsus. 
 Because of the narrowness of the normal tarsus of the lower lid, we 
 need only take a very small piece of cartilage from the ear. On the 
 contrary, to cover the wound-surface we must take a much larger 
 piece of skin. There is first made a vertical incision of adequate length
 
 Il8 OPHTHALMIC SURGERY. 
 
 on the posterior surface of the ear. This will at once retract somewhat, 
 and at the point of retraction an incision is made through the cartilage, 
 corresponding to the length of the tarsus. This edge of the flap forms 
 the new lid-margin. Next the dissection is continued 3 mm. further 
 beneath the cartilage, that is, between cartilage and skin of the anterior 
 surface of the ear, and the cartilage is cut through from in front with- 
 out wounding the skin. In order to free the skin, it is dissected an 
 additional 5 mm. with a slightly convex incision. In consequence, 
 the freed flap shows the shape viewed from the raw surface (Fig. 57). 
 As the ear-cartilage is too thick, it is shaved down by cutting away 
 thin lamellae with a scalpel applied flatwise, 
 until it approximately equals the thickness of 
 a normal tarsus. This flap is fastened by 
 sutures to the previously dissected skin-flap 
 (Fig. 58), so that the wound-surfaces are 
 FIG. 57. Flap from the apposed to each other; that is, the skin of the 
 
 posterior surface of the ear; . 
 
 c., cartilage; w. s., skin seen ear-flap is directed posteriorly toward the eye- 
 
 from the wound-surface. straight edge CQmes to He aga i nst 
 
 the free upper margin (ab} of the pedicled skin- 
 
 flap. In order to avoid unsightly indentations of the new lid-margin 
 by pressure of the sutures, we employ sutures armed with two needles. 
 Both ends are pushed from behind forward through the skin and the 
 cartilage, 2 mm. below the free margin. They are tied over a glass 
 bead. At least three sutures are necessary. In like manner one or 
 two sutures are brought through the lower border of the skin- and 
 cartilage-flap in an anterior direction and tied, in order to secure a 
 firm approximation of the flap to its new base. 
 
 The pedicled flap, with its posterior surface thus provided with a 
 sufficiently large cutaneous surface, is sutured after adequate rotation, 
 to the edges of the defect, as in Dieffenbach's original method. To 
 prevent mechanical injury to the cornea by the flap, which is some- 
 what stiff at first and readily produces erosions and ulcers, I am 
 accustomed to draw the upper lid far downward by two stiches passing 
 through its margin, and to bring both ends of each suture through the 
 base of the flap, which has been rotated inw r ard; not until then is the 
 flap fastened to its new position. Thus the new lower lid lies at 
 first against the upper lid. The defect produced externally is covered 
 in exactly the manner described by Dieffenbach. The flap of skin and 
 cartilage heals in promptly. Both eyes are bandaged and the dressing
 
 PLASTIC OPERATIONS ON THE EYELIDS. IIQ 
 
 changed for the first time after two days. The fixation-sutures of 
 the upper lid, which were tied over small gauze pads, are allowed to 
 remain as long as they hold. They cut through in from five to six 
 days. However, the upper lid continues to hang down for several 
 days more, completely covering the cornea, but by the time it can be 
 elevated, the flap of skin and cartilage have long since healed, and in 
 its moist environment the skin has become so delicate that an in jun- 
 to the cornea need no longer be feared. 
 
 
 FIG. 58. The flap represented in Figure 57 is here so sutured to the posterior side 
 (that is, the raw surface) of the pedicled skin flap that the skin (s) comes to lie posteriorly 
 toward the eye. The flap is now twisted into the defect of the lid and sutured in such a 
 fashion that (b) comes to lie in apposition to c and a of the flap in apposition to b of the 
 canthus. 
 
 The flap, which at first seemed too thick and bulging for a lower 
 lid, later becomes gradually thinner. It resembles quite well a lower 
 lid deprived of its eyelashes, especially as it stands up freely owing to 
 its cartilaginous substratum, and is not drawn against the eyeball 
 through the formation of a cicatrix. This method is particularly 
 valuable, because the motility of the eyeball remains unaffected, and 
 a deep conjunctival sac is created, similar to the normal. Further- 
 more, the transplanted flap, free of hairs, does not give rise to corneal 
 irritation. These are sufficient reasons, to undertake Dieffenbach's 
 method only with the proposed modification. 
 
 If the entire upper lid must be extirpated in the removal of a neo-
 
 120 OPHTHALMIC SURGERY. 
 
 plasm, the eye is usually lost; but an attempt should be made to restore 
 the upper lid by a flap, which is formed according to Fricke's method, 
 its posterior surface being covered in by a delicate layer of epithelium 
 taken from the arm. 
 
 OPERATIONS FOR SYMBLEPHARON. 
 
 If the connection between the conjunctival surface of the lid and 
 the eyeball is in the form of isolated bands, which interfere with the 
 movements of the eye and produce diplopia, an indication for their 
 division exists in every instance. The separation of the cicatricial 
 strands must be followed by a closure of the resulting wound, in order 
 to prevent the two raw surfaces from again growing together. In the 
 case of small strands, closely-applied sutures will usually be sufficient. 
 The neighboring conjunctiva must, however, be loosened so that the 
 sutures may draw it over the defect; incisions in the surrounding tissue 
 to relieve tension are of considerable value. 
 
 If more of the conjunctival sac is affected, that is, if the symble- 
 pharon is broader, there will not be enough mucous membrane to draw 
 over and to cover the defect. In this event it is necessary to dissect 
 either a pedicled flap from the conjunctiva of the neighborhood, or a 
 flap without pedicle from a suitable point, usually the upper con- 
 junctival fold, or it may be taken from the conjunctiva of the patient's 
 sound eye. 
 
 The greater number of the symblepharon-operations are required 
 to the lower lid. If a symblepharon involving the lower internal 
 portion of the conjunctiva has been divided, and on account of the size 
 of the defect a plastic operation is indicated, it is possible to take a 
 pedicled flap from the adjacent conjunctiva and cover the defect by 
 rotating it over the wound and fastening it there by means of sutures. 
 The new defect produced by the excision of the flap may be allowed 
 to cicatrize, as, lying to the outer side of the wound in the lid, it does 
 not give rise to new adhesions; or the defect may be covered, as well as 
 possible, by loosening of the neighboring structures and sutures. 
 
 The formation of pedicle flaps is, however, in most instances 
 difficult, and it is, therefore, preferable to cover in the defect in the 
 conjunctiva of the eyeball with a flap taken from the upper conjunctival 
 fold. The flap is held in its new position by several delicate silk 
 sutures. Naturally, the removal of this flap is only possible when the 
 conjunctiva of this fold shows no cicatricial changes. The normal
 
 PLASTIC OPERATIONS ON THE EYELIDS. 121 
 
 fold offers ample conjunctiva for broad flaps, but, if contracted, the 
 flap may be taken from the patient's other eye, provided, of course, 
 that it is normal ; this gives the greatest chances of satisfactory healing. 
 
 From personal experience it may be stated, that all similar proceed- 
 ings with mucous membrane from a rabbit are to be completely re- 
 jected. Even if the graft is successful, which is much more uncertain 
 than when human conjunctiva is employed, the animal mucous mem- 
 brane subsequently contracts so greatly that the good effect pro- 
 duced is entirely lost. 
 
 In all methods of covering the defects with conjunctiva, we must be 
 content to do so over only one of the wounds, as flaps large enough 
 for the wound in the eyelid cannot be obtained. Though the covering 
 of the one defect is sufficient in most cases, it is always better to have 
 both wounds provided with epithelium, not only to prevent the for- 
 mation of a new symblepharon in case the single flap does not heal in 
 properly, but because the scar arising from the uncovered wound may 
 contract later on and gradually draw the lid inward and cause trichiasis; 
 or result in limitation of motion of the eyeball. For the foregoing 
 reasons many plastic methods have been devised, intended to cover 
 the wound in the lid. The various methods, as in all plastic oper- 
 ations, consist either in applying a pedicled flap from the neighboring 
 skin or a free flap of epidermis. 
 
 In cases of complete symblepharon of the lower lid the repair of the 
 lid-wound is especially imperative. The defect on the eyeball is too 
 large to be covered in its entirety by conjunctiva taken from other 
 places. We have repeatedly employed in these cases a combination 
 of conjunctival and skin-flap with good results. After thoroughly 
 dividing the scar and covering the wound on the eyeball with a pedicled 
 flap taken from the upper conjunctival fold, the wound in the lid should 
 be covered by a skin-flap, which, following Rogman's method, may 
 be taken from the lower lid itself. From the skin of the lower lid 
 (Fig. 59) a flap (abed) is made, the base (ad) of which is situated 
 directly at the upper level of the conjunctival fold in need of recon- 
 struction. This flap is as long and as high as the lid. Next, an 
 incision beginning at the lower level of the conjunctival fold and 
 corresponding to the line (ad), divides all the structures in such" a 
 manner as to leave only the skin intact. It is then an easy matter 
 to rotate the flap in through the slit so made. This should be done 
 so that its raw surface is turned toward the wound in the lid, and the
 
 122 
 
 OPHTHALMIC SURGERY. 
 
 margin (be} of the flap may be fastened with sutures to the margin 
 of the lid. The flap is certain to become attached, as its base remains 
 connected to the surrounding tissues. The wound on the outside of the 
 lid is, as far as possible, tied by sutures. At first, however, there is a 
 slit left through which the new conjunctival sac can be reached from 
 the outer side. After about eight days, the connection is severed; 
 the slit now rapidly closes through cicatrization. Rogman, in his 
 original method, repeated this procedure at a later date by rotating 
 through the slit another flap formed from the still remaining skin on 
 
 FIG. 59. Operation for symblepharon after Rogman. After separation of the symble 
 pharon between the eyeball and the lower lid, there is formed from the skin of the lower 
 lid the flap (abed); it has its base at a d. This flap is rotated backward through a slit 
 in such a fashion that the edge (b c) can be sutured to the palpebral margin and the skin 
 serving the function of a palpebral conjunctiva is turned toward the eyeball. There is 
 rotation of 180. 
 
 the lower lid. I much prefer the foregoing combination to Rogman's 
 original method, as there is too little skin available for the second 
 plastic operation on the lid. 
 
 The best method to thoroughly remove a total symblepharon 
 is as follows: The scar is divided as in the other methods by means 
 of a scalpel, and an external canthoplasty performed. From the end 
 of the skin-incision, a cut 3 cm. long is made outward and down- 
 ward. From this point on, the skin is dissected off toward the lid, 
 until finally the entire lower lid can be reflected toward the nose as a 
 free flap. The dissection must be carried beyond the scar-area into 
 the healthy tissue, so that, finally, there is a large raw surface which 
 stretches in one plane from the limbus to the lid-border. After this, 
 a large skin-flap of a suitable shape is dissected from the delicate skin
 
 PLASTIC OPERATIONS OX THE EYELIDS. 123 
 
 of the upper arm, according to the rules already mentioned (see 
 Cicatricial Ectropion, p. 52), and fitted accurately to the raw surface 
 up to the palpebral fissure. The flap may be sewed with several fine 
 sutures to the lid-margin on the one side, and to the limbus on the 
 other. As the lid is now turned back again into its original position, 
 the flap folds up properly of itself, the place doubled down representing 
 the new fornix. In order to fix the fold in this position, two sutures 
 are carried through from this spot out to the cutaneous surface, and 
 their ends tied outside over gauze. The operation is completed by 
 the suturing of the incisions made at the beginning. Both eyes are 
 bandaged and the dressing changed for the first time at the end of 
 three days. 
 
 The fornix is at first adnormally deep, but, later, diminishes in 
 size through contraction, without, however, shrinking so much as to 
 prevent free movement of the eye on the comfortable wearing of a 
 prothesis. In these cases we must begin to insert a prothesis quite 
 early, and to make eventually properly fitting protheses from Stent's 
 composition, a substance used by dentists for taking impressions. 
 Such protheses extend deeply down into the fornix. 
 
 Insertion of an unpedicled flap without making the incision 
 proposed is not recommended, as the limited space makes the operation 
 more difficult, and an adequate adaptation of the flap is impossible. 
 It is only by accident that such a flap heals in properly. Likewise, 
 the same can be said about the proposition of laying the unpedicled 
 flap over the prosthesis in such fashion that its epithelial surface is 
 turned toward the latter, the prothesis with this covering being inserted 
 after cutting through the scar.
 
 CHAPTER XI. 
 EXTRACTION OF SENILE CATARACT. 
 
 The accompanying illustrations have all been made from photo- 
 graphic views, and are intended, primarily, to reproduce faithfully the 
 position of the hands of the operator as well as those of his assistant 
 during the different operative procedures. This can be accomplished 
 better by a picture (especially a photograph) than by the most exten- 
 sive description. In so far as possible, the operative procedure on 
 the eye itself is also delineated sufficiently well in the same illustration. 
 However, when it seemed necessary, the operation on the eye has been 
 represented by itself in accompanying diagrams. The photographs 
 were taken from the operator's side. In order to render recognition 
 easier, the hands of the operator are indicated by the latter o; those 
 of the assistant, by the letter a. In all instances the operator sits to 
 the right of the patient, while the assistant stands to the left. The 
 relative positions assumed by the hands and the fingers of the operator 
 and assistant should be observed. The figures show clearly how 
 the hands are supported, how the instruments are held, etc. 
 
 TECHNIC. 
 
 The technic of the various steps of the operation will first be con- 
 sidered, and then the complications which may occur in each of these 
 steps. 
 
 i. Fixation of the Eye (Figs. 60 and 61). It is best to sit at the 
 right of the patient who is lying upon the operating table. The 
 incision is made from the outer side, on the right eye with the left 
 hand, and on the left eye with the right hand, the other hand being 
 engaged in the fixation of the eyeball. For this purpose an ordinary pair 
 of toothed fixation forceps with three dentations is held between the 
 thumb and forefinger. The forceps must be applied perpendicularly 
 to the sclera and quite near the limbus, so as to get hold of a tight fold 
 of the conjunctiva. If the conjunctiva is seized at even a slight 
 distance from the limbus, the fold picked up is so loose that the eye 
 is not sufficiently fixed. During the cataract-incision the forceps 
 
 124
 
 EXTRACTION OF SENILE CATARACT. 
 
 125 
 
 at the lower part of the limbus grasps the eye exactly in its vertical 
 meridian. The operator at the right of the patient finds no difficulty 
 in fixation of the right eye, as the forceps held in the right hand are 
 placed directly opposite to the right eye, but it is not so easy, especially 
 for the beginner, to fix the left eye from the position mentioned. To 
 this end the left upper arm, with the elbow in a strongly flexed position, 
 
 FIG. 60. Beginning of the cataract-incision in the left eye. While the assistant holds 
 the eye open according to the rules given on page 236, the forceps held in the left hand 
 grasp the eye below, close to the limbus and exactly in the vertical meridian. The patient 
 during this procedure looks well downward. The knife held in the right hand with its 
 edge directed upward is applied exactly at the limbus and is held horizontal and parallel to 
 the plane of the iris. 
 
 is pressed firmly against the chest, while the hand, itself bent dorsally, 
 guides the forceps held between thumb and forefinger, vertically to 
 the lower portion of the limbus, where the fold is raised. Through 
 this unaccustomed position of the arm, the beginner very easily falls 
 into the error of pressing upon the eye instead of pulling forward, a 
 mistake that is frequently the cause of unpleasant complications.
 
 126 
 
 OPHTHALMIC SURGERY. 
 
 The fold of the conjunctiva must be raised exactly in the vertical 
 meridian. Since the operation is performed in most cases with an 
 iridectomy, it is essential that the incision be made accurately above, 
 so that the coloboma, which corresponds to the central portion of the 
 cut, will also be directed upward, and be completely covered by the 
 upper lid. If, however, the eyeball is grasped sideways, for example, 
 
 
 FIG. 61. Beginning of the cataract-incision in the right eye, the operator and the assist- 
 ant occupying the same position. The eye is fixed with the right hand, the knife is held 
 in the left'. 
 
 at the end of the horizontal meridian, a rotation of the eye is unavoid- 
 able, as the eye must be drawn continually downward during the 
 incision, in order to expose the upper corneal margin. In consequence 
 of this rotation the incision is placed in an oblique and undesirable 
 position, and with it also the coloboma. If the eye is fixed below, 
 exactly in the vertical meridian, there ensues no rotation, so that no 
 mistake can be made concerning the situation of the incision. In
 
 EXTRACTION OF SENILE CATARACT. 127 
 
 inserting the knife, it is true that the eye may rotate slightly out of 
 its position, but this can not further displace the incision. By means 
 of the elevated fold the eye is drawn not merely downward, but also 
 slightly forward. During the incision the patient is directed to look 
 well downward. 
 
 2. The incision (Figs. 60 to 64) is probably the most difficult part 
 of the operation and demands the most detailed description. It is 
 made with the narrow Graefe cataract-knife. It is executed in an 
 upward direction, should include about one-third of the corneal 
 
 FIG. 62. Diagram showing the point of the knife directed toward a point in the cornea 
 about i mm. within the limbus, so as to begin the counterpuncture. 
 
 periphery, and in its entire length should run in the limbus or close 
 behind it. 
 
 While inserting the knife its point is placed on the limbus externally 
 1-2 mm. above the end of the horizontal meridian, while it is held 
 horizontally between the thumb and first and second fingers. Mean- 
 while, the hand is supported by the little finger placed on the patient's 
 head (Figs. 60 and 61). The edge of the knife is directed upward 
 and the blade is parallel to the surface of the iris. The point of the 
 knife pierces the eye at the limbus, and is pushed without a pause 
 
 FIG. 63. Diagram showing the point of the knife thrust just through at the limbus. 
 
 through the anterior chamber in order that the counteropening inter- 
 nally is made in a symmetrical position. Here it should be emphasized 
 that the chief factor in the success of an incision, which is to open the 
 anterior chamber, is the avoidance of any pause or retrograde 
 movement. 
 
 The most difficult point for beginners is to make the counter punc- 
 ture in ;he proper position. To their astonishment, most novices 
 find the knife emerging in the sclera behind the limbus. The reason for 
 this error is clearly understood from a study of the anatomical relations 
 of the anterior chamber (Figs. 62 and 63). The limbus extends much
 
 128 OPHTHALMIC SURGERY. 
 
 further (2 mm.) anteriorly than the angle of the anterior chamber. 
 If the knife is brought as far as this angle, the inevitable consequence 
 is that the counterpuncture is performed in a faulty place far beyond 
 the limbus. In order that it is made either directly at the limbus, or 
 close to it, the knife must be directed to a point in the cornea about 
 i mm. from the limbus, where, as viewed from in front, transparent 
 cornea is still present. The impression thus given is that the knife 
 will appear at the surface in transparent cornea, but to the operator's 
 surprise the point emerges in the limbus. The beginner is, therefore, 
 usually told to direct the point of the knife toward a spot in the cornea, 
 situated about i mm. distant from the limbus. 
 
 After completing the counterpuncture the knife is steadily carried 
 upward in sawing movements, at all sides parallel to the limbus. 
 This procedure is somewhat troublesome for the beginner, as he must 
 cut away from himself in a manner to which he is not accustomed. 
 A keen-edged knife readily passes through the tunics of the eye, so 
 that the incision can be completed in two or three drawing motions. 
 Short sawing motions must be avoided, as they produce an irregular 
 wound. The reason that the beginner frequently does not advance 
 the knife, in spite of many short sawing movements, lies usually in the 
 fact that instead of pushing the edge upward, he presses the knife 
 backward toward the sclera. 
 
 After completion of the counterpuncture, the incision should be con- 
 tinued without delay, in order to pass smoothly over the pupillary margin 
 before evacuation of the aqueous humor. If the completion of the 
 incision is delayed, the anterior chamber is abolished and the iris falls 
 in the way of the knife, and is unavoidably injured. To pause after 
 the counterpuncture, however, is a very common error with beginners. 
 If properly executed, the sawing movements, claimed by many to be 
 so disadvantageous, cause no inconvenience whatever. In this way 
 with a keen-edged knife the incision may be completed in two move- 
 ments by sawing sections just as well as when it is performed by 
 elevating and lowering the handle of the knife. 
 
 During the incision the knife must remain exactly parallel to the 
 iris, as any turning of the edge forward or backward would naturally 
 result in a deviation of the cut, either into the cornea or into the sclera. 
 Only after cutting through the outer tunic of the eye, and the knife 
 is seen under the conjunctiva, is it recommended to turn the blade 
 through an arc of 90 degrees (Fig. 64), so that the edge looks anteriorly.
 
 EXTRACTION OF SENILE CATARACT. I2Q 
 
 This secures a conjunctival flap that is much shorter than if the 
 knife in the previous position had been permitted to cut through. A 
 long conjunctival flap is an unpleasant impediment to a proper per- 
 
 FIG. 64. In this illustration the incision has advanced so far, that the cornea-sclera 
 is already cut through and the knife i>, beneath the conjunctiva. In order to cut the flap 
 off short, the knife is turned in such a manner that the edge looks forward. The knife is 
 now turned up. Note the change in the position of the hands of the operator as compared 
 with Fig. 60. The line of the incision in the cornea-sclera, as far as it lies behind the base 
 of the conjunctival flap, is designated by dots. 
 
 formance of the operation. The incision having been completed, the 
 forceps are released and the rest of the operation finished without fixation. 
 3. Iridectomy. (Figs. 65 to 68). In this procedure there are used 
 iris-scissors (De Weckcr's pince-ciseaux Fig. 69) and the iris-for- 
 ceps (Fig. 70.) The patient looks well downward, and the closed 
 9
 
 130 OPHTHALMIC SURGERY. 
 
 forceps, held in the left hand between thumb and forefinger are in- 
 troduced vertically from above, through the wound alongside of the 
 iris, to the pupillary margin, with the concavity of the blade forward. 
 The forceps are then opened slightly and a narrow fold of iris is 
 seized, drawn forward and quickly cut off with the scissors held in the 
 
 FIG. 65. Second step. Iridectomy. The eye is fixed no longer. With the thumb 
 of the right hand, the assistant holds the upper lid up from the side in such a manner that 
 the operator is not hindered in inserting the closed iris-forceps directly from above through 
 the wound to a point very near to the pupillary margin. The right hand meanwhile holds 
 the iris-scissors already opened close by, ready to quickly cut off the iris as soon as it is 
 drawn forward. For the sake of clearness the conjunctival flap is not represented on this 
 and the following figures. 
 
 right hand (Figs. 65 to 68). The hand guiding the forceps must take a 
 position of marked flexion, in order to introduce the instrument 
 exactly from above. Should the conjunctival flap interfere with the 
 introduction of the forceps, it may be turned down over the cornea 
 by aid of the closed scissors, while the forceps press the scleral edge 
 of the wound slightly back.
 
 EXTRACTION OF SENILE CATARACT. 131 
 
 The arms of the pince-ciseaux are best directed upward during the 
 excision (Fig. 68), as by this maneuver we obtain most readily a narrow 
 coloboma having the form of a pointed arch. It is, however, no mis- 
 take to make the cut with the arms of the scissors held parallel to the 
 limbus. 
 
 4. In opening the anterior lens-capsule (Figs. 73 to 75) we employ 
 
 FIG. 66. The blades of the iris-forceps held close to the pupillary margin 
 have just been opened. Figs. 59 to 61 show in natural size the maneuvers 
 in seizing and extracting the iris. 
 
 capsule-forceps (Figs. 71 and 72). The manipulation of this instrument 
 is, it is true, somewhat more difficult than that of cystotome. The 
 operator holds the forceps in the right hand between the thumb and 
 forefinger, and raises the upper lid of the patient with his left hand, 
 
 FIG. 67. The blades have been closed and have seized a fold of the iris. 
 
 while the assistant draws the lower lid slightly away from the eye, 
 the patient, meanwhile, looking well-downward. The closed instru- 
 ment is introduced vertically from above (hence a position of the 
 hand analogous to that in iridectomy), and pushed forward into the 
 
 FIG. 68. The portion of the iris, which has been drawn forward, is cut off 
 by the scissors brought from below. 
 
 anterior chamber until the dentated parts of the arms lie in the pupil, 
 while their posterior portion is situated in the coloboma. 
 
 The forceps must be in such a position that both arms, when opened, 
 glide along the surface of the anterior capsule (Fig. 74). A common 
 mistake of the beginner is to hold the forceps obliquely so that only 
 one arm lies against the capsule, while the other rests a greater or 
 lesser distance away in the chamber. After the forceps have been
 
 132 OPHTHALMIC SURGERY. 
 
 placed properly on the capsule, the instrument is opened as widely as 
 the size of the pupil permits, although still greater opening may be 
 obtained by permitting the arms to push the pupillary margin of the 
 iris gently back. Next, under a slight degree of pressure exerted in the 
 
 FIG. 69. Iris-Scissors (Pince-Ciseaux, de Wecker). 
 
 direction of the lens, the forceps are again closed, and a fold of the 
 capsule seized between the teeth, which are directed inward (Fig. 75), 
 and torn loose from its surroundings by a slow pulling movement. 
 
 FIG. 70. Iris-forceps. 
 
 The capsule-opening must be performed gently, and especially must the 
 separated piece of capsule be drawn slowly from the eyeball in order 
 that it be not detached from the forceps and left folded up in the 
 wound. 
 
 FIG. 71. Capsule-forceps open (side view.) 
 
 After withdrawing the forceps it is desirable to ascertain that the 
 piece of capsule is in their grasp and does not by any mischance re- 
 main behind in the wound. Ordinarily, there is obtained a some- 
 what round piece of the anterior capsule, which is usually about the 
 
 FIN. 72. Capsule-forceps closed, showing the toothed portions only in contact. 
 
 size of the pupil but may sometimes be much larger. The degree of 
 pressure needed to raise up a fold of capsule is very slight; if too much 
 is exerted, there is obviously danger of luxating the lens. In order 
 to avoid seizing the iris, the forceps must be constructed in such a
 
 EXTRACTION OF SENILE CATARACT. 133 
 
 way that, when closed, the posterior portions of the arms remain apart 
 from each other, and besides, in raising up the fold of the capsule, the 
 forceps are so held, that only the toothed edges impinge, while the 
 posterior parts of the arms are free in the chamber (Fig. 72). In extrac- 
 
 
 , 
 
 S, 
 
 FIG. 73. Third step. Opening of the capsule. The eye is not fixed. The operator 
 himself is holding the upper lid elevated with his left hand, while with the right he is just 
 beginning to introduce parallel to the plane of the capsule the closed capsule-forceps. 
 The assistant holds the lower lid slighty away from the eye, not only to freely expose the 
 cornea, but also to prevent any pressure on the eye by the lid should it be forcibly con- 
 tracted by the patient. The other hand of the assistant holds the spoon directed toward 
 the upper lid in such a manner that he can bring it at any time and at once beneath the lid, 
 if the patient should begin to wince and there would be danger of his pressing the upper 
 lid into the wound. 
 
 tion with iridectomy this factor plays no role, as the posterior portions 
 of the arms lie within the confines of the coloboma. On the other 
 hand, in extraction without iridectomy, it is important, by these precau- 
 tionary measures, to prevent a pinching of the iris. 
 
 Of greater relative simplicity is the opening of the anterior capsule
 
 134 OPHTHALMIC SURGERY. 
 
 by means of the pointed tenaculum of the cystotome. During the 
 introduction into the anterior chamber the tenaculum should be made 
 to slide down close to the posterior surface of the cornea and parallel 
 to it, so as not to become entangled. When it reaches the pupillary 
 area, it turns through an arc of 90 degrees until the point is directed 
 backward. It is then brought into contact with the anterior lens- 
 
 FIG. 74. Diagram showing both blades of the capsule-forceps 
 widely opened gliding over the anterior capsule. 
 
 capsule, and several superficial cuts are made in various directions. 
 During this procedure, no degree of force is either necessary or per- 
 missible. The instrument is withdrawn from the eye in the same 
 manner as it was introduced, that is, parallel to the corneal surface. 
 The great advantage of the capsule-forceps, which outweighs the 
 
 FIG. 75. The blades have been closed and have grasped between 
 them a fold of the capsule which is now being pulled out. 
 
 disadvantage of its somewhat more difficult manipulation, lies in 
 the fact that a large opening is made in the anterior capsule directly in 
 the pupillary area. The result of this loss of tissue is that the capsule 
 cannot produce optical disturbances later on. Again, the remnants 
 of the cataract left behind in the capsule-sac are exposed to the action 
 of the aqueous humor, with the result that even in the operation for 
 unripe cataract 01 when a large number of cataract-remnants are pres- 
 ent, they usually undergo spontaneous absorption immediately after 
 the operation. 
 
 5. Expression of the Cataract (Figs. 76 and 77). The patient 
 looks downward; the eye is not fixed. The manipulations which the 
 operator must perform in order to deliver the lens from the eye are 
 comprised in two different acts. While the upper lid is raised by
 
 EXTRACTION OF SENILE CATARACT. 
 
 the thumb of the left hand, the forefinger of the right hand begins 
 to exert pressure through the lower lid in an anterior-posterior 
 direction against the region of the lower corneal margin. The immc- 
 
 FIG. 76. Kxpression of the lens. The manner in which the operator holds his hands 
 should be observed. With the thumb of his left hand, he raises the upper lid and at the 
 same time pulls it slightly away from the eyeball. The forefinger of the right hand exerts 
 pressure on the lower half of the cornea through the lower lid; this causes gaping of the 
 wound and the edge of the lens presents in the wound. The assistant holds the spoon, 
 as already described, ready, on the one hand, to care for the upper lid and, on the other, 
 to roll the lens completely out of the eye after it has protruded half way. 
 
 diate result is that the lens rotates upon its horizontal frontal axis in 
 such a way that the upper edge of the lens-nucleus is turned anteriorly, 
 and presents in the wound, a procedure which the operator has to
 
 136 OPHTHALMIC SURGERY. 
 
 watch very closely. The wound begins to gape and in it the edge of the 
 lens begins to appear. This pressure must be made with great caution, 
 and only with gradually increasing force, in order to prevent a rupture 
 of the hyaloid membrane. 
 
 From the moment the edge of the lens presents in the wound, the 
 direction of the pressure is to be changed from below upward, as a 
 further continuance of the backward pressure would only cause the 
 vitreous to appear. The lens is now pushed up and out of the 
 wound by a stroking movement exerted on the eye with the assist- 
 ance of the lower lid. It is not permissible, however, to stroke up- 
 ward above the middle of the cornea, as this would compress the 
 
 FIG. 77. Diagram showing the spoon just about to be applied to the lateral 
 margin of the half -delivered lens so as to roll it completely out. 
 
 wound and cause the lens to retreat into the eye. As soon as the upper 
 half of the lens has passed the wound, the assistant applies the spatula 
 to the margin of the nucleus and removes it from the eye (Fig. 77). 
 At the same time the operator ceases pressure. The presentation of 
 the lens-border in the wound can be facilitated by a slight depression of 
 the scleral edge of the wound through the aid of Daviel's spoon. In 
 the average case, however, this is not necessary, and we only use this 
 depression when the delivery of the lens is accompanied by some 
 difficulty. 
 
 After the exit of the lens, the upper lid is at once guided carefully 
 down over the eye, so as to prevent the wound from gaping. Through 
 similar stroking and kneading motions, any cortical remnants still 
 remaining behind, are brought out through the wound. The more 
 carefully this is done, the less likelihood there will be of secondary 
 cataracts. Sometimes lens-tissue remnants are brought up from 
 below behind the iris by this massage, and the pupil, which at the 
 outset appeared black, turns gray again until the particles of tissu e
 
 EXTRACTION OF SENILE CATARACT. 
 
 137 
 
 have passed into the wound. Their removal is, at times, anything but 
 easy. Occasionally they can be got out by inserting David's spoon 
 into the anterior chamber. But while doing this the operator must not go 
 too far in his endeavor to get the pupil as clean as possible. As soon 
 as it is seen that the wound shows an inclination to gape, and the vitreous 
 is bulging forward and is in danger of prolapse, it is better to desist 
 
 FIG. 78. Reposition of the inner margin of the coloboma. The eye is not fixed. The 
 operator himself holds the upper lid in the same manner as above. His right hand intro- 
 duces the spatula from without, obliquely into the inner angle of the wound, in order to 
 smooth the iris down from this point. The lower lid is drawn slightly away by the assistant. 
 
 from attempts at removal of the remnants, and to end the operation. 
 It may happen that although the pupil is thought to be free of cortical 
 substance, on the day after the extraction it is found to be full of 
 swollen masses of lens material. At the time of the operation this 
 material was transparent, and, of course, could not be detected. 
 
 6. Toilet of the Eye (Fig. 78 to 81). This represents the final 
 stage of the operation, and the most important part in it is the reposi-
 
 138 
 
 OPHTHALMIC SURGERY. 
 
 tion of the iris. After removal of the lens it is often hard to recog- 
 nize whether the iris is really in a correct position. 
 
 We cannot expect to see in every case sharply projecting sphincter- 
 angles. Occasionally the iris has been excised in such a manner that 
 one of the angles produced is extraordinarily obtuse. Of only really 
 great importance is the position of the sphincter, which can be recog- 
 nized through its color being different from that of the rest of the iris. 
 
 FIG. 79. Reposition of the outer margin of the coloboma. The operator himself holds 
 the upper and lower lids by means of the thumb and forefinger of the right hand, while 
 the spatula is introduced with the left hand from the inner side obliquely into the outer 
 angle of the wound and the iris smoothed back. 
 
 It is true, however, that through the presence of hemorrhages on the iris, 
 a proper view can be hindered. The reposition is achieved by the spatula 
 which is pushed carefully through the lips of the wound into its angle 
 (Fig. 80). The spatula must be held parallel to the plane of the iris, 
 as the turning of the end backward will result in injury of the hyaloid 
 membrane and prolapse of the vitreous. When the anterior chamber is 
 reached, gentle pressure is exerted on the iris, one edge of the spatula
 
 EXTRACTION OF SENILE CATARACT. 139 
 
 being turned slightly posteriorly at the same time (Fig. 81). By moving 
 the spatula toward the center of the pupil, the iris is stroked into its 
 proper position. It is of no importance which hand is used in this 
 manipulation. We employ alternately, as a rule, the right and left hand 
 for the right and left angles of the wound, respectively. In many 
 
 FiG.So. FiG.Si. 
 
 FIG. 80. Diagram representing the eye and spatula during the reposition in natural 
 size. For the purpose of reposition the spatula is introduced into the angle of the wound 
 between cornea and iris. 
 
 FIG. 81. In order to accomplish the backward stroking more easily, the spatula is 
 rotated a few degrees (set on edge) and then by a suitable movement the angular extremity 
 of the sphincter is smoothed down. 
 
 cases one can smooth the iris out directly from above downward, by 
 holding the spatula in a vertical manner. 
 
 The proper position of the conjunctival flap is to be considered 
 last. This should be carefully stroked into its intended position by 
 aid of the spatula. Occasionally the conjunctival flap is included in 
 the wound, which naturally causes a material disturbance in its closure. 
 
 After the conjunctival sac had been freed of blood and lens rem- 
 nants, the eye is closed and a binocular bandage applied.
 
 CHAPTER XII. 
 EXTRACTION OF SENILE CATARACT (Continued). 
 
 ACCIDENTS AND COMPLICATIONS. 
 
 The foregoing description concerns the operation for extraction 
 of senile cataract when no undue incidents have occurred. Untoward 
 accidents, however, may complicate each stage of the operation, and 
 these complications are described and classified under the particular 
 stage of the operation in which they occur. 
 
 1. Fixation of the eyeball. 
 
 The conjunctiva may be torn out. In elderly people the conjunctiva 
 is often very friable, and in grasping it the forceps are likely to tear 
 out. In case of this accident, if the operator is already in the midst of 
 the incision and the patient does not of his own volition look downward, 
 a muscle-insertion must be seized with the forceps, either that of the 
 inferior rectus, or, preferably, of the superior rectus, the eye being pulled 
 somewhat forward out of the orbit. It would be useless to seize the 
 conjunctiva in another place, for it would tear out again. It is not 
 permissible to bring the knife to a standstill while it is in the anterior 
 chamber, as the aqueous humor escapes and the iris falls in the way of 
 the knife. The only disadvantage of grasping a muscle-insertion lies 
 in the fact that if the incision is not yet commenced, the knife in the 
 act of making the puncture causes a marked rolling of the eye, which 
 renders the beginning of the cut somewhat difficult. 
 
 2. The incision. 
 
 The experienced operator rarely fails to get the cut in the desired 
 position, while with the beginner the opposite is often the case. The 
 errors possible in regard to the incision concern: a. the position; b. the 
 length; c. the manner in which it is executed. 
 
 a. The incision may either fall too far forward in the cornea, or too 
 far backward from the limbus in the sclera. The latter especially 
 occurs when the operator is a novice, and is usually due to the following 
 circumstances. The puncture at the limbus is naturally quite easy. 
 On the contrary, the counterpuncture is much more difficult on 
 account of the already described relations of the peripheral part of the 
 
 140
 
 EXTRACTION OF SENILE CATARACT. 141 
 
 anterior chamber. If the knife is pushed on directly into the angle of 
 the chamber, the sclera is pierced in an oblique direction and the knife 
 is seen to appear far behind the limbus beneath the conjunctiva. In 
 order to bring the knife out directly at the limbus, the point should be 
 steered toward a spot in the cornea about i mm. distance inward 
 from the limbus. The operator, looking at the eye from in front, 
 thinks that the point of exit will be much too far in the cornea, and 
 is surprised to see, in spite of this, the point of the knife appearing 
 in the limbus or close behind it. Hence, the novice may naturally 
 fall easily into the opposite error, of making the counterincision much 
 too far into the cornea. 
 
 Both of these abnormal incisions have great disadvantages. The 
 peripheral incision in the sclera is usually accompanied by severe 
 hemorrhage, which renders the operation exceedingly troublesome, 
 the more so as the blood from the wound situated higher up, continues 
 to flow into the chamber and hides the iris and lens from the operator's 
 view. Besides, the incision is quite painful for the patient, as the 
 cocain has not the same effect on the sclera as on the cornea. 
 
 Because of the position of the peripheral incision, the knife passes 
 through nearly in the plane of the iris. This is the reason why the 
 iris falls into the way of the knife and why a large piece is excised, 
 the lens-capsule being in addition frequently injuied at the same time. 
 When we consider that the patient in consequence of the painfulness of 
 the incision usually winces, we have an explanation why this single 
 error in making the incision, which is so frequently seen in the extrac- 
 tion by the novice, gives rise to the common distressing experience of 
 wound of the iris and lens-capsule the lens protruding through the 
 gaping wound, and behind it the vitreous pouring out. 
 
 Gaping of the wound is in general one of the great disadvantages 
 of peripherally situated incisions, particularly as it predisposes to an 
 extensive prolapse of the vitreous. It may almost be said that an 
 incision situated too far forward in the cornea is better than one made 
 too far in the sclera, but it also has objections, the chief of which is its 
 relative shortness. The further into the cornea the incision, the more 
 it becomes shortened from the arch to its chord. The delivery of the 
 lens is consequently made more difficut. This will be discussed further, 
 later on. 
 
 A high grade of astigmatism is another unpleasant sequel of corneal 
 incisions and unfortunately it may remain permanent. The formation
 
 142 OPHTHALMIC SURGERY. 
 
 of an anterior synechia is another no less disagreeable complication, 
 as the periphery of the iris cannot be excised, and in consequence 
 increase in tension may follow by the obturation of the angle of the 
 chamber. 
 
 The greater liability of the corneal wound to infection is of less 
 significance nowadays, since the operation is performed under anti- 
 septic precautions. 
 
 b. The length of the incision. 
 
 On an average the incision should include about a third of the 
 corneal periphery. No difficulties are presented in finding the right 
 point of the insertion i mm. above the end of the horizontal meridian. 
 Only through an abnormally oblique passage of the knife through the 
 anterior chamber, an improperly situated counterpuncture can 
 result, in consequence of which the cut will be too short. The 
 relative shortness of a corneal incision has already been mentioned. 
 The type of patient must, however, be always taken into consideration 
 in determining the length of the incision. If a comparatively young 
 individual (in the early forties), in all probability a shorter incision 
 will suffice, as at this age the lens nucleus is still small. Greater length 
 of the incision at the very outset is to be considered, if a large brown 
 cataract, a totally sclerosed lens, is present. Should the patient 
 have an abnormally small cornea, the incision must be begun further 
 below, if necessary at the horizontal meridian, to insure a diameter 
 of sufficient size. 
 
 c. The manner of performing the incision deserves a special 
 discussion. The first rule to be observed is under no circumstances 
 to withdraw the knife after it has once pierced the outer tunic of the 
 eye and entered the anterior chamber. The beginner, becoming fright- 
 ened at seeing the knife pierce a small bit of iris, draws the knife 
 backward in order to free it. The immediate result is escape of the 
 aqueous humor, and instead of a small piece, the whole width of the 
 iris must now be cut through. It is never permissible to draw the 
 knife backward, nor even bring it to a standstill. The counter- 
 puncture once completed, no delay is allowable, and the incision is to 
 be continued immediately. 
 
 If it should happen that the anterior chamber has been entered with 
 the edge of the knife directed downward, the counterpuncture is first 
 to be made, and then the knife rotated as quickly as possible 180 in its 
 long axis, so that its edge becomes directed upward. The quick rotation
 
 EXTRACTION OF SENILE CATARACT. 143 
 
 ] in- vents the escape of the aqueous humor. Turning of the knife in 
 the wound is without disturbing consequences, if its edge passes the 
 arch in the direction toward the cornea. 
 
 In making the puncture, if the knife is held with its point directed 
 too far forward, it may happen that, instead of entering the anterior 
 chamber at once, the blade courses between the lamellae of the cornea 
 for some distance the so-called intralamellar incision. This 
 error results in a wound much too small. An intralamellar incision is, 
 however, rare in the cataract-operation, as the anterior chamber is 
 usually deep and the operator has no fear of piercing the limbus per- 
 pendicularly, as in the operation for glaucoma, where the danger of 
 injuring the lens is always present. If the improper direction of the 
 knife between the lamellae of the cornea is noticed early enough, that 
 is, before a puncture into the anterior chamber has resulted in escape 
 of the aqueous, the knife can be withdrawn and the incision repeated 
 at once in the correct place. If the aqueous humor has already escaped, 
 the operator must continue with the incision, no matter how it termin- 
 ates, and eventually widen it later with the scissors. 
 
 The surface of the knife blade must always be parallel to the 
 surface of the iris. Only in this way is it possible to continue cutting 
 in the same plane. Should the edge of the knife be turned slightly 
 forward, the incision deviates anteriorly into the cornea; if directed a 
 trifle backward, it is made more and more obliquely into the sclera. 
 
 No direct pressure should be made with the knife ; on the con- 
 trary, the blade is to be drawn through in an upward direction with 
 long sawing movements. Pressure of the knife against the sclera, 
 stops its forward progress. Thus a novice may believe that he has a 
 dull knife, while he himself is responsible for the poor incision. 
 
 The knife should be carried through the chamber in a hori- 
 zontal direction. While it is lightly held between the thumb on one 
 side, and fore- and middle fingers on the other, the handle of the knife 
 rests upon the first joint of the forefinger. The little finger is supported 
 in the region of patient's temple to prevent making a false cut, should 
 he move unexpectedly. 
 
 After the sclera has been cut through, and the knife is beneath the 
 conjunctiva, it is turned so as to cause the edge to look anteriorly. It 
 is, however, an error, to turn the knife while it is still embedded in 
 the sclera, as not merely irregularity in the wound will occur, but the 
 incision will lie in a false position, too far into the cornea.
 
 144 OPHTHALMIC SURGERY. 
 
 Finally, there is to be considered which hand should make the 
 incision? To operators who are not naturally lefthanded, the cut 
 made with the left hand does not present any unusual difficulties. 
 
 The surgeon who only employs the right hand must operate on the 
 right eye from behind, and on the left eye from in front. There are 
 operators who always operate from behind, and who, for that reason, 
 must use the right and left hand alternately. The great objection to 
 this position is that the surgeon must bend over the patient, a circum- 
 stance which certainly is not favorable for proper asepsis of the wound. 
 
 3. Performance of the Iridectomy. 
 
 The first complication to present itself during this step of the opera- 
 tion may be hemorrhage. If the incision bleeds considerably, the 
 blood in the anterior chamber obscures the view, so that one has to 
 seize the iris without seeing it. The actual cutting of the iris is usually 
 not especially painful, as the cocain has a sufficient anesthetic effect. 
 
 The iridectomy is beset with difficulties if an intractable patient 
 does not look down, or looks up or aimlessly around, and it may 
 be impossible to seize the iris with the forceps. One may then draw it 
 forward with a blunt hook, bent in a proper manner, and do the exci- 
 sion. We fix the eye with the forceps only with great unwillingness and 
 only in case of absolute necessity while doing an iridectomy, as the 
 fixation invariably causes the wound to gape. 
 
 An unpleasant accident which may happen in iridectomy is the pro- 
 duction of an iridodialysis. If, after the iris has been seized with the 
 forceps, the patient suddenly moves his eye or head, unless the operator 
 is quick enough to release the iris, there may ensue a separation of 
 the iris at its ciliary margin to a greater or lesser extent. As a rule a 
 considerable hemorrhage occurs directly after, which greatly adds to 
 the difficulties of further operating. 
 
 Should the iris during the incision fall into the way of the knife, 
 a broad piece is usually cut out, which prolapses into the wound. If 
 the prolapse shows in the incision at once, it requires only removal with 
 the forceps. In other cases it must be removed from the anterior 
 chamber. Only when it is still connected in one place with the rest 
 of the iris, it has to be excised at that point. 
 
 If only the periphery of the iris falls into the way of the knife, a 
 bridge-shaped coloboma is formed, in which a more or less wide portion 
 of the pupillary margin persists. It is not necessary to draw it up 
 and cut it off. Sometimes a narrow sphincter bridge cannot be
 
 EXTRACTION OF SENILE CATARACT. 145 
 
 caught with the forceps, so that one has to resort to the blunt hook to 
 pull it out. If the bridge is permitted to remain, it may either persist 
 unharmed during the delivery of the lens, the nucleus passing through 
 the coloboma, or it may tear away. 
 
 4. Opening the capsule. 
 
 In spite of the somewhat more difficult manipulation of the capsule- 
 forceps, we usually prefer them to the cystotome, and only in certain 
 selected cases use the sharp tenaculum. As that portion of the 
 anterior capsule which corresponds to the pupil, presents an obstacle 
 to vision, it is naturally better to remove it. The extensive absorption 
 of the remnants of the lens in the presence of a large opening in the 
 capsule has already been alluded to. However, there are circumstances 
 in which the use of the forceps is objectionable. If the anterior cham- 
 ber is filled with blood, and the boundaries of the pupil cannot be seen, 
 the use of the capsule-forceps is likely to be dangerous, and by mis- 
 chance a fold of the iris might easily be grasped by mistake and pulled 
 out. In restless patients it is preferable to resort to the cystotome 
 tenaculum. If the pupil is narrow, it may also be desirable to open 
 the capsule with the tenaculum in an extraction without iridectomy, 
 to avoid a possible seizure of the iris by the forceps. 
 
 The employment of the capsule-forceps will be influenced to a 
 considerable extent by the condition of the capsule when dealing with a 
 greatly distended cataract, and a hypermature, complicated cata- 
 ract with thickened capsule. If the lens is so swollen that the capsule 
 is tense, a fold of it cannot be lifted up with the forceps, except by 
 exerting more force than is permissible. If the operator feels that he" 
 cannot grasp a fold of capsule between the teeth of the forceps by 
 gentle pressure, he should effect the opening by the aid of the tenaculum 
 as too much force will cause a prolapse of the vitreous. 
 
 Should the capsule be thickened, great care is demanded in the 
 use of the forceps. It is, of course, an advantage to remove the 
 thickened anterior capsule from the pupillary area, especially if it 
 occupies the whole extent of the latter, as the dense membrane seriously 
 impairs vision. In using the forceps it may happen that the thickened 
 capsule offers more resistance than does a defective zonula; the fibers 
 of the latter tear through and the whole lens in its envelope is with- 
 drawn from the eye. In any event the operator must be prepared to 
 assist in the exit of the lens by a downward pressure on the scleral 
 wound-margin at the moment he sees the whole lens yielding. This is
 
 146 OPHTHALMIC SURGERY. 
 
 done in order to remove the obstacle presented by the sclera, so that 
 the capsule may not finally rupture and leave the half-luxated lens 
 behind in the eye. If the patient is quiet and the vitreous of normal 
 consistency, a prolapse of the latter does not of necessity accompany 
 the extraction of the intact capsule. Sometimes such prolapse cannot 
 be avoided. Should extraction with the capsule succeed, the terminal 
 result is excellent, as the pupil is free of all remnants of tissue. 
 
 It is perhaps superfluous to state that the pressure to be exerted on 
 the lens with forceps in opening the anterior capsule must be gentle in all 
 instances. A luxation of the lens backward into the vitreous could 
 possibly follow excessive pressure with the instrument. 
 
 5. Expression of the cataract. 
 
 The manner in which pressure is to be made on the eyeball to effect 
 exit of the lens has already been described. If the operator does not 
 exert it against the lower part of the lens, but instead presses too high 
 up, perchance against the middle of the cornea, he will, of course, wait 
 in vain for the appearance of the lens in the wound. However, in spite 
 of pressure made in the proper manner and with a proper degree of 
 force, the lens-nucleus may fail to appear in the wound and make its 
 exit. This is a most critical moment for the operator, and here he must 
 think right and act quickly, well mindful of his purpose. 
 
 The causes of such a contingency are as follows: 
 
 a. The wound may be too small. If the operator has begun the 
 incision too high up, or, after an accurate puncture, has wrongly made 
 the counterpuncture too far above, a relatively short incision is the 
 consequence. 
 
 If it is seen that the lens-nucleus is pressing against the wound but can 
 not make its way through, the incision must be prolonged either at one 
 or both ends, with a small pair of curved blunt scissors, one blade of 
 which is carefully pushed into the angle of the chamber between the 
 cornea and iris, while the other blade remains on the outside of the 
 eyeball. If shortness of the incision is the real cause that prevents the 
 proper delivery of the lens, the latter easily slips out of the eyeball 
 after the cut has been enlarged. 
 
 It may be, however, that though the incision is sufficiently long, the 
 lens-nucleus may be exceptionally large. On this account, in cases 
 of black cataract, the incision should be made larger than usually at 
 the beginning of the operation. A cut which is too short, because made 
 too jar into the cornea, presents still another factor which may
 
 EXTRACTION OF SENILE CATARACT. 147 
 
 hinder the exit of the lens. The further the incision in the cornea is 
 removed from the limbus, the more must the edge of the lens rotate 
 forward to present in the wound. That is, the greater the force which 
 the operator must exert on the eye, the more danger there is of prolapse 
 of the vitreous. Therefore, the only thing to do to facilitate the extru- 
 sion of the lens is to prolong the incision by making lateral cuts along 
 the limbus, and the same procedure is indicated if itXis too short, on 
 account of being made for some distance between the corneal lamella. 
 
 b. The sphincter may offer too great resistance. This will 
 be discussed when describing extraction without iridectomy. 
 
 c. The anterior lens-capsule may not have been opened. 
 The operator who can see the fold which his forceps have raised in 
 opening the capsule, or has at least convinced himself of the presence 
 of a piece of the membrane between the branches of the forceps after 
 they are withdrawn, will always feel safe against this error. If he is 
 not certain of having sufficiently opened the capsule, he should intro- 
 duce the forceps a second time or have recourse to the cystotome. 
 
 d. A fourth possible causative factor is dislocation of the lens, 
 usually a slight subluxation upward. This may be due to traction 
 of the forceps on the capsule, to pulling too strongly on the tunics of 
 the eyeball during the incision, or to the initial pressure having been 
 exerted in a direction, which pushed the lens slightly upward instead of 
 rotating it about its horizontal axis. Consideration of the associate 
 physical conditions renders clear the impossibility of delivering the lens. 
 The pressure made by the finger naturally falls only on the vitreous, and 
 has no longer any influence on the position of the lens. The latter does" 
 not rotate its margin into the wound, and the operator who thinks to 
 accomplish this purpose by increasing the pressure simply forces the 
 vitreous into the opening, at the same time completely luxating the lens 
 backward. The removal of the lens can then only be accomplished by 
 returning it to its original position, which may be obtained by introducing 
 a spatula into the anterior chamber and bringing the instrument into 
 contact with the anterior surface of the lens, pushing it downward into 
 its normal position. After this maneuver the expression of the lens 
 is at once obtained by pressure exerted. 
 
 If the lens becomes luxated in any direction other than upward, 
 for example, internally or externally, it must be treated as described 
 elsewhere. 
 
 When the lens-nucleus has become considerablv diminished in
 
 148 OPHTHALMIC SURGERY. 
 
 size, its exit may also be more difficult, as is frequently seen in compli- 
 cated cataract and invariably in over-ripe cataract (Morgagnian cata- 
 ract). One understands that the employment of pressure, in the 
 manner just described, is absolutely useless, if the lens is not normal 
 in position and size. If the cortical substance has liquefied and pours 
 out after the anterior lens-capsule has been opened, the small nucleus 
 either sinks down to the bottom of the capsule-sac or is carried slightly 
 upward behind the iris by the escaping cortical matter. In neither of 
 these two instances is it possible through the regular expression to 
 influence the position of the lens-nucleus. Pressure is absolutely con- 
 traindicated. If the lens lies far down, it may be gradually worked 
 upward by gentle stroking movements, and finally brought out of 
 the wound with Daviel's spoon. If, however, it has been pushed 
 up behind the iris, it must be first stroked down by means of the spoon 
 into the pupil and from there guided upward out of the wound. 
 
 6. Prolapse of the vitreous is the most unpleasant of accidents, 
 and, although it does not usually occur until during the act of expressing 
 the cataract, it may happen in any of the stages of the operation. It is 
 of less significance when it ensues after the removal of the lens, and 
 that time it is best to do nothing further than make sure that the corneal 
 flap remains in its proper position, and is not bent forward through 
 the pressure which the vitreous exerts from behind. To undertake a 
 reposition of the iris is not advisable, as by doing so there would only 
 be caused further protrusion of the vitreous. The best procedure, there- 
 fore, is to close the patient's eye immediately the vitreous appears, the 
 upper lid being carefully guided over the flap with the assistance of the 
 spoon held beneath the lid. As the protrusion of the vitreous causes 
 pain, the patient usually winces, which may cause still more 
 vitreous to be pressed out of the eye. Moreover, it is easily possible 
 for the upper lid to fall into the open wound and to turn the flap 
 forward. This accident will be discussed more fully when speaking of 
 the duties of the assistant during the cataract-operation (p. 237). 
 
 After the patient has closed the eye, the upper lid is slightly raised 
 with great care (best by means of the eyelashes) and at the same time 
 the lower lid is drawn away from the eye. The position of the flap 
 behind the upper lid may then be inspected, and, if necessary, is 
 smoothed out by a spatula. After this, the patient should not be 
 allowed to open his eye and for this reason it is of advantage to keep 
 the other eye also closed by a bandage.
 
 EXTRACTION OF SENILE CATARACT. 149 
 
 When the vitreous appears prior to the removal of the lens, 
 
 the accident naturally becomes much more troublesome. If the iris 
 has not as yet been excised, an iridectomy can only be performed if the 
 iris has been so floated into the wound by the vitreous that it can be 
 seized readily by the forceps and cut out. If, however, the iris has 
 not fallen forward, any attempt to seize it with the forceps must be hope- 
 less, as the instrument picks up only the vitreous, never the iris, which 
 had been pushed backward toward the ciliary body, so that a large 
 coloboma upward is to be seen. 
 
 Expression of the cataract after appearance of the vitreous 
 is impossible, since every time that pressure is made a further pro- 
 lapse occurs. Instead, extraction of the lens in its capsule must 
 be resorted to, and for this purpose, either a loop (Weber's) or a 
 double tenaculum (Reisinger's) is employed, the manipulation of 
 the former being easier for the beginner. 
 
 The loop, (Fig. 82) directed obliquely back-ward (Fig. 83), is 
 introduced through the wound, until it reaches a position in the mid- 
 dle of the vitreous and about opposite the posterior pole of the lens. 
 It is then turned forward in such a way (Figs. 84 to 87) that the 
 
 FIG. 82 . Weber's loop. 
 
 lens is pressed against the posterior aspect of the cornea and glides out 
 between the cornea and the instrument; in other words, it is lifted out 
 of the eye by the loop. 
 
 Reisinger's double tenaculum (Fig. 87) is inserted closed into the 
 vitreous area in a manner similar to that used in introducing the loop, 
 in order that the points of the tenaculum may not become entangled in 
 the edges of the wound, the instrument is held with the plane of the 
 bent portion parallel to the wound, therefore, in a frontal direction. 
 Not until the instrument is found to be behind the middle of the lens, 
 is ]it rotated about 90 on its long axis, so that the points are now di- 
 rected forward. The two arms are then permitted to separate and sink 
 into the posterior surface of the lens, which is now pressed against the 
 posterior aspect of the cornea and in this manner withdrawn from the 
 eye. This instrument, therefore, can only be used when a firm lens-
 
 OPHTHALMIC SURGERY. 
 
 nucleus is present. If the nucleus is soft, the loop is recommended, as 
 
 the tenaculum would cut through the soft mass without bringing it out. 
 
 Both the instruments must be carried backward into the vitreous 
 
 in an oblique manner, for the reason that if held vertically, they would 
 
 a 
 
 FIG. 83. Introduction of Weber's loop in case of escape of vitreous prior to the delivery 
 of the lens. The loop is directed backward through the gaping wound behind the lens 
 into the vitreous. The assistant holds the upper lid well-fixed with the thumb of the right 
 hand and has the spoon in the left hand ready, after the extraction has been completed, to 
 guide the upper lid down over the gaping wound. The operator himself fixes the lower lid. 
 
 push against the margin of the lens and produce a luxation into the 
 vitreous. During the entire manipulation, the lids must be drawn 
 away from the eye, so that they can exert no pressure on the globe.
 
 EXTRACTION OF SENILE CATARACT. 
 
 The upper lid is best raised by means of a Desmarres spoon. In every 
 cataract-operation the loops and tenaculum should be kept near at 
 hand and sterilized, as prolapse of the vitreous occasionally takes 
 
 
 FIG 84. Second step of this procedure. The loop has been placed upright in such a 
 fashion as to press the lens against the posterior aspect of the cornea and can now be drawn 
 along the latter and out of the eye. 
 
 place in operations in which a completely normal course had been 
 expected. 
 
 Generally speaking, the greater the dexterity of the operator, the 
 rarer will be prolapse of the vitreous in uncomplicated cataract. Severe 
 straining, holding the breath, etc., on the part of the patient may be 
 responsible for the accident, while the surgeon may induce the prolapse
 
 152 
 
 OPHTHALMIC SURGERY. 
 
 by undue pressure on the eye with the forceps during the incision, in 
 delivery of the lens, or in scraping out the lens-remnants. Quite 
 unavoidable often is the prolapse in the presence of complicated cata- 
 racts, when the zonula is destroyed, or the vitreous has lost its normal 
 consistency. 
 
 Prolapse of the vitreous is the most serious complication in 
 the operation for cataract-extraction, and it is absolutely necessary to 
 recognize at the right time whether a prolapse is imminent, and if so, 
 to prevent it if possible. 
 
 FIG. 85. FIG. 86. 
 
 FIG. 85. Diagrammatic representation of the introduction of the loop. The loop is 
 directed backward in an oblique manner. 
 
 FIG. 86. The loop is raised up and the lens pressed against the posterior wall of the 
 cornea. 
 
 Several phenomena are associated with this complication: 
 i. Very characteristic is the forward bulging through the pupil and 
 coloboma of the vitreous with the hyaloid membrane still unruptured. 
 If after the expression of the lens-nucleus, the pupil and coloboma are 
 filled with greyish lens-remnants which suddenly separate at one point, 
 and the pupil in this locality becomes a deep black, we have the first 
 sign that the vitreous, still contained within its uninjured membrane, 
 has pushed forward and penetrated the tissues in front. Only the 
 inexperienced operator will continue to exert pressure to remove the 
 remaining lens-particles, for the rupture of the hyaloid membrane
 
 EXTRACTION OF SENILE CATARACT. 153 
 
 would occur the next moment. It is better to be satisfied with care- 
 fully stroking back the iris, and even this is only possible if the patient 
 remains correspondingly quiet, but it often becomes displaced again 
 through the vitreous pushing forward. 
 
 2. The same bulging forward of the vitreous in the unruptured hya- 
 loid membrane may also occur with a simultaneous marked deepening 
 of the anterior chamber. A hernia of the vitreous presses at the 
 same time through the pupil into the anterior chamber, filling it out and 
 pushing back the iris. 
 
 3. Another characteristic sign is the deepening of the anterior 
 chamber in consequence of the accumulating vitreous, which is already 
 poured in through a rupture in the hyaloid membrane. This is natur- 
 ally followed at once by an outflow of the vitreous through the wound. 
 The first indication of the vitreous flowing into the anterior chamber 
 is occasionally manifested by changes, which the blood undergoes 
 
 FIG. 87. Reisinger's double tenaculum. 
 
 through coming into contact with the vitreous. It coagulates into 
 thread-like clots becoming lighter in color. 
 
 Deepening of the anterior chamber may also be produced by the 
 entrance of air, but as the air-bubble is always clearly seen, it cannot 
 be confounded with the appearance just described as due to the vitre- 
 ous. The air in itself is not harmful, but it may so disturb the appa- 
 rent relations of the anterior chamber, especially the position of the 
 margins of the iris, that an attempt should be made to remove it from 
 the eye by massage. As the air is easily sucked in again, this measure 
 is usually valueless. 
 
 4. If the lens is still in the eye, the tendency to vitreous-prolapse is 
 indicated by a turning up of the edges of the wound, and in conse- 
 quence the wound gapes. While vitreous-prolapse may sometimes 
 be caused by the patient holding his breath or straining down, in other 
 cases no cause can be found, the prolapse occurring unexpectedly. 
 Especially during peripheral incisions the hyaloid membrane may 
 rupture in the region of the wound, and the vitreous extrude through 
 the widely gaping wound, without any previous sign whatever having 
 been noticed in the anterior chamber. 
 
 If the vitreous is perfectly fluid, it will ooze steadily from the eye
 
 154 OPHTHALMIC SURGERY. 
 
 immediately after the incision, without any gaping of the wound. 
 Great loss of fluid is only recognized by collapse of the eyeball. 
 As this precludes regular extraction of the lens, the loop or tenaculum 
 must be resorted to. On the whole, the loss of perfectly fluid vitreous 
 is in general much better tolerated than the loss of the normal vitreous. 
 In a few hours it is replaced by new fluid, which returns the eye to its 
 normal state of tension. As the wound does not gape, it heals smoothly ; 
 whereas, in the loss of normal vitreous, the cicatrix remains ectatic for 
 a long time. 
 
 In the rare instances in which the protruding vitreous constantly 
 turns the corneal flap forward, and it cannot be retained in its proper 
 position by stroking it back with the spatula, nothing remains to be 
 done except to fasten it w T ith two or more silk sutures. 
 
 When the dressings are changed on the day after the operation, it 
 may be found that the corneal flap is turned downward. This 
 is caused by the patient with a gaping wound opening the eye beneath 
 the bandage, so that the upper lid in closing enters the wound. After 
 instilling cocain-solution the flap must be carefully stroked upward 
 and brought into its proper position. If no infection ensues, which, 
 however, is a likely result, the eye need not be considered as lost. For 
 a long time a straight white line is retained as a sign of the corneal injury. 
 
 The sequelae of prolapse of the vitreous may in all cases be seri- 
 ous. A replacement of the iris is impossible, and, therefore, an attach- 
 ment of its margins to the wound is a usual occurrence, in consequence 
 of which cystic scars, glaucoma, and signs of irido-cyclitic irritation 
 often appear. Hemorrhage into the open vitreous chamber may lead 
 to marked opacities which later are seen as free floating membranes 
 or hang into the vitreous chamber from the point of attachment. 
 Detachment of the retina occurs only after great loss of vitreous 
 except in an eye especially predisposed (myopia, etc.). 
 
 Several other accidents during the cataract operation must 
 be mentioned. 
 
 The lens may be displaced back into the vitreous chamber, 
 either spontaneously or through the unskillful manipulation of the 
 operator. In such case any attempt to recover it is useless and results 
 only in further injury to the eye. The operation has to be stopped 
 and the eye bandaged. Iridocyclitis often follows this accident. 
 
 The so-called collapse of the cornea, which is occasionally met 
 with during the operation for cataract, is of absolutely no importance.
 
 EXTRACTION OF SENILE CATARACT. 155 
 
 Immediately after completing the incision, or after expression of the 
 lens, the cornea sinks down so that a depression appears. This hap- 
 pens in softened eyes, and when the cornea is flabby, especially in old 
 people, whose cornea is often extremely atrophic. 
 
 Expulsive hemorrhage is fortunately an infrequent complication. 
 It may occur during the course of the operation, but usually appears 
 suddenly several hours afterward; it is seen not only aftei extraction 
 complicated by the loss of the vitreous, but also following operations 
 with a perfectly normal course. The hemorrhage is retrochorioideal 
 and is so extensive that the vitreous, chorioid and the retina are driven 
 outward through the wound. Immediate enucleation spares the 
 patient a long period of suffering. Unfortunately, we have no means 
 to prevent this accident; indeed, we do not even know of a single symp- 
 tom which will afford warning of the danger before the operation. 
 As associated factors the following must be taken into consideration: 
 the sudden lowering of the intraocular pressure caused by the operation; 
 the rigidity of th? external tunic of the eye; arteriosclerosis and the con- 
 comitant tendency of the blood-vessels to rupture; and increase in blood- 
 pressure occurring during the operation on account of the increased 
 activity of the heart due to the excitement of the patient. To at least 
 exclude the last factor, Fuchs gives those patients who have lost one 
 eye through an expulsive hemorrhage, a large dose of bromids before 
 the operation (two grams). The danger that hemorrhage may follow 
 extraction of a cataract from the other eye is not sufficiently great to 
 warrant the operator in performing a depression of the cataract into the 
 vitreous humor after the old method instead of the usual extraction. 
 Here it may be mentioned that we do not perform preliminary iri- 
 dectomy, either in unripe or complicated cataract, it having no special 
 advantage; on the contrary, it adds to the danger of a second operation. 
 
 EXTRACTION WITHOUT IRIDECTOMY. 
 
 Apart from the cosmetic standpoint there is no sound argument that 
 can be advanced in favor of the operation without iridectomy. On the 
 contrary, this method possesses several disadvantages, which must not 
 be underestimated. Prominent among these are the necessity of a 
 second operation in case of subsequent prolapse of the iris, and the 
 increase in pressure caused by the occasional distortion and fixation of 
 the iris to the scar. 
 
 Indications. This operation may be performed if it is certain
 
 156 OPHTHALMIC SURGERY. 
 
 that the patient will lie quietly in bed afterward; hence, it should 
 never be undertaken in very old people or if the patient has a cough. 
 If there is good vision in the other eye, extraction without iridectomy 
 may sometimes be permissible. If, however, the other eye is incapaci- 
 tated or its vision diminished in consequence of some disease apart 
 from incipient cataract, the extraction must always be performed with 
 iridectomy so as to avoid any complications. To be successful, extrac- 
 tion without iridectomy further depends upon certain conditions of the 
 eye. With a narrow pupil and a large lens-nucleus, it is readily under- 
 stood that the operation must be done with an iridectomy; the same is 
 true in all cases of complicated cataract. Therefore, it is only when 
 the iris tends to retain its position in the eye and shows no inclination 
 to fall forward, and the course of the operation promises to pass off 
 uncomplicated, should the careful operator conclude to perform extrac- 
 tion without iridectomy. Hence, it often happens that it is not decided 
 to do the iridectomy until after delivering the lens-nucleus through 
 the round pupil. If it is seen that, in spite of persistent attempts 
 to replace the iris, the pupil draws upward after each reposition, or 
 even if it is suspected that the iris will prolapse later, iridectomy is 
 indicated. Because of these precautions the reported percentage of 
 prolapse of the iris on the day following the operation is comparatively 
 small. It occurred in 8 per cent, of my patients, of which about one- 
 third were operated without iridectomy, and it must be understood that 
 among this 8 per cent, there are included all those cases in which the 
 pupil was not absolutely round, but only slightly oval-shaped, without 
 a real prolapse in the wound. 
 
 The opening of the capsule may be difficult in patients with narrow 
 pupils, and in such cases it is advisable to use the small tenaculum 
 instead of the forceps. A narrow pupil is often a marked impediment 
 in the delivery of the lens, especially if the nucleus is large. The opera- 
 tor must decide whether or not the lens can be delivered through the 
 pupil without the use of too strong pressure, and if not, perform an 
 iridectomy rather than risk a prolapse of the vitreous by exerting 
 excessive force. 
 
 The assistant can facilitate the removal of the lens when the iris 
 is stretched ovsr the protruding nucleus by attempting to push it over 
 its edge at its pupillary margin with the spatula. The resistance of 
 the sphincter, which is particularly rigid in the iris of old persons, is 
 sometimes considerable. The sphincter is occasionally torn when the
 
 EXTRACTION OF SENILE CATARACT. 1 57 
 
 lens pushes through, and it is then better to perform an iridectomy, 
 since the relaxed and lacerated pupil fails to retain its normal position 
 and becomes irregular through retraction of the margin of the tear. 
 If a prolapse of the vitreous occurs during the operation, an iridectomy 
 is then usually impossible, and the lens should be delivered with the 
 loop or the double tenaculum, in the manner already described. The 
 iris in the region of the incision is turned backward and it is only 
 \vhen the vitreous floats it into the wound, that the surgeon is in a posi- 
 tion to excise a portion which should be as large as possible. 
 
 The removal of the cortical substance is more difficult in the 
 simple than in the combined extraction. If during the expression of 
 the nucleus, the pupil has been pulled upward and the iris presents in 
 the wound, it is advisable to massage the soft remaining particles of 
 the cortex out of the eye, as in this way only can success attend subse- 
 quent efforts to replace the iris. Once the pupil has regained its round 
 contour, massage carries the lens-particles upward behind the iris, 
 without bringing them out of the eye. Individual flakes contained 
 within the pupillary space can be removed with the Daviel spoon. 
 
 The incision for simple extraction does not differ from that of 
 the ordinary combined operation, but, here in particular, it should be 
 the endeavor to make it exactly at the limbus. 
 
 After the operation it is customary to instill eserin into the eye, 
 without, however, considering it of any great value. If, on the day 
 following the operation, the pupil is not perfectly round, the wound 
 is re-opened after thorough cocainization, and the iris resected; this is 
 done even if the iris does not lie directly in the wound. In case of true 
 iris-prolapse, iridectomy is a foregone conclusion. If the anterior 
 chamber is re-established on the second day and the pupil round, the 
 further use of eserin is quite unnecessary. If the eye is irritated, atropin 
 may be employed as early as the second day. 
 
 Excision of the prolapsed iris is usually difficult, as the irritated 
 eye cannot be made sufficiently insensitive by the cocain. The con- 
 sequent wincing of the patient renders very likely prolapse of the vitre- 
 ous. If the wound has re-opened with a conical probe, the operator 
 should drop cocain directly on the exposed iris. After excising a 
 piece of the iris, it is often an easy matter to stroke lens remnants out 
 of the eye, which on the previous day could not be removed. Replace- 
 ment of such prolapsed iris, without excising a portion, should not be 
 considered, as in all probability the prolapse would recur.
 
 CHAPTER XIII. 
 DISCISSION, OPTICAL IRIDECTOMY. 
 
 DISCISSION. 
 
 Under this heading are included i, the incision of the anterior 
 lens-capsule (the lens being either cloudy or transparent), and 2, 
 the cutting of the secondary cataracts. For the performance of this 
 
 FIG. 88. Discission through the cornea. Diagram showing how the vertical incision 
 is made in discission through the capsule of the lens. The handle of the needle is lowered, 
 thus bringing its point into such a position (a) that it lies near the upper margin of the pupil. 
 Next, while the needle inclines to the plane of the lens-capsule at an angle of about 45 
 degrees, the handle is elevated from (a) to (b), thus making a vertical incision through the 
 capsule. 
 
 operation discission-needles are employed, which are small knives 
 with convex and concave cutting edges. The incision may be made 
 either through the cornea or the sclera, and each operative procedure 
 will be considered separately. 
 
 Discission through the Cornea (Figs. 88 and 89). After the 
 pupil has been dilated with atropin, the eyeball is fixed and the 
 
 158
 
 DISCISSIOX, OPTICAL IRIDECTOMY. 159 
 
 cornea pierced on the outer side near the limbus. The operation 
 on the right eye is best performed with the left hand, and on the left 
 eye with the right hand, the operator in each instance sitting to the 
 right of the patient. The dilatation of the pupil is intended not 
 only to expose the anterior lens-capsule as much as possible, but 
 particularly to protect the iris from injury. 
 
 The needle is held between the thumb and the first and second 
 
 FIG. 89. The eye is fixed below at the limbus by means of forceps. With the discission 
 needle held in the right hand, when the left eye is operated on, the cornea is perforated at 
 the limbus, and a horizontal incision is then performed through the anterior lens-capsule. 
 
 fingers, while its handle rests upon the base phalanx of the fore- 
 finger. After perforating the cornea in about the horizontal merid- 
 ian, the knife-point is pushed forward and upward, until it reaches 
 the upper margin of the pupil. Using the corneal perforation as the 
 rotating point, the handle of the instrument is moved from below 
 upward, describing an arc of about 90 degrees, and held so, that its
 
 l6o OPHTHALMIC SURGERY. 
 
 long axis is inclined to the plane of the lens-capsule at about an angle 
 of 45 degrees. In this way the point of the knife-needle makes an 
 incision into the capsule from above downward, cutting through 
 the lens-substance obliquely (Fig. 88). After completing the verti- 
 cal capsular opening, the point of the instrument is brought back 
 in the anterior chamber by depressing the handle, and approached to 
 the inner margin of the pupil. Starting from an almost horizontal 
 position of the needle, the handle of the instrument is elevated now 
 through an arc of about 45 degrees, the corneal perforation being 
 utilized again as a fulcrum. Through this maneuver the point of 
 the needle describes a small arc and makes a horizontal incision 
 in the anterior capsule of the lens (Fig. 89). In order that the point 
 does not sink too deeply and injure the posterior capsule, the needle 
 is withdrawn slightly while making the cut and finally quickly pulled 
 out of the eye. 
 
 The most important precaution in the operation is to avoid injuring 
 the posterior capsule of the lens. This accident may result from 
 introducing the needle too deeply, and directing it too perpendicularly. 
 On that account the needle should be made to glide obliquely through 
 the substance of the lens during the vertical incision, and be drawn out 
 of the eye during the horizontal incision. If the instrument is inserted 
 too perpendicularly, a perforation of the posterior lens-capsule readily 
 occurs. 
 
 The opening in the anterior chamber may be made either in the 
 outer part of the cornea or in the limbus itself or even beyond it in the 
 sclera. In entering through the sclera the needle is pushed forward 
 slightly under the bulbar conjunctiva before the perforation is com- 
 pleted. This produces immediate closure of the perforation-wound, 
 as the opening in the conjunctiva and that in the eyeball occupy 
 different positions. However, entering the knife through the cornea 
 is preferable in those cases in which, because of a shallow anterior 
 chamber or a pupil which has remained small in spite of atropin, an 
 injury to the iris is to be feared if a peripheral incision is made. 
 
 As for opening in the capsule we prefer a crucial incision, because 
 a permanent opening is thereby assured. The four flaps retract, so 
 that a healing of the wound in the capsule is absolutely prevented. If 
 only a single incision is made, closure of the wound not infrequently 
 occurs. On the other hand more than two incisions are superfluous. 
 
 The aqueous humor should not be allowed to escape during
 
 DISCISSIOX, OPTICAL IRIDECTOMY. l6l 
 
 the operation. On this account, the needle must be quickly with- 
 drawn from the eye. Through the escape of the aqueous humor, 
 adhesion of the iris to the place of perforation may develop, thus leading 
 to the formation of an anterior synechia. 
 
 Discission of a transparent lens is only undertaken in high-grade 
 myopia, for the purpose of completely removing the lens. The imme- 
 diate consequence of discission is, of course, a traumatic cataract. 
 The rapidity with which this forms depends chiefly upon the size of the 
 capsular wound. If only a single cut has been made, the opacity 
 not infrequently remains limited to the tissue immediately surrounding 
 it as the capsular wound may close in the meantime. Therefore, if 
 after a few days, the cataract should make no progress, it is best to 
 repeat the discission, and to incise the capsule of the lens more 
 freely. If the anterior lens-capsule is opened sufficiently, there is 
 not only a total opacity of the lens quickly produced, but also a swelling 
 of the lenticular substance which soon fills the anterior chamber. 
 
 The swollen lens-substance is rather slow in being absorbed and many 
 weeks may be required, during which the eye is in a state of constant 
 irritation. Hence, we prefer after about fourteen days, by which 
 time the entire lens has become opaque and soft, to remove the masses 
 from the eye by an incision made with the lancet at the lower corneal 
 margin (analogous to linear extraction). Provided the posterior lens- 
 capsule has not been injured by the discission, this trifling operation 
 is performed without accident, especially as an incision 5 mm. long 
 usually suffices. If, however, the posterior lens-capsule has been 
 injured in performing the discission, prolapse of the vitreous body 
 into the wound is the immediate consequence. This, of course, makes 
 impossible the massaging of the soft lenticular masses from the eye, 
 as more vitreous would be squeezed out. The iris is likewise dis- 
 placed from its proper position by the vitreous and remains perma- 
 nently distorted. For the foregoing reasons the operator should be 
 particular not to injure the posterior lens-capsule. 
 
 During the period of swelling of the lens, the pupil must be kept 
 widely dilated by atropin. The development of the cataract is suffi- 
 cient in itself to setup a state of intense irritation and ciliary hyperemia; 
 and atropin is necessary, not only to hinder the formation of posterior 
 synechia, but to freely and constantly expose the capsular wound and 
 prevent incarceration of the swelling lens-substance in the narrowing 
 pupil, which would soon terminate in increase of pressure. The
 
 1 62 OPHTHALMIC SURGERY. 
 
 latter, moreover, not infrequently follows the swelling of the lens after 
 discission, and especially when the incisions are free so that the swelling 
 takes place rapidly. If the tension increases and the pupil is not 
 dilated sufficiently, it should be our first task to open the pupil as 
 much as possible by thorough cocainization followed by the application 
 of dry atropin, and at the same time apply iced compresses to the closed 
 lids which exercise a beneficial influence. If the pupil is sufficiently 
 dilated, we must not instill miotics with the hope of decreasing pressure. 
 If the glaucoma does not disappear within 24 hours and at the same 
 time is considerable, a puncture of the anterior chamber will remove 
 it permanently, by which we try to get out as much of the swollen lens 
 as possible, as previously described. 
 
 The indications for the operation in high-grade myopia are 
 as follows: 
 
 1. The degree of myopia must be more than 16 diopters; if patients 
 with less myopia are operated on, they will require after operation 
 convex glasses for distance vision and still stronger lenses for near 
 vision. The difference in the refraction produced by the removal 
 of the lens in myopia amounts to nearly 20 diopters on an average, as 
 against 10 diopters in normal eyes. 
 
 2. The visual acuity of the eye to be operated upon must not have 
 suffered too severely through intraocular changes and must at least 
 be one-sixth to one-quarter of the normal and not seriously disturbed 
 by a central scotoma. 
 
 3. The patient's othef eye must still be useful, that is, it must not 
 have suffered detachment of the retina, severe chorioiditic processes, 
 or other diseases. 
 
 4. The operation is limited to patients under forty years of age. 
 Narrowing the foregoing indications down to these limits, the results 
 
 obtained by the operation are on an average good. It is of the greatest 
 importance to guard against injuring the vitreous during the 
 operative procedures. It must be remembered that in high myopia 
 the vitreous shows a marked tendency to become diseased. But it 
 becomes frequently impossible to leave this humor permanently undis- 
 turbed. While it is the duty of the operator not to injure the vitreous 
 in performing discission of the transparent lens, it often happens that, 
 after the removal of the lens, a secondary cataract develops through 
 subsequent thickening of the capsule of the lens, which makes further 
 operations necessary. Naturally this cannot be done without injury
 
 DISCISSION, OPTICAL IRIDECTOMY. 163 
 
 to the vitreous. There is no doubt that eyes operated upon for 
 myopia are especially prone to develop detachment of the retina, and 
 the patient's attention should be called to all the possibilities of disaster 
 before the operation, and especially should it be stated that the oper- 
 ation is no guarantee against the serious intraocular changes that 
 usually occur sooner or later as a consequence of the high grade myopia. 
 
 Discission is also used for the removal of partial cataract. In 
 this latter variety, besides discission for removal of the lens, optical 
 iridectomy must also be considered. 
 
 Discission for the Removal of Totally Opaque Lenses. In 
 congenital total cataract, discission is the only safe operation. Linear 
 extraction is recommended only in patients of relatively advanced 
 age and considerable intelligence, so they may be relied upon to remain 
 quiet during and after the operation. On that account, in children 
 we are accustomed to perform discission, as no extreme precautionary 
 measures are demanded and there is ample time to wait until spon- 
 taneous absorption of the lens has taken place. The latter progresses 
 usually promptly and completely in young patients. Occasionally 
 it may be necessary to perform discission a second or even third time. 
 Not infrequently after discission of even shrunken cataracts in children, 
 an increase in intraocular pressure develops, which usually dis- 
 appears, however, within a few days by the use of eserin and cold 
 compresses. Only in rare instances will puncture of the cornea be 
 necessary and the incision should not be longer than 2 millimeters at 
 the most, so that danger of prolapse of the iris may be excluded. 
 
 As already noted, in some cases of congenital complete cataract 
 in children, there is a greatly shrunken lens, so that in the course of 
 discission after dividing the membrane, which consists of the anterior 
 and posterior capsule with remains of slightly clouded lens, a black 
 space immediately makes its appearance. 
 
 In total cataract of young adults the operation giving the most 
 rapid results is linear extraction. We usually employ it in patients 
 over the age of 12, but even in these cases discission followed even- 
 tually by puncture of the anterior chamber may be given pref- 
 erence. As the cataract in such eyes is often a complicated one, it 
 may happen that the fluid vitreous escapes from the wound as soon 
 as the incision has been made with the lancet. In this event a supple- 
 mentary discission of the capsule of the lens must suffice, as it would 
 be impossible to remove by massage the lens-masses from the eye.
 
 164 OPHTHALMIC SURGERY. 
 
 OPTICAL IRIDECTOMY. 
 
 The indications for optical iridectomy are as follows: In 
 
 soft lenses, with perinuclear opacities which only slightly interfere with 
 visual acuity, it is best not to operate at all. In all other cases the 
 tests should be made with the ordinary size of the pupil and afterward 
 with fully dilated pupil. If the vision is improved by the dilatation 
 of the pupil in cases in which the diameter of the central disc-shaped 
 cataract is a small one and is brought to a degree suitable for the 
 necessities of the individual concerned, i.e., at least a third of the 
 normal acuity, this degree of sight can be obtained permanently by an 
 optical iridectomy, whereby the patient has the advantage of still 
 possessing the lens and with it the power of accomodation. In such 
 case, the coloboma is best made below and to the inner side. 
 
 If, however, the improvement in vision following dilatation of the 
 pupil is not sufficient, discission of the cataract is indicated. By 
 this means the opacity can be completely removed, and the visual 
 power returned to its normal range. The patient, of course, is forced 
 to wear permanently strong convex glasses. In the greater number 
 of cases of perinuclear cataract the latter operation is indicated, and 
 in a much smaller number, iridectomy. The objection made against 
 iridectomy that the cataract will probably become progressive and 
 lead to total opacity of the lens, thus rendering the operation value- 
 less, is, however, not sustained. 
 
 The technic of optical iridectomy differs from that of iridec- 
 tomy for glaucoma not only in the method of incision but also in the 
 type of excision of the iris. As the purpose of optical iridectomy 
 is to alter the position of the pupil slightly, only that portion of the 
 iris which borders on the pupillary margin should be excised. As the 
 periphery of the iris must be preserved for optical reasons, the incision 
 is placed in the limbus or a little to its inner side in the cornea. Other- 
 wise, essentially the same details are followed as in iridectomy for 
 glaucoma. The incision is made with the lancet, except in cases in 
 which a shallow anterior chamber, for example, one the result of an 
 anterior synechia, makes the use of the Graefe knife necessary. When- 
 ever possible, the coloboma is placed to the inner and lower side, as 
 experience shows that this position gives the best optical results. 
 Very often, however, another portion of the cornea must be selected, 
 as the remainder of the corneal surface has lost its transparency 
 because of extensive opacities. Of course, it is readily understood
 
 DISCISSIOX, OPTICAL IRIDECTOMY. 165 
 
 thai care must be taken that the coloboma is not entirely covered 
 by the upper lid. If in a one-eyed individual only the part of the 
 cornea covered by the upper lid remains transparent and is suitable 
 for an optical iridectomy, nothing remains but to produce a per- 
 manent depression of the eyeball by tenotomizing the superior rectus, 
 so that the coloboma will lie uncovered in the palpebral fissure. 
 
 The iris is withdrawn with the forceps in the same manner as pre- 
 viously described. It is sufficient, however, to draw out the smallest 
 possible fold and to cut off the tip with the blades of the de Wecker's 
 scissors held perpendicular to the corneal incision. In this manner, 
 a coloboma limited to the central part of the iris is produced, which at 
 once enlarges considerably by retraction of its margins. 
 
 Precorneal iridotomy is an operation to obtain a smaller coloboma. 
 In this operation, after the lancet-incision has been made, the iris is 
 seized at its pupillary margin and drawn out of the wound. A 
 small radial incision is made in the pupillary margin, after which 
 the iris is replaced. As both ends of the sphincter retract, the cut 
 turns into a coloboma of such a size that it is nearly impossible to 
 recognize whe her it has been produced by an iridotomy or an iridec- 
 tomy. As, however, this precorneal operative method has undoubted 
 disadvantages, the most important of w-hich is the surgical un- 
 cleanness of the procedure, namely, replacing the iris lying in the 
 conjunctival sac into the eye, the regular iridectomy is decidedly 
 preferable. 
 
 The ideal indication for an optical iridectomy is when corneal 
 scars cover the center of the pupillary area. In order that we should 
 not be disappointed by the actual results of an optical iridectomy, 
 a careful examination of the cornea with the magnifying lens, to 
 ascertain the condition of the so-called transparent parts of the cornea, 
 is particularly demanded. Delicate diffuse opacities will frequently 
 be found in those portions which were judged to be of perfectly normal 
 transparency when examined with the naked eye. Not until the 
 iridectomy is completed, are the corneal opacities easily visible against 
 the black background, and they then often seem quite intense, while 
 previously they entirely escaped the notice of the less careful observer. 
 In making an examination with the magnifying lens, not only those 
 portions of the cornea must be looked for which are at the same 
 time the most central and transparent, but also we- must take into 
 consideration the areas where the opacity contrasts most sharply with
 
 1 66 OPHTHALMIC SURGERY. 
 
 the surrounding parts. The sharper the margin, the denser the 
 opacity; the broader the remaining transparent border, the better the 
 outlook for a good result. 
 
 Recourse to an optical iridectomy should not be had too early in 
 cases of corneal opacity. Opacities resulting from deep-seated kerat- 
 itis, especially after parenchymatous keratitis in young people, often 
 clear up slowly after many months. On the other hand, not much 
 clearing up of scars after severe ulcerative processes in adults, should 
 be expected. The cases particularly suitable for an optical iridectomy 
 are those in which the opacity has resulted from a \vell-circumscribed 
 area of disease (especially from ulcus serpens, infected wounds, etc.) 
 while the rest of the cornea has remained approximately well. Con- 
 ditions for a good result are much less favorable when the opacities 
 have resulted from deep corneal inflammations, because the cornea is 
 usually so affected that delicate, grayish, indefinite areas are found 
 throughout its entire surface. The optical iridectomy, therefore, 
 improves the vision but little, even when the pupillary area of the 
 cornea is affected by a rather dense opacity. It must be remembered 
 that the diffuse haziness of the peripheral portion of the cornea often 
 causes marked disturbance of vision. 
 
 In any event, an exact determination of the visual acuity after 
 painstaking correction of the errors of refraction (especially astig- 
 matism) by the use of the stenopaeic disk is necessary. For this pur- 
 pose, Fritsch, of Vienna, has constructed a movable stenopaeic disk, 
 which may not only be placed into the various meridians by merely 
 turning it, but can be easily shifted into a horizontal and vertical 
 position. At the same time it is lodged in such a frame that it can 
 readily be adjusted to any pair of spectacles. As often only a certain 
 definite position of the slit gives the patient a substantial improve- 
 ment in vision, the ordinary examination, with the trial frame com- 
 monly found in the test-case, does not serve the purpose. The tests 
 with the disk should be carried out by adjusting it to the glasses which 
 the patient is constantly wearing. For this purpose, we determine 
 first as well as possible on the naked eye of the patient, the lens that 
 gives him relatively the best vision for near work and for distance. 
 Not until the patient has received the prescribed lenses from the 
 optician, is the position of the stenopaeic slit determined by attaching 
 the instrument to them. The position in which the optician has to 
 place the stenopeic slit on the glasses, is then readily decided. This
 
 DISCISSION, OPTICAL IRIDECTO.MY. 167 
 
 accurate procedure is of the greatest importance, especially for those 
 patients who are dependent upon one eye. The improvements 
 occasionally produced by application of the stenopaeic disk are quite 
 marked, and not infrequently the vision can be increased from finger- 
 counting at 2 meters to 6/24 or 6/18, thus making possible reading 
 and writing. 
 
 As already stated optical iridectomy is usually performed in cases 
 with dense central corneal opacities rather sharply defined from 
 surrounding healthy cornea. Before deciding on the operation we 
 must first determine provisionally the effect of an optical iridectomy 
 by dilating the pupil with atropin. Artificial mydriasis, however, 
 cannot be exactly compared to that produced by an optical iridectomy, 
 as atropin dilates the pupil symmetrically; but the operator learns 
 from such an examination that in complete absence of improvement 
 from uncovering a portion of the pupil behind a less clouded part of 
 the cornea, a satisfactory result cannot be expected from an optical 
 iridectomy. Moreover, if the patient's vision is lessened by dilatation 
 of the pupil, a permanent reduction in his sight will follow by per- 
 forming an optical iridectomy, as it is just in such cases that the impair- 
 ment of the sight is dependent upon the irregular diffusion of the 
 rays of light. It happens not infrequently that persons with diffuse 
 corneal opacities see much better with a contracted pupil (comparable 
 to a stenopaeic disk), than with the pupillary orifice widened. 
 
 Frequently, also, it is necessary to decide whether it is not possible 
 to improve the vision by tattooing of the cornea, with or without 
 subsequent iridectomy. In such cases it is recommended to tattoo 
 the corneal scars provisionally as it were, by applying a piece of fine 
 silk paper, absolutely black in color and cut as to exactly fit the opacity 
 in the cornea. This paper adheres readily and makes possible a test 
 of the visual power for comparison with the earlier test. In order that 
 the piece of paper can be applied, the cornea should be rendered 
 anesthetic by the use of alypin, which unlike cocain has no influence 
 on the pupil, so that there is no artificial dilatation to interfere with the 
 examination. 
 
 On the whole the results of optical iridectomy in corneal opacity 
 are only mcderate, and the cases suitable for the performance of this 
 operation are relatively few. The bcncficient clearing effect on 
 corneal opacities which has been ascribed to iridectomy depends prob- 
 ably only upon a delusion, occasioned in eyes in which surgical inter-
 
 1 68 OPHTHALMIC SURGERY. 
 
 ference was undertaken too early. Optical iridectomy gives much 
 more favorable results in central lenticular opacity, that is, large 
 central capsular cataract and especially in large lamellar cataract 
 in which the opacity is sharply defined and has a small diameter. 
 
 Exudates, such as the connective-tissue membranes in the pupillary 
 area following iritis, also afford an indication for optical iridectomy. 
 Of course, due consideration must be given to the usually existing 
 adhesions of the iris to the capsule of the lens resulting from the iritis, 
 and a broader iridectomy performed in order to prevent a later rise 
 in pressure. It must also be remembered that the result can be 
 nullified by the pigmented layer of the iris-membrane adhering to the 
 capsule of the lens and covering the coloboma.
 
 CHAPTER XIV. 
 
 SECONDARY CATARACT. IRIDOTOMY. LINEAR 
 EXTRACTION. 
 
 DISCISSION IN SECONDARY CATARACT. 
 
 As a secondary cataract forms the only septum between the aqueous 
 and the vitreous chambers, discission cannot be performed without 
 some injury to the vitreous, which always should be as little as possible. 
 In other details the operation is done in the same manner as already 
 described, and here also the pupil must first be widely dilated by 
 atropin; a good side illumination from the lamp is important, especially 
 in those cases with a glassy membrane in which the pupil occasionally 
 appears quite black. If after the first incision a free space is noted at 
 once, the needle must be withdrawn. Only when the first cut is with- 
 out result is a second or third made in different directions, never 
 penetrating the vitreous body deeply. 
 
 Complications. If the pupil is held by posterior synechia, so that 
 dilatation by atropin is impossible, the operation becomes somewhat 
 more difficult, although an injury to the iris can be averted in conse- 
 quence of the great depth of the anterior chamber. 
 
 If the membrane is tough, and has become adherent to the margin 
 of the pupil, it may evade the needle and be pushed back under marked 
 pulling of the iris, even producing laceration into the attachment of 
 the iris (iridodialysis) ; or it gives way to the knife by detaching itself 
 from the iris at one point and becomes pressed backward like a lid, 
 returning quickly to its original position in the pupil when the needle 
 is drawn forward, so that the result of the operation is frustrated. 
 
 If we fail to incise the membrane, it is useless to repeat the foregoing 
 maneuvers, but resort should be had to a discission with two needles 
 (Bowman). In this procedure one needle is introduced from the 
 outer and the other from the inner side of the cornea, the needles 
 crossing so that the point of the former lies near the inner margin of 
 the pupil, and that of the latter near the outer margin. By raising 
 the handles, the needles are moved in opposite directions and accom- 
 plish a tearing asunder (dilaceration) of the membrane. Combined 
 
 169
 
 170 
 
 OPHTHALMIC SURGERY. 
 
 discission with one needle entered through the cornea and the other 
 through the sclera may also be of advantage. 
 
 The operation with the needle is suited for cases in which the second- 
 ary cataract consists only of the capsule and the remnants of the lens. 
 But if the membrane contains a layer of connective-tissue, following 
 an iridocyclitis after a cataract-extraction, the needle is not sufficiently 
 strong to freely divide it. In such cases it must be replaced by the 
 v. Graefe's knife and the operation is then called capsulotomy, or, 
 if at the same time some iris must be cut into, iridotomy. 
 
 FIG. 90. Iridotomy. The pupil is displaced upward by the scar resulting from the 
 cataract operation, and is obstructed by a membrane. The patient is looking well upward ; 
 the eye is fixed at the side. The von Graefe knife, directed obliquely upward, is introduced 
 into the cornea in the vertical meridian rather close to the lower limbus; the edge of the 
 knife is directed backward. 
 
 The application of iridotomy may best be illustrated by a typical 
 case. If, after an extraction with loss of vitreous, the pupil is drawn 
 upward into the region of the dense scar and closed by a membrane 
 consequent upon an iritis, the accompanying picture (Fig. 90) may 
 be seen. Before any operative procedures are undertaken, it is 
 necessary to make sure of gocd light-perception and projection, 
 and also to wait until the inflammation of the eye has completely 
 subsided and the irritation of the eyeball, manifested by the 
 appearance of mild ciliary injection, is no longer occasioned. The
 
 SECONDARY CATARACT. IRIDOTOMY. 171 
 
 contemplated operation must accomplish two purposes, namely, to clear 
 the pupil and to alter its position, so that it will come to lie behind the 
 center of the cornea. It is not sufficient, therefore, to simply cut the 
 membrane in the pupil, but the incision must extend through the iris 
 and the dense fibrous membrane which lies behind it. For this 
 purpose the cornea is penetrated below by a sharp Graefe's knife, the 
 cutting edge of which is backward while the point is directed upward 
 toward the pupil A vertical incision (Fig. 91). from above down- 
 ward is made through the pupillary membrane and the 
 iris, producing a vertical fissure which extends to . 
 below the center of the cornea. Only a very sharp 
 knife will divide the membrane without pulling on 
 the iris. Iridc dialysis may occur if the membrane ^ n mdotom y!' 
 together with the attached iris evades the knife and is 
 pressed backward. It is frequently observed that the dense membrane 
 is readily divided, while the delicate tissue of the iris escapes the 
 knife, resisting all attempts to incise it. 
 
 After the incision has been completed, the knife is withdrawn and 
 pressure immediately exerted on the eye through the closed lids by 
 means of the finger, and a pressure-dressing applied at once. A 
 firm bandage is of the greatest importance in preventing hemor- 
 rhage, which can occur not only from the cut vessels of the iris, if the 
 latter has been incised, but also from division of the newly formed 
 vessels found in the dense fibrous secondary membrane. Such hemor- 
 rhage would make the entire result of the operation doubtful and in 
 most cases render it worthless. From extensive experience we know 
 how difficult of absorption is a hemorrhage in the anterior chamber 
 in eyes affected by a chronic iridocyclitis. If after many weeks the 
 blood gradually disappears, it will usually be found that the clear 
 space obtained by the operation is again closed by a fibrous membrane 
 formed by organization of the clot. We are accustomed to remove 
 the pressure bandage after six to eight hours, and to replace it by an 
 ordinary protective dressing. By this time a sufficient closure of the 
 injured vessels has taken place, and a secondary hemorrhage need not be 
 feared. The many published bad results of the iridotomy just de- 
 scribed, can usually be traced to neglect of the proper procedures for 
 the prevention of hemorrhage. 
 
 The depth of the anterior chamber is not decreased by iridotomy, 
 and a prolapse of the vitreous is impossible. The dressing may be
 
 172 OPHTHALMIC SURGERY. 
 
 removed as early as the day after operation, and rest in bed is not 
 necessary. Provided that no serious intraocular conditions exist 
 (dense vitreous opacities, retino-chorioiditic areas, etc.), vision may 
 become good. However, these complications are not infrequent, and 
 the unsatisfactory results must not be attributed to the operation. 
 
 A vertical incision gives the advantage of cutting approximately 
 parallel to the fibers of the iris without seriously injuring any of its 
 vessels. The disadvantage of making the incision in the direction of 
 the fibers of the iris arises from the fact that the cut shows no tendency 
 to gape and sometimes exists only as a fine line, which soon closes 
 completely through the accurate application of the wound-edges. 
 If a horizontal incision, running transversely to the direction of the 
 iris-fibers, is used, we are able to make it at any height desired (there- 
 fore, exactly behind the center of the cornea), and in addition produce 
 a broader gap through retraction of the iridal tissue. A horizontal 
 incision, it is true, divides many more of the blood-vessels of the iris, 
 and, therefore, the pressure-dressing must be applied to the eye with 
 special rapidity after the incision has been made. If, however, as is 
 not infrequently the case, the iris has undergone a fairly high degree 
 of atrophy, a large number of the iridal vessels will have been obliter- 
 ated and the injury to them is of but little importance. 
 
 Should the result be unsatisfactory, there is no objection to an 
 early repetition of the operation, provided that the eye is not much 
 irritated. 
 
 The foregoing method of iridotomy is the only operation we employ 
 in cases of complicated secondary cataract. Its superiority over the 
 various other operations- recommended (discission after de Wecker, 
 etc.), consists in not opening the anterior chamber thus making a loss 
 of vitreous impossible, in its greater rapidity, in the careful handling 
 accorded to the iris, and in the almost invariable satisfactory result, if 
 such an issue of the operation is at all possible. 
 
 Discission through the sclera (Fig. 92). This operation is adapted 
 only to secondary cataract. The needle should be stronger than that 
 ordinarily employed for discission through the cornea. By entering 
 through the sclera, there is the advantage of being able to use more 
 force in dividing the membrane than is possible by the operation 
 from the front. 
 
 To avoid various unpleasant complications, the perforation with 
 the needle must be made posterior to the ciliary body, that is, at a
 
 SECONDARY CATARACT. IRIDOTOMY. 
 
 173 
 
 distance of at least 6 millimeters from the limbus and either above or 
 below the horizontal meridian, so as not to injure the posterior long 
 ciliary artery. It is easier to enter at the outer and inferior side, 
 while the patient looks upward and inward, and the eye is held in this 
 
 position by forceps. The needle is directed forward and pushed 
 through the membrane in the pupil so that the point appears in the 
 anterior chamber (Fig. 92). By elevating the handle of the instrument 
 the membrane is divided. In order not to injure the vitreous more
 
 174 OPHTHALMIC SURGERY. 
 
 than is necessary, as few cuts as possible are made. If, after the first 
 cutting movement, a black space is seen to appear in the membrane, 
 the needle is quickly withdrawn from the eye. Only in case the first 
 incision fails to produce a free opening, and simply depresses the 
 membrane so that it springs back again into the pupil, must a second 
 or third attempt be made to incise it. The injury to the vitreous 
 incurred by this method is no greater than when the operation is 
 performed through the cornea. In all cases of secondary cataract, 
 injury to the vitreous cannot be absolutely avoided. A great advantage 
 of this operation is that the surgeon is able to move the needle in a 
 larger area of excursion than when the needle must be pushed through 
 the cornea into the deep anterior chamber in a perpendicular direction. 
 The latter procedure leaves very little freedom of motion to make the 
 incision. After discission through the sclera, complications such as 
 increase of intraocular pressure and cyclitis frequently occur. 
 The former usually disappears within a few days under the use of 
 eserin and cold compresses. In most cases the cyclitis is also a transient 
 phenomenon. 
 
 LINEAR EXTRACTION. 
 
 Linear extraction is an operation employed for the removal of soft 
 cataracts. The thirty-fifth year is approximately about the upper 
 age limit at which this operation can still be performed. 
 
 After dilatation of the pupil by atropin, a linear incision about 
 6 to 8 mm. long is made with the lancet below and exactly at the limbus. 
 Sitting to the right of the patient the operation is performed on the 
 right eye as well as the left with the right hand. Essentially the same 
 rules described for the iridectomy incision, are the guide in holding 
 the lancet (Fig. 93). It is first applied rather perpendicularly, and 
 as soon as the point has perforated the limbus, the blade is turned 
 parallel to the iris (Fig. 94), and without either forward or backward 
 pressure, pushed in until the incision has reached the desired length. 
 If the iris is well retracted, it is not exposed to any danger of injury. 
 As with all cuts which open the anterior chamber, the instrument must 
 not stop in its progress, otherwise escape of the aqueous humor would 
 render impossible a further lengthening of the incision. The eye is 
 held fast at any suitable point. As the operation is performed without 
 iridectomy, the point at which the eye is grasped with the forceps for 
 the purpose of fixation plays no r61e. The lancet is slowly withdrawn
 
 SECONDARY CATARACT. IRIDOTOMY. 
 
 175 
 
 from the eye so that the aqueous humor escapes gradually. At the 
 moment the anterior chamber collapses, the pupil frequently becomes 
 suddenly narrow. In other cases, however, the iris is floated into the 
 wound by the aqueous humor. 
 
 The second step of the operation consists in opening the lens- 
 
 
 Fir.. 93. Linea extraction in the right eye. The operator's left hand fixes the eye 
 with a pair of forceps, above at the limbus, while with the right hand he applies the lancet 
 almost vertically below, exactly at the limbus. The pupil is dilated by atropin. A diagram 
 showing the position of the incision in this operation may be seen in the sketch (;n glauo ma 
 (Fig. 96). 
 
 capsule. Here also we prefer the use of the capsule-forceps for the 
 reasons mentioned in Chapters XI and XII. They must be slightly 
 raised after they have entered the pupil, so that the posterior untoothed 
 part of the closed blades does not seize the iris. With a relatively short 
 incision and a narrow pupil it may be difficult to use the forceps without 
 untoward results, and the pointed tenaculum, which must always be
 
 i 7 6 
 
 OPHTHALMIC SURGERY. 
 
 at hand, is to be employed to incise the capsule several times. In 
 so doing the tenaculum must be applied without making pressure, 
 in order to avoid displacement of the lens. 
 
 3 
 
 El 
 
 ll 
 
 .<2'u 
 u c 
 c " 
 
 '" O) 
 
 The third step of the operation, the removal of the lens, is accom- 
 plished easily. If the cataract is soft, it suffices to merely depress the 
 scleral wound-margin slightly by means of the spoon, in order to
 
 SKCONDARY CATARACT. I K 1 1 >< >T< ) M Y . I 77 
 
 allow the soil mass to sli<U- out through tin- gaping wound. If. at the 
 same time, the cataract is gcntlv stroked from above downward with 
 another spoon against the eornea (Fig. 95). the escape of the lens- 
 substance will be rendered easier. Occasionally, after the pupil has 
 become black, new opaque particles appear from above and behind 
 tlie iris as the result of this gentle massaging. These must be removed 
 through the wound by further massage. 
 
 Diiliculties in the removal of the lens-substance occur only when 
 the lens unexpectedly contains a fairly large nucleus, which presses 
 against the wound and cannot be forced through safely, since- no great 
 torce dare be- used in the massaging. A rather dense nucleus may be 
 found even in young people. In these cases it is better to lengthen 
 the incision at one or both ends by means of the scissors, allowing the 
 nucleus to escape easily, rather than to run the risk of a prolapse of the 
 vitreous by applying too strong pressure. A careful replacement 
 of the iris concludes the operation. 
 
 In this type of operation care of the iris requires the most careful 
 consideration. This delicate membrane must not be- injured either 
 during the incision or in opening the capsule of the lens, nor disturbed 
 too much in massaging out of the cataractous mass with the spoon. 
 Care should also be taken to avoid injury in replacing it with the 
 sj alula. A lorn iris may give rise to most unpleasant sequehc. by 
 shrinking or by adhering to the corneal scar. If the iris has been 
 considerably injured it should be excised. The resultant coloboma 
 lying exposed in the palpebral fissure, however, causes annoying visual 
 disturbances. As the operation usuallv passes off smoothly, the 
 incision below is preferable, because the patients more readily look 
 upward, and so freely expo-e the field of operation. If performed 
 near the specified age-limit, it is better to make the corneal incision 
 above, so that in the event of a large nucleus the wound can be length- 
 ened and the iris, should it prolapse, excised. 
 
 After the operation a dressing is applied and the patient put to bed. 
 It is not nccessarv to instil e-erin as it would have no inthi'Tice. the iris 
 being under atropin. If no complications have occurred, the dressing 
 may be discarded after six days. 
 
 In old and complicated cataracts the len> capMi'.e is thickened, and 
 it may happen that the lens together with its capsule i- pulled out of 
 the eve with the cupsuk'-forceps. Occa-ionall\ such an operation is 
 performed in blind eves, but onlv for cosmetic reason-. In this
 
 1 7 8 
 
 OPHTHALMIC SURGERY. 
 
 Ml 
 
 *2 3 rf 
 
 I^e 
 
 c rt +-" 
 ?| 
 
 111 
 
 goo 
 
 ls| 
 
 XJ PO 
 
 3 
 
 . M > 
 
 rt rt o 
 
 5^ P 
 
 - ^ M 
 KO 4) -S 
 
 .S'5'g 
 
 V V cfi 
 
 p, c/) 
 
 : il 
 
 i^5 
 
 5 -^ 
 
 03 
 
 'c^
 
 SECONDARY CATARACT. IRIDOTOMY. 179 
 
 procedure there is always the danger of prolapse of the vitreous. 
 However, as the vitreous rarely has its normal consistency, but is 
 fluid and the eyeball soft, the wound shows no tendency to gape, and 
 the iris usually retains its normal position. Much more unpleasant 
 is prolapse of vitreous of normal consistency during the course of a 
 linear extraction. In this instance, not only is the further removal 
 of the soft lenticular mass prevented, but no replacement of the iris 
 can be attempted, and the pupil remains permanently distorted. 
 Moreover, the wound frequently gapes, and has its healing process 
 interfered with by the lower lid pressing against it during the ocular 
 movements. Application of a suture to produce coaptation of the 
 edges of the wound may become indispensable. 
 
 Linear extraction near the lower age-limit has already been 
 discussed.
 
 CHAPTER XV. 
 GLAUCOMA. 
 
 IRIDECTOMY. 
 
 The incision for iridectomy in glaucoma does not penetrate 
 the sclera at the limbus, but i^ mm. behind it. The line cd 
 (Fig. 96) shows the direction of the penetration of the point of the 
 knife, the lancet applied vertically to the sclera. This, however, is only 
 possible if the angle of the anterior chamber is deep. If the chamber 
 is shallow, or if the iris-root is in contact with the posterior wall of the 
 
 FIG. 96 Anterior portion of the eyeball in cross-section to demonstrate the relations in 
 position of the angle of the chamber and limbus (enlarged). The limbus reaches about 2mm. 
 further forward than is represented by the situation of the angle or the chamber, a and 
 a'; limbus. ab and a'b'; position for the incision of the extraction. Graefe's knife, which 
 in cataract incisions is inserted just at the limbus, at a, perforates the posterior wall of 
 the coi nea at b. In order that the knife shall come out exactly again at the limbus at a', 
 the counterpuncture must be begun already at b', that is, at a point which to the oper- 
 ator seems to lie about i mm. from the limbus, in the direction toward the cornea. 
 
 cornea, an injury to the iris would be unavoidable. Moreover, as in such 
 a puncture the inclination to bring the lancet into the plane of the iris 
 is very strong, it is recommended not to apply it too vertically against 
 the sclera when making the puncture. 
 
 The Incision with the Lancet. As it is the intention to extirpate 
 the iris at its ciliary attachment the incision must lie in the sclera at 
 a distance of about i to IY mm. from the limbus, the instrument being 
 carried through the angle of the anterior chamber, the relations of which, 
 
 1 80
 
 GLAUCOMA. 
 
 iSl 
 
 as pointed out in the operation for cataract, render clear the situation 
 of the scleral incision. If, therefore, the incision is made with the 
 lancet, its point must be placed against the sclera at the distance 
 named, the blade forming an angle of about 45 to the curving of the 
 sclera (Fig. 97). The lancet is held in the right hand between the 
 
 FIG. 97. Iridectomy for glaucoma in the left eye. Beginning of the incision. The 
 assistant fixes the upper lid with one finger of his right hand in such a manner that the 
 operator is not interfered with in the second act of the incision, when the position of the 
 lancet is changed. The lancet is applied slantingly against the sclera at a distance of at 
 least i mm. 
 
 thumb and first and second fingers, while the little finger is steadied 
 against the head of the patient, the operator sitting on the right side 
 of the patient. The eyeball is fixed below, exactly in the vertical 
 meridian, as in the operation for cataract, so that the coloboma is 
 directed upward. An undesirable laterally situated cut and correspond-
 
 182 
 
 OPHTHALMIC SURGERY. 
 
 ing coloboma is the result of rotation of the eye if the forceps holds 
 the ball at the side. The patient himself should look well down- 
 ward during the incision. . In the slanting position the point of the 
 lancet is made to penetrate the sclera. 
 
 Immediately after the perforation the lancet is turned so that the 
 
 FIG. 98. The position of the lancet is changed to the plane of the iris and is held so 
 that the incision on all sides has the same distance from the limbus. The lancet penetrates 
 further downward, than is shown in the figure. 
 
 surface of the blade is parallel with the iris (Fig. 98). The turning of 
 the lancet at the proper time is the most difficult part of the incision, 
 and can be told only by the sense of touch, as after completion of the 
 perforation the resistance of the ocular tunics disappears. If the 
 direction of the knife is changed too soon, the cut is made irregularly,
 
 GLAUCOMA. 183 
 
 and, what is still worse, placed too far forward into the cornea, and the 
 internal opening, instead of being placed into the angle of the chamber, 
 is found nearer the cornea. After the knife enters the eye, and its 
 surface is parallel with the iris, it is pushed downward without inter- 
 ruption, until the point passes the lower border of the pupil, and the 
 cut is as large as needed (Fig. 100). In this maneuver the point of 
 the lancet naturally approaches near to the posterior surface of the 
 cornea. During the incision the lancet must not be pressed back- 
 ward against the sclera, as the wound will gape and the aqueous 
 humor flow away, thus making prolongation of the incision impossible, 
 as through it the iris and lens would most likely be injured. As in 
 all other incisions which open the anterior chamber, 
 any withdrawal of the instrument while making the 
 cut is absolutely forbidden, as this would frustrate 
 the further progress through the escape of the 
 aqueous. 
 
 The incision must be made parallel to the limbus. 
 (Fig. 99 ab}. For this purpose the lancet itself 
 must be held parallel to the same. If, for ex 
 ample, one edge of the knife is turned slightly for- The solid line ab de- 
 
 , ,,. ., .,, . , notes the position of 
 
 ward, the cut on this side will not remain at the t h e cut. 
 same distance from the limbus at which the point 
 of the lancet was first placed, but will deviate forward into the cornea. 
 Indeed, the difficulty of the incision with the lancet lies in the fact 
 that the eye of the operator must at the same time control the point of 
 the instrument penetrating more and more downward, and also the 
 appearance of the cut above at the limbus. When the lancet has 
 entered far enough downward, and the incision, therefore, has been 
 made long enough, the instrument is slowly withdrawn from the eye, 
 with the blade parallel to the iris. 
 
 Especially the point must on no account be turned backward, as other- 
 wise the lens-capsule will be injured while passing the pupil. One 
 can avoid the latter altogether by a slight sideward movement of the 
 point of the lancet and thus carry it upward in front of the iris. In 
 withdrawing the lancet we do not increase the length of the incision, 
 as practised by some operators, by pushing the lancet somewhat forward 
 along the side of the limbus. During the withdrawal of the knife the 
 aqueous humor may rapidly escape, and float the iris forward with it, 
 or the flow may be slow; the pupil then remains round.
 
 184 OPHTHALMIC SURGERY. 
 
 The Incision with the Graefe Knife. 
 
 As regards fixation of the eye and the employment of the right or 
 left hand, the same rules apply as in the operation for cataract, the 
 operator sitting at the right side of the patient. Only on the right eye, 
 if the anterior chamber is very shallow, it may be preferable to operate 
 from behind, as in this position the right hand can be steadied on the 
 head of the patient better than the left when operating from the front. 
 The length of the incision should be the same as when the lancet is 
 used, about 8 mm. To obtain a sufficiently peripheral position, the 
 knife-point is entered in the sclera at a distance of ii mm. from the 
 limbus. It is passed through the sclera approximately parallel to the 
 plane of the iris. If held more upright against the sclera, an injury to 
 the iris, and indeed even to the lens, is easily incurred. After the point 
 of the knife has appeared in the angle of the chamber, the instrument is 
 pushed forward to the outermost part of the opposite angle, always 
 remaining in front of the iris to avoid the pupil, and the counterpuncture 
 is made ii mm. from the limbus. The knife is carried upward with a 
 sawing motion, during which it is held in a plane parallel with the iris, 
 so that the incision remains at a uniform distance from the limbus 
 throughout. Not until the knife has arrived beneath the conjunctiva, 
 is its cutting edge turned forward to form the short conjunctival flap, 
 as in the cataract-operation. 
 
 The incision must be made with the Graefe knife : i. If the an- 
 terior chamber is very shallow. 2. If the pupil is dilated. 3. If the 
 cornea is so opaque as to prevent the operator's view of the path of the 
 knife. 4. In restless patients. Before an iridectomy for glaucoma the 
 pupil should be contracted as much as possible by energetic use of eserin, 
 which, however, is often without effect when the pressure is consider- 
 ably increased and advanced atrophy of the iris is present. Alypin 
 is used for anesthetization, instead of cocain, because the former pro- 
 duces no dilatation of the pupil. The lack of vaso-constrictor influence 
 can be remedied by the stimultaneous administration of adrenalin. 
 
 The incision with the lancet has the advantage that its edges are 
 smooth and easily apposed, so that after a few days the wound has closed 
 faultlessly, in fact, the scar is often scarcely visible. The incision 
 with the knife is more inclined to gape, and, on account of its irregular 
 edges, does not heal so promptly. But this factor may be considered 
 as an advantage in eyes with an increase of pressure, inasmuch as 
 fluid will ooze out more easily and for a longer time through a wound
 
 \vhich does not close rapidly than through one \vhich heals promptly 
 and solidly. 
 
 There are a number of important disadvantages of the incision 
 with the lancet. The lancet is an extraordinarily sensitive instru- 
 ment. The previously faultless point may be injured even by simple 
 boiling. Much pressure is not permissible while perforating the sclera 
 with the lancet. A good cutting point glides easily into the sclera 
 without much resistance. If. however, the point is slightly bent or not 
 sufficiently sharp, it would be a mistake to try to make the perforation 
 with force. For, at the moment when the damaged point has penetrated, 
 and the good cutting lateral portions of the instrument are engaged, the 
 instrument suddenly slips forward and injury to the iri> and lens is 
 scarcely avoidable. The same accident may take place also while 
 making the incision with the lancet, when a nervous patient suddenly 
 makes a brisk movement with the eye or head. The knife is undoubt- 
 edly much less dangerous, especially for the beginner, and a more peri- 
 pheral position is more easily attained with it than with the lancet. 
 On this account the lancet is only used in those cases in which the 
 anterior chamber is not too shallow, and those with a cor.tracted pupil, 
 when quiet behavior of the patient is probable. 
 
 \Yhile the performance of the incision with the knife lessens some- 
 what the danger of injuring the iris and lens through too rapid and too 
 deej) penetration, it occasionally leads to the opposite error -the 
 intralamellar incision. The experienced operator at once recogni/.es 
 the false position of the knife through the persisting resistance, which 
 otherwise disappears as soon as the anterior chamber is opened. Also, 
 a retraction of the cornea is visible at the site of the knife, when it 
 is being pressed backward slightly. As already stated, the cut may be 
 repeated at once at the proper point, if the anterior chamber has not 
 been opened, provided, however, that the aqueous humor is still 
 there. In the latter case, nothing re-mains except to postpone the 
 operation until the next day. 
 
 The excision of the iris is performed with the instruments already 
 described in the operation for cataract the iris forceps and deWecker's 
 forceps- scissors. The iris forceps are held in the left hand and 
 introduced closed into the wound parallel to the iris until they reach 
 nearly to the upper margin of the pupil. They are then opened 
 widely and a fold of iri> is drawn up and pulled out of the wound. 
 The excision is then quickly completed with de Wecker's scissors.
 
 1 86 OPHTHALMIC SURGERY. 
 
 which have been held ready. The iris-section is, however, essentially 
 different from that in cataract-operation. As our object is not only 
 to excise the iris close to its attachment, but also to remove as large a 
 piece as possible, the scissors are now held parallel and closely to the 
 wound (Fig. 100), which may even become slightly depressed by them, 
 and the iris has to be severed by making two cuts. The right half of 
 the iridal fold is cut through first, after which the rest of the iris, is 
 drawn with the forceps still further toward the other angle of the 
 
 wound, thus pulling still more membrane 
 from the eye, and then the left half cut 
 through. As the excision of the iris 
 is ordinarily quite painful, it should be 
 done as quickly as possible. The scis- 
 sors, therefore, must be prepared and 
 ready close to the wound as soon as the 
 iris is grasped. 
 
 The Reposition. After the iris is 
 excised, it lies in most instances in 
 both angles of the wound or is, at 
 FIG. loo. The iris drawn out from \ ea& * squeezed into them. An accu- 
 
 tne eye is cut off near its attachment 
 
 by the scissors, the blades of which rate reposition is all the more impor- 
 
 are held parallel with the limbus. tant? because a healing in of the iris 
 
 in situ would likely lead to a renewed attack of glaucoma. It is 
 much more difficult to effect reposition than in the operation for 
 cataract, but is accomplished in exactly the same manner (see p. 138). 
 The greater difficulty is due to the relatively higher pressure which 
 squeezes the margins of the coloboma into the angles of the wound more 
 than in the cataract-operation, and, as the iris is frequently in a state of 
 atrophy, it shows but little tendency to resume its normal position. 
 Reposition is a very delicate operation, as the spatula occasionally in- 
 jures the lens-capsule. It should, therefore, be the aim to avoid touch- 
 ing this membrane. The spatula must be withdrawn from the eye in 
 the neighborhood of the coloboma, after the operator, coming from 
 the angle of the chamber, has stroked the sphincter edges into their 
 proper position. Care should be taken not to press the iris up again. 
 Attempts at reposition are not be discontinued until after both sphincter- 
 margins have been returned to their normal position. As in the opera- 
 tion for cataract, the last step of this procedure consists in attention 
 to the proper position of the conjunctival flap.
 
 GLAUCOMA. 187 
 
 The indications for iridectomy are primary glaucoma, as well as 
 cases of secondary glaucoma which are not of a transient nature, as, 
 for instance, increase of pressure caused by anterior synechiae, exclusion 
 of the pupil following iritis, luxation of the lens, cysts of the iris, begin- 
 ning ectasia of the conjunctiva or sclera, etc. 
 
 The complications which may arise in the course of an iridectomy 
 for glaucoma have mostly been described in the operation for cataract, 
 and need only brief mention here. The most important are: 
 
 1 . Laceration of the conjunctiva when grasped by the forceps. 
 
 2. Intralamellar incision. 
 
 3. Transfixion of the iris by Graefe's knife. If the anterior chamber 
 is shallow, the point of the knife may catch in a protrusion of the sur- 
 face of the iris and penetrate its tip. This piercing of a few fibers of 
 the iris with the knife is of no significance, as they are always cut through 
 during the continuation of the operation, so that the freed iris again 
 resumes its normal position. As in all other incisions which open the 
 anterior chamber, it should be considered the cardinal rule never to 
 withdraw the knife with the intention of freeing it. 
 
 The escape of aqueous humor at the moment of withdrawal makes a 
 continuation of the incision impossible. The only indication for the 
 withdrawal of the knife is when the operator, while introducing the 
 knife, gets in back of the iris. In this case, if the faulty incision were 
 continued, even more extensive injuries to the iris and lens would 
 occur than after immediate withdrawal of the knife. As the incision 
 is relatively much shorter than that in cataract-extraction, and is 
 ordinarily above the region of the pupil, "a falling of the iris in the 
 way of the knife" is an extraordinarily rare occurrence in spite of the 
 shallow chamber. 
 
 4. Production of an Iridodialysis during the Incision with the 
 Lancet. If the point of the lancet catches in the iris, the latter 
 may be drawn down and thus torn off at its ciliary attachment. This 
 unpleasant occurrence is usually followed by an intense hemorrhage, 
 which will greatly impede the further course of the operation, especially 
 as it is difficult to pull the severed piece of iris out with the forceps 
 without endangering the exposed lens-capsule. It is safer to employ 
 the blunt hook for pulling out the iris instead of the forceps. 
 
 5. The possibility of injuring the lens when introducing the lancet 
 has already been considered. 
 
 6. Incorrect position of the incision is due to a faulty manner of
 
 1 88 OPHTHALMIC SURGERY. 
 
 holding the knife (turning the cutting edge forward) or through 
 improperly inserting the point of the knife. A cut directly forward 
 against the cornea naturally lessens the likelihood of excision of the 
 iris to its root. Especially to be avoided is too long an incision, which 
 may be produced by introducing the knife too low down. The 
 high intraocular pressure would cause the wound to gape and the lens 
 to appear in the wound. 
 
 Complications in the Course of the Iridectomy Itself. The 
 excision of the iris for glaucoma is on the.average much more painful 
 than that done in cataract-extraction. The influence of the anesthetic 
 is much slighter on account of the injection of the eye, and perhaps 
 also because of the alteration in transfusion-conditions. It is our 
 custom, therefore, after the incision to instil several drops of a sterile 
 3 per cent, solution of cocain upon the wound, which, by direct contact, 
 appreciably reduces the sensitiveness of the iris. The extreme suscep- 
 tibility of the iris to pain complicates the operation, as, during the 
 excision, tearing loose of the membrane from its attachment, and even 
 pulling out of a large piece, may occur if the patient suddenly gives 
 a vigorous jerk, just as the operator takes hold of the iris with the 
 forceps. 
 
 Especial care is required in using the forceps to bring the iris 
 forward to prevent injury of the lens-capsule. They should be 
 introduced into the wound parallel with the iris and pushed close to 
 the margin of the pupil, but not brought within the pupillary space 
 itself. If the iris has already floated into the wound, the forceps 
 must not be pushed into the interior of the eye at all; but should lift 
 up the exposed iris, which becomes plainly visible after the conjunctival 
 flap has been laid back on the cornea. Should the patient not look 
 well downward, the excision of the iris may become difficult and the 
 danger of injury to the lens-capsule increased; especially if he keeps 
 moving his eyes around, or suddenly looks up, while the forceps are 
 in the eye. In such cases it is better to fix the eye with forceps, which 
 ordinarily we avoid in doing iridectomy. Instead of the iris-forceps 
 it may be necessary to draw out the iris with a blunt hook which has 
 been bent in a suitable direction. It is self-evident, that we occasionally 
 must be content with the excision of a small piece of the iris, the re- 
 moval of a large one, under the circumstances, being inadvisable or 
 impossible. 
 
 Iridectomy may be difficult if the iris is atrophic and so friable
 
 GLAUCOMA. 189 
 
 that the forceps tear out at each attempt to grasp it. The iridectomy 
 is also complicated in well-advanced glaucoma by the fact that the 
 upper half of the iris is sometimes so small that it disappears behind 
 the limbus. In such cases, we make the coloboma below, as the iris 
 is ordinarily somewhat broader there. The disturbance to vision 
 due to the uncovered coloboma is of no importance, as the eyes have 
 already been seriously damaged by the glaucoma. 
 
 The earlier the iridectomy in glaucoma, the easier the operation. 
 As long as the anterior chamber is not too shallow, and the iris almost 
 normal, the production of a large coloboma is possible. As a result 
 of the peripheral situation of the incision, the coloboma should reach 
 to the attachment of the iris. Considered technically, the longer the 
 operation is delayed, the harder it becomes and the less satisfactory 
 the result. If the angle of the chamber has been obliterated by 
 adhesion of the root of the iris; that is, if it is displaced further for- 
 ward, the incision cannot be made as near as desirable to the periphery. 
 
 Hemorrhage may become a disturbing factor in iridectomy for 
 glaucoma. It may occur during the performance of the incision, 
 originating either from dilated conjunctival or anterior ciliary vessels 
 or as a consequence of injury to Schlemm's canal. The anterior cham- 
 ber becomes filled with blood so that the iris is hidden from view. 
 At first we must try to remove the blood from the eye by stroking it out, 
 assisting it to escape by slightly depressing the peripheral edge of 
 the wound. Usually the blood reaccumulates quickly. It may be 
 impossible, however, to remove the blood, as it becomes attached to 
 the walls of the anterior chamber in the form of a clot. As the pupil 
 cannot be seen, the lens-capsule is in danger during the pulling out 
 of the iris. The presence of the blood also greatly disturbs the 
 replacement. 
 
 Complications During Reposition of the Iris. The greater 
 difficulty in replacing the iris-margins in this operation as com- 
 pared with that for cataract has already been mentioned, especially 
 the possibility of injury to the lens-capsule. One may even be 
 compelled to desist from the replacement if the patient cannot be 
 induced to look downward. Fixation of the eye has always the great 
 disadvantage that the wound is made to gape and increases the 
 likelihood of an injury to the lens, the margin of which may present 
 in the wound. The necessity of proper replacement need not ibe 
 further enlarged upon. It must, however, be expressly pointed out,
 
 1 90 OPHTHALMIC SURGERY. 
 
 that, when as the result of one of the margins of the coloboma growing 
 fast to the wound a renewed increase in pressure is noted, no other 
 procedure is indicated beyond the freeing of the adherent iris by 
 operative interference. Neither a second iridectomy nor a sclerotomy 
 nor any other similar operation fulfills the indication. 
 
 The liberation of attached iris is performed in the following 
 manner: An incision is made with Graefe's knife, which is inserted 
 at one angle of the scar, carried through the anterior chamber until 
 it reaches the other side of the site of adhesion, and is then brought 
 out as far in the periphery as possible. The incision is completed 
 with sawing movements. Frequently the knife has already separated 
 the iris from the scar, and the membrane assumes its proper position 
 immediately after the incision has been completed. If this result 
 is not secured, the iris must be brought out from the wound with the 
 iris-forceps, and as large a piece as possible excised. The cut edges 
 are then replaced. Because of the state of ocular irritation, this 
 operation is often difficult of performance, but is usually followed by a 
 favorable result. The blackish scar, which has been ectatic, soon 
 flattens out during healing, and the increase in pressure does not recur. 
 
 This operation is also indicated in adherent iris after cataract- 
 operations in which there has been an increase in tension. In order 
 to prevent a gaping of the wound and a prolapse of the vitreous, it is 
 recommended to leave a bridge of conjunctiva and then bring the iris 
 out under it. By the same method one has to remove the so-called 
 cystic scars after cataract-operations. 
 
 Prolapse of the vitreous is a relatively rare occurrence in iri- 
 dectomy for glaucoma. It is most likely to happen in old absolute 
 glaucoma, especially if there is ectasia of the sclera. The prolapse not 
 only makes excision of the iris impossible, but also a reposition of its 
 margins. Besides, the wound gapes because of the interposition of 
 the vitreous, and, although an ugly ectatic scar is formed, it is one of 
 the relatively good outcomes of the operation. In most instances 
 renewed attacks of increase in pressure follow, which, on account of 
 their painfulness, finally render enucleation of the eye compulsory. 
 Occasionally the vitreous prolapse leads to a still graver complication, 
 namely, expulsive hemorrhage. On account of the sudden decrease 
 in pressure, severe hemorrhages under the chorioid occur, which is 
 pushed forward with the retina and squeezed out of the eye through 
 the wound. Particularly in the operations for old absolute glaucoma
 
 GLAUCOMA. IQI 
 
 is this accident seen. Such eyes must be immediately enucleated; 
 otherwise weeks would pass before the eye atrophied and became 
 quiescent. The bleeding which occurs with expulsive hemorrhage 
 is usually very considerable, and to arrest it temporarily the application 
 of a pressure-dressing is necessary. 
 
 Subluxation of the lens may occur in connection with its altered 
 position following the opening of the anterior chamber and the escape 
 of the aqueous humor. The lens then inclines forward, and its upper 
 border tends to turn forward on account of the lessened resistance of 
 the coverings of the bulb in the region of the wound. This presages 
 a bad prognosis for the later behavior of the eye. The anterior 
 chamber does not become re-established for a long time, intense attacks 
 of renewed increase in pressure follow, and in spite of repeated sclerot- 
 omies and other operations such eyes are usually lost. 
 
 Cataract, which occasionally follows the operation, deserves special 
 mention. Injuring of the lens, the danger of w r hich has been fre- 
 quently mentioned, occurs in the region of the anterior capsule, and if a 
 careful examination is made, the scar of the capsule wound, from which 
 the cataract had its origin, can always be demonstrated. The cataract 
 does not always become complete, but may be confined either to a 
 clouding in the neighborhood of the capsular wound, or to a stellar 
 opacity in the anterior or posterior lamellae of the cortex. 
 
 Occasionally after iridectomy for glaucoma there may occur a 
 spontaneous rupture of the lens-capsule in the region of the 
 equator. This is especially seen in cases in which, after completing 
 the iridectomy, a subchorioidal hemorrhage produced an increase ia 
 intra-ocular pressure, by which the lens is displaced forward and its 
 border presents in the wound. In this condition the capsule, being 
 deprived at this point of its protecting intra-ocular pressure, ruptures 
 through the forward pushing of the lens-substance. As the rupture 
 lies in the equator of the lens, no capsule wound is seen by lateral illu- 
 mination, and the clouding of the lens begins in the posterior cortical 
 substance. The lens-capsule may burst spontaneously over a wide 
 area and the lens-substance with the nucleus be either discharged 
 from the eyeball or become incarcerated into the wound (Hernia 
 lenlis), which remains highly gaping under the conjunctiva. Fortu- 
 nately, such cases are rare. We must be prepared, however, for such 
 accidents in operations on eyes with long-continued, high-grade in- 
 crease of pressure, when the eye is of stony hardness, the anterior
 
 OPHTHALMIC SURGERY. 
 
 chamber almost obliterated, the sclera becoming ectatic, the iris 
 markedly atrophic and the eye itself painful. The operation often 
 cannot be performed without a general anesthetic. If the eye is 
 completely blind, enucleation should be advised.
 
 niAPTKR XVI. 
 GLAUCOMA (Continued). 
 
 ANTERIOR SCLEROTOMY DE WECKER,. 
 
 Anterior sclerotomy is done with a (iraefc cataract-knife, and 
 resembles the incision made for the extraction of a senile cataract, 
 except that it is placed more peripherally. The opening into the 
 anterior chamber mav be made above or below, the eve beintr fixed 
 
 Fir.. 101 . - Anterior sclerotomy in the left eye.-, performed In-low. Beginning of the inci- 
 sion. The left hand of the operator fixes the eye. either laterally or alxive; the rutting edge 
 of the knife is directed downward. The incision is begun at least i mm. away from the 
 limhus in the sclcra. The lower lid i> drawn far downward by the assistant. 
 
 at such a point that the forceps will not be in the way of the knife. 
 As the operation has for its object an incision into the an^le of the 
 chamber, the points of entrance and exit of the knife must lie in the 
 sclcra at least i to i \ mm. from the limbus, according to the relations
 
 194 OPHTHALMIC SURGERY. 
 
 of the parts already described. As the knife can be entered only 
 from without, the directions given in the discussion of the operation 
 for cataract as to the use of the right or left hand hold good here 
 (Fig. 101). 
 
 As the anterior chamber is usually shallow in the eyes in which 
 anterior sclerotomy is indicated, the performance of the incision is by 
 no means easy. If the point of the knife is thrust through the sclera 
 too vertically, the iris may be pierced and even the lens injured. For 
 this reason, in the effort not to wound the iris, 'the knife is applied 
 parallel to its surface. If its point is directed slightly forward, it is 
 
 pushed between the layers of the 
 cornea an intralamellar incision. 
 Frequently it cannot be seen that the 
 knife is passing between the layers of 
 the cornea, but the experienced oper- 
 
 FIG. 102. Diagram showing the , , .-, 1 , , 
 
 position of the knife in the eye during ator detects the error because of the 
 the incision of the sclera. it lies at continued resistance, which disappears 
 
 least i mm. away from the limbus in 
 
 the sclera. at once when the perforation is made 
 
 properly. After the point of the knife 
 
 has entered the angle of the chamber, it is slowly carried onward 
 between the cornea and iris, until it reaches the angle of the chamber 
 on the other side, where it is made to penetrate the sclera, reappearing 
 at the same distance from the limbus as the first pucture (Fig. 102). 
 The incision is continued with sawing movements as described in 
 the operation for cataract. 
 
 In order, however, to prevent a prolapse of the iris, the cut is not 
 completed, but a small bridge of sclera is permitted to remain; in other 
 words, the knife is withdrawn from the eye before the incision is 
 finished. But, as it is the intention to cut into the angle of the chamber 
 of this portion too, the handle of the knife is depressed, i. e., raised, 
 while withdrawing the blade so that its point cuts through the angle 
 of the chamber from within (Fig. 103) . The length of the entire incision 
 is somewhat less than that of the cataract-incision. We begin, there- 
 fore, about 3 mm. from the horizontal meridian, as seen in the illus- 
 tration (Fig. 104). Usually after completion of the incision the iris 
 remains in its normal position, especially if the patient is quiet, but 
 should the pupil be distorted or the iris prolapsed, reposition is done 
 according to the prescribed rules. It may happen that, when the 
 dressing is changed on the following day, the iris is found misplaced
 
 or prolapsed, in which case it is best to perform an excision of the 
 prolap>e. 
 
 Accidents may occur during the execution of an anterior sclcrotomy. 
 the most important of which are the following: 
 
 i. Intralamellar incision, mention of which has already been 
 made. It the faulty incision is discovered before the anterior chamber 
 is perforated, it i- best to withdraw the knife and to make a new 
 
 I-' ic,. ID}. -Termination of the incision. In order to i ut through the inner lamella- of 
 the sclera in the neighborhood ol the srleral bridge, which is permitted to remain, the knile 
 is turned bv an elevation ot its handle in such a manner that its point pnxluco the desired 
 incision into the angle of the < hambcr. 
 
 Compare the position of tin operator's hand holding the knife while performing the tir^t 
 act of the operation (Fig. ion and while withdrawing it < Fig. 1031. 
 
 puncture. If, however, the aqueous humor has already escaped, the 
 operation must be interrupted, as it is impossible to continue it without 
 injuring the iris. The traumatic opacity of the cornea consecutive 
 to an intralamellar incision is of no real significance, as it eventually 
 clears up completely. 
 
 2. The incision may not lie far enough in the periphery. As 
 
 we can expect favorable re- 
 
 e opera! ion oniv u 
 
 :, '
 
 1 96 OPHTHALMIC SURGERY. 
 
 passes through the angle of the chamber, it is a serious mistake to 
 place it at the limbus or in the cornea itself, except when the root of 
 the iris is adherent to the posterior surface of the cornea, thus displacing 
 the angle of the chamber further forward and making it impossible 
 for the operator to begin the incision to the outer side of the limbus, 
 as the knife would then be carried in back of the iris. 
 
 3. An accident occasionally noted in this operation in connection 
 with the misplacement of the recess of the anterior chamber is irido- 
 dialysis, the knife carried to the periphery dividing the iris-root 
 adherent to the cornea. A severe hemorrhage may follow this injury. 
 The results of anterior sclerotomy are in the greater number of 
 cases not only temporarily good, but also perma- 
 nently lasting, if the operation is not used as the 
 primary one in glaucoma, but is reserved for 
 cases, in which after a formal iridectomy there 
 is a renewed increase of pressure. In such cases 
 FlG ;i! 04 '^ I r this dia " it is our custom not to perform a second iridec- 
 
 gram the solid line repre- 
 sents the perforating cut, to my at once, which, as it would have to be 
 the dotted line that part 111-1 < n i- 
 
 of the incision, in the made below, is always followed by a severe dis- 
 range of which only the turbance in the visual power, but to place our 
 
 inner lamellse of the 
 
 sclera are cut through. reliance on an anterior sclerotomy. When 
 necessary this operation may be repeated several 
 times on the same eye, and it is optional whether the incision should 
 be made above, below or at any other favorable point. In the eyes 
 with a coloboma upward we prefer to make the sclerotomy below, to 
 have the knife separated from the anterior capsule of the lens by the 
 iris, to insure against a possible injury of the capsule. 
 
 In this, as in every glaucoma-operation, the eye must be energetically 
 treated with eserin before the operation, in order to bring about as 
 marked a contraction of the pupil as possible. 
 
 Anterior sclerotomy is recommended for simple glaucoma, as 
 well as hemorrhagic glaucoma and hydrophthalmos. In hemorrhagic 
 glaucoma it should be used as a preliminary operation, to lower the 
 pressure, in order that an iridectomy may be performed later under 
 less dangerous conditions. ' 
 
 POSTERIOR SCLEROTOMY. 
 
 This operation consists in the pucture of the vitreous space through 
 the sclera with a Graefe cataract-knife. In order to avoid injuring the
 
 GLAUCOMA. 
 
 197 
 
 more important parts of the eye, the following rules must be observed : 
 The perforation of the sclera is made posterior to the ciliary body; that 
 is, at least 6-7 mm. from the limbus in the human eye. As the nose 
 interferes with such a peripheral incision on the inner side of the 
 eyeball, the operation is usually performed to the outer side, or best 
 
 FIG. 105. Posterior sclerotomy. The eye, which is directed well upward and inward, 
 is fixed with forceps at the limbus and Graefe's knife is introduced at the outer and lower 
 portion in a meridional direction, the cutting edge looking backward, the point toward the 
 center of the eyeball. The assistant pushes the lower lid far downward. 
 
 at the outer and lower portion between the external and inferior rectus 
 muscles, while the patient looks inward and upward. The eye is 
 fixed with forceps to prevent any unexpected movement. In posterior 
 sclerotomy the cutting edge of the instrument is directed backward ; 
 that is, away from the ciliary body so as not to bring this organ into 
 danger. The incision is made in a meridional direction, corresponding 
 to that of the fibers of the sclera and the blood-vessels in the chorioid.
 
 198 OPHTHALMIC SURGERY. 
 
 An equatorial incision, that is, one parallel to the limbus, would divide 
 a series of blood-vessels in the choroid. For the same reason the cut 
 must not be placed in the horizontal meridian, because the posterior 
 long ciliary artery runs in this direction. Injury to this vessel would 
 destroy the eye through a severe hemorrhage into the vitreous. 
 
 During the puncture the point of the knife is directed toward the 
 center of the eyeball, in order not to pierce the posterior capsule of 
 the lens, which could readily occur if the blade were passed obliquely 
 forward (Fig. 105). Moreover, the puncture must have a definite 
 length as long as the breadth of the knife. In order to lower the 
 
 tension of the eye by the escape of 
 a small amount of vitreous humor, 
 the knife must be turned, while in 
 the scleral wound, from a meridional 
 direction to an equatorial one (Fig. 
 106), so that the wound is caused 
 to gape. After the knife has been 
 
 FIG. 106. in this diagram, the knife, returned to its original position, it 
 which is now in the eyeball, is turned to is withdrawn from the eye. 
 
 the equatorial direction, so that the wound 
 
 gapes allowing the vitreous to exude. Indications. Posterior Sclero- 
 
 tomy is of small value as an opera- 
 tion for glaucoma, as the diminution of pressure induced by it usually 
 soon disappears, sometimes after a few hours, and the scar which is 
 later to be met with at the site of the incision is so dense that a nitra- 
 tion of the ocular fluids outward cannot take place. Hence, posterior 
 sclerotomy is used in glaucoma only as a preliminary operation in cases 
 in which iridectomy is technically impossible because of the complete 
 obliteration of the anterior chamber in the presence of enormous 
 increase in pressure. In most cases an iridectomy may be proceeded 
 with immediately after the posterior sclerotomy, as the escape of the 
 vitreous produces a softening of the eyeball and simultaneously the 
 anterior chamber commences to reappear. Posterior sclerotomy is 
 further employed in puncturing the sub-retinal space in detachment 
 of the retina. In such cases the operation must often be repeated, 
 and, according to Deutschmann, may be associated with perforation of 
 the retina itself. Good results are unfortunately not to be expected. 
 The principal value of posterior sclerotomy lies in the possibility of 
 employing it as an accessory operation in the removal of foreign bodies 
 from the vitreous chamber, as will be found described elsewhere.
 
 GLAUCOMA. 
 
 I 99 
 
 CYCLODIALYSIS (HEINE). 
 
 The Operation. Cyclodialysis, invented by Heine, is executed in 
 the following manner: While the patient looks upward, an incision 
 
 U &> 3 
 ='-' 
 
 < 5 o 
 
 111 
 
 III 
 
 bi 
 
 is made with the scissors into the conjunctiva at its outer and lower 
 part, at a distance of about 5 mm. from the limbus, and the sclera
 
 200 
 
 OPHTHALMIC SURGERY. 
 
 exposed by undermining. An assistant holds the wound open with 
 two double tenacula, and a cut 2 mm. long is made with the 
 
 ,C 
 
 .2 
 
 73 
 
 11 
 
 r-; 
 
 II 
 
 en a 
 
 a, 
 
 .r 
 
 43 -O 
 -^ C 
 
 >4H ^ 
 
 _ W 
 
 <u 73 
 
 2 
 
 g u 
 
 lancet vertically through the sclera at a distance of 5 mm. from the 
 limbus and parallel to it (Fig. 107), the eye being fixed with forceps.
 
 GLAUCOMA. 201 
 
 As the ciliary body, which lies immediately beneath, must not be 
 injured, we must proceed very cautiously with the cutting, and slowly 
 divide the tissues layer by layer, until the black of the uvea appears 
 in the wound. The incision is not made with the point of the knife, 
 but with one of its lateral edges, so that the same depth is kept in the 
 entire length of the wound. 
 
 Xext a spatula, such as is used in reposition of the iris, under con- 
 tinuous fixation of the eye is carefully carried forward through the 
 wound between the sclera and the ciliary body, with its plane parallel 
 to both (Fig. 108). If all the fibers of the sclera have been divided, 
 this can be done without any resistance. Soon the point of the spatula 
 
 FIG. 109. FIG. no. 
 
 Figs. 109 and no show the position of the spatula during the performance of the 
 lateral movement intended to detach the ciliary body. 
 
 appears below in the angle of the chamber. Now the spatula is pushed 
 forward with lateral movements to the right and to the left (Figs. 
 109 and no) and in this manner the ciliary body is detached from the 
 sclera. The aqueous humor does not escape during this procedure, 
 unless one edge of the spatula is turned forward slightly, causing the 
 wound to gape. If the ciliary body is not hurt during the incision, 
 no bleeding occurs into the anterior chamber. 
 
 At the beginning of the operation we must be careful not to injure 
 the anterior ciliary veins, which are often dilated in glaucomatous 
 eyes, as such a hemorrhage would not only make the further progress 
 of the operation difficult, but also during the introduction of the spatula 
 cause blood to be sucked into the anterior chamber. Bleeding from 
 the small scleral vessels is best prevented by repeated dropping of 
 adrenalin into the wound during the incision. One may even be 
 compelled to stop severe hemorrhage from a ciliary vein, injured at its 
 point of exit from the sclera, by application of the thermocautery. 
 If the cut is carried too deep, the vitreous may be pushed into the wound
 
 202 OPHTHALMIC SURGERY. 
 
 after division of the uvea. The spatula must be introduced carefully 
 and pushed forward close to the posterior surface of the sclera, in 
 order not to get behind the iris. By the entrance of the spatula into 
 the anterior chamber the ligamentum pectinatum is divided, the 
 angle of the chamber opened, and the ciliary body, together with the 
 iris springing from it, is detached from the sclera. 
 
 An iridodialysis is no more to be feared than an injury to the canal 
 of Schlemm, as the iris arises from the anterior surface of the ciliary 
 body, and the latter is sufficiently protected through a projection of 
 the sclera. Occasionally, the detachment of the ciliary body from the 
 sclera may be plainly distinguished by the recess of the chamber 
 becoming black just as in iridodialysis. After withdrawal of the 
 spatula the ciliary body resumes its original position and the angles of the 
 chambers show no further visible alteration. If, during the operation, 
 a hemorrhage into the anterior chamber occurs, a pressure-dressing 
 must at once be applied. This not only prevents a further accumu- 
 lation of blood, but also causes a disappearance of part of the blood 
 already present in the eye. 
 
 One of the most frequent complications is the detachment of 
 Descemet's membrane from the cornea. If the spatula is not sharp 
 enough to sever the fibres of the ligamentum pectinatum, it may glide 
 in front of them on the anterior side of Descemet's membrane, thus 
 getting caught between the latter and the parenchyma of the cornea. 
 This faculty position of the instrument is recognized by a marked 
 resistance. By slightly withdrawing, the spatula must be freed before 
 the undermining is performed, otherwise the membrane becomes 
 detached, thus leading to an opacity of the corneal parenchyma, 
 which, however, disappears within a few weeks. Generally the spatula 
 finds its right way even in those eyes in which the root of the iris is 
 attached to the posterior surface of the cornea (peripheral anterior 
 synechia), and an iridodialysis is an exceptional occurrence. 
 
 After withdrawing the spatula from the wound the conjunctiva 
 is sutured and the eye bandaged. 
 
 The operation is undoubtedly much less radical and associated \vith 
 much less danger for the eye than an iridectomy. To test its influence, 
 I purposely did not permit the aqueous humor to escape from the eye 
 in most of my cases, so that immediately after the operation the eye 
 was as hard as before. In this manner, therefore, I could observe 
 the effects of the operation with the factor of puncture omitted from
 
 GLAUCOMA. 203 
 
 consideration. I do not mean, however, that one should not let out 
 the aqueous humor, as it may be irremissible to reduce the tension at 
 once. Neither do I use miotics after the operation, although we think 
 their employment is a great advantage, because the consequent con- 
 traction of the pupil aids in pulling the freed root of the iris away from 
 the angle of the anterior chamber. 
 
 The proper results of cyclodialysis develop gradually and attain 
 their highest degree only one to three days later. According to the 
 condition of the eye after the~ operation, three kinds of cases may be 
 distinguished: Those in which (i) the tension is reduced perma- 
 nently; (2) the diminution of the pressure is only temporary; (3) the 
 operation had no influence at all. In the first class of cases (about 
 30 per cent.) the tension sinks gradually during the first three days 
 after the operation, and the eye may even become softer than normal. 
 The previously hazy cornea becomes lustrous, the anterior chamber 
 somewhat deeper, though it remains shallower than normal, the pupil 
 a little less dilated than before. In this condition the eye may 
 remain permanently. In about 40 per cent, the diminution of the 
 tension is only temporary and the increase of pressure returns within 
 a few r weeks; and in about 30 per cent, the operation had no effect 
 at all on the glaucoma. This is the result especially in glaucoma 
 absolutum. 
 
 Cyclodialysis is indicated in, i. Cases of primary glaucoma, 
 in which the iridectomy is not only difficult but dangerous, either 
 because of the increase in pressure being very high, or the intra-ocular 
 changes so far advanced, that a regular iridectomy is practically 
 impossible (no anterior chamber, atrophic iris, maximal dilatation of 
 the pupil). The performance of the cyclodialysis is independent of 
 the existence of the anterior chamber, and complications mentioned in 
 iridectomy may be disregarded. 
 
 Even though the reduction of pressure may be only a temporary 
 one, the operation has to be considered as a valuable preliminary 
 to iridectomy. If the tension is once diminished by the cyclodialysis, 
 an iridectomy can be accomplished without any of the dangers already 
 described. 
 
 2. In cases of glaucoma in patients who have lost the other eye by 
 glaucoma malignum or a severe hemorrhage after an iridectomy, also 
 in old, infirm, coughing or restless people, because after this operation 
 such patients do not need to be kept in bed.
 
 204 OPHTHALMIC SURGERY. 
 
 3. The operation renders remarkable services in certain cases of 
 secondary glaucoma caused : (a) By anterior synechia, in which in spite 
 of iridectomy the tension increases again, (b) By luxation of the lens 
 in the vitreous chamber. Loss of vitreous, unavoidable in performing 
 an iridectomy and rendering the same dangerous and its result uncer- 
 tain, does not complicate the cyclodialysis. (c) After cataract-extrac- 
 tion, provided that the edges of the coloboma are in their proper 
 position. If there is adhesion of one or both sides of the coloboma to 
 the operation-scar, the excision of the attached iris is, of course, indi- 
 cated (page 190). 
 
 In brief, cyclodialysis, though able to diminish the intra-ocular 
 pressure, cannot be called preferable or even equal to the iridectomy. 
 It should not be used indiscriminately in place of iridectomy, but 
 should be considered as a valuable aid when iridectomy fails or is 
 contra-indicated. 
 
 The suggestion of this operation by Heine had its origin in the 
 articles by Fuchs giving detailed descriptions of the chorioidal detach- 
 ment following iridectomy for glaucoma and extraction of cataract, 
 pointing out the co-existent diminution of pressure, and presuming 
 that the chorioidal detachment was brought about by the aqueous 
 humor oozing backward through tears in the ligamentum pectinatum 
 produced by the operation. Heine tried, by establishing through an 
 artificial cleft in the ligament a communication between the anterior 
 chamber and the suprachorioidal space, to give rise to a detachment 
 of the chorioid and thereby to a reduction of the intra-ocular pressure. 
 In conceiving the method of the cyclodialysis he took for granted, first, 
 that the tear would not heal again spontaneously, and, second, that the 
 suprachorioidal space represented either a natural passage for the 
 intra-ocular circulation respectively for the carrying off of the liquids 
 from the interior of the eye, or that it was created such a one by the 
 operation. But the expected detachment of the chorioid failed to 
 appear, even when the eyes had been perfectly soft. The fact that in 
 successful cases the tension remains below normal for months proves 
 that the result is independent of a supposed detachment of the chorioid, 
 which, as a rule, p v asses away within a few days or, if extensive, within a 
 few weeks, and with it the lowering of the tension. The theory, 
 therefore, on which the operation had been based, seems to be incorrect. 
 But this should not bias our actual judgment. It is likely that the 
 occasional success is accomplished by the undermining of the angle
 
 GLAUCOMA. 205 
 
 of the anterior chamber. Cyclodialysis should be regarded as an 
 operation to free this angle, just as many other methods that have 
 been recommended for glaucoma, to which iridectomy also probably 
 belongs. 
 
 OPERATIONS FOR SECONDARY GLAUCOMA. 
 
 The indications for operation in secondary glaucoma are dependent 
 upon whether the phenomena are only temporary or whether the 
 increase of pressure will remain permanent. 
 
 Paracentesis of the cornea is indicated in transient increase of 
 pressure; as, for example, in traumatic cataract with rapid swelling 
 of the lens; and in acute iritis, in which the increase in pressure is 
 associated with the anterior chamber deeper than in the normal eye. 
 However, the operation should not be done until after the usual local 
 applications of ice-compresses and atropin have failed, especially in 
 cases of iritis. 
 
 The incision is made with the lancet at the limbus below and not 
 more than 3 mm. long. The cocainized eye is fixed laterally. The 
 site of fixation is not so important as an iridectomy is not contem- 
 plated, and the incision need not be made exactly in the vertical 
 meridian. The lancet, held in the right hand, is applied almost 
 vertically against the limbus, and penetrates the cornea. The length 
 of the cut, however, must not exceed 3 mm. As soon as the point 
 appears in the anterior chamber, its direction must be changed to that 
 of the plane of the iris, as in operations previously described. All 
 backward movements of the lancet should be avoided, in order to - 
 prevent a disastrous escape of the aqueous humor. 
 
 When the lancet is now withdrawn, the wound-edges come together 
 so that the aqueous cannot flow off. The operator may permit it to 
 run out as slowly as he desires and in any quantity he pleases, by 
 slightly depressing the scleral wound-margin with the spatula, thus 
 making the wound a little gaping. Sudden escape of the aqueous 
 humor is not only painful, but may cause prolapse of the iris and 
 hemorrhage from the iris, and even in the retina as a result of the 
 sudden diminution of pressure. A lancet with stop-shoulders has been 
 devised which will prevent an over-penetration into the eye, but such 
 instruments are superfluous for the operator of experience. No 
 force must ever be employed when introducing the lancet. If the 
 point is bad, it is preferable to use another instrument. A faultless
 
 206 OPHTHALMIC SURGERY. 
 
 knife-point penetrates the cornea without any appreciable resistance. 
 If the pressure is greatly increased, it is our custom not to permit all 
 the aqueous humor to escape, but only just as much as to reduce the 
 pressure to normal or a trifle below. Thus we are most likely to pre- 
 clude disastrous intra-ocular hemorrhages. If the iris is floated out 
 during the sudden escape of the aqueous humor, it should be at once 
 accurately replaced with a spatula. Only in exceptional cases, when 
 the protrusion of the iris is several times repeated, is excision of a 
 small piece indicated. This unpleasant accident occurs when the 
 incision has been made too long. 
 
 Puncture of the cornea may be repeated as often as needed. If, 
 for example, in acute iritis the tension increases the next day, the 
 scleral lip of the wound after cocainizing may be slightly depressed 
 with the spatula and the aqueous humor allowed to again escape. 
 The healing of the wound does not advance so quickly for several days 
 as to hinder easy re-opening by passing the spatula carefully between 
 the edges. 
 
 If the corneal puncture is made because of increase in pressure, 
 the result of swelling of the lens, it is better to make the cut somewhat 
 longer (5 mm.), so as to permit not only the aqueous humor to escape, 
 but also extract some of the lens-mass itself by massage, as described 
 elsewhere. In such a case the operation more nearly resembles a 
 linear extraction. 
 
 Puncture of the cornea may also be employed in progressive 
 corneal ulcers, and is then frequently combined with cauterization 
 of the ulcer. The puncture may be advantageous in those cases in 
 which a rupture is imminent. The obliteration of the anterior chamber 
 by the puncture overcomes all the disadvantages of a sudden rupture 
 of the ulcer, such as prolapse of the iris, etc. In chronic inflammation 
 of the cornea (keratitis profunda) puncture occasionally exerts a 
 favorable influence on the disease-process. 
 
 Secondary glaucoma, in which the increase of pressure is certainly 
 not of transient nature, requires a typical iridectomy, as described in 
 the chapter on primary glaucoma. This is true, therefore, in increase 
 of pressure due to adhesion of the iris to the cornea or to change of 
 position of the lens, and other conditions, as previously mentioned. 
 
 The performance of the iridectomy in secondary glaucoma 
 may be difficult because of the accompanying pathological changes 
 in the eye. For instance, the iris may be so atrophic from the chronic
 
 GLAUCOMA. 20- 
 
 inflammation tluu it cannot be pulled forward with the forceps, as it 
 tears at the slightest touch, and we must be satisfied with tearing out 
 single pieces with the forceps instead of excising one section. Again, 
 the iris may have grown fast to the lens-capsule, and we may succeed 
 in drawing it forward and in excising a portion, but the pigment-layer 
 remains adherent to the lens-capsule, rendering valueless the optical 
 effect of the operation. 
 
 In luxation of the lens or ectasia of the sclera it is prolapse of 
 the vitreous which produces severe complications during the opera- 
 tion. \Ye should never operate in a case of luxation or subluxation of 
 the lens (except luxation in the anterior chamber) unless forced to by 
 an increase of pressure. Experience has shown that some eyes tolerate 
 a displacement of the lens without a corresponding increase of pressure, 
 at least for some time. Operative procedures in these cases are always 
 so dangerous that they should be postponed until the last resort. As 
 the zonula is torn, the vitreous presents in the wound as soon as the 
 incision is made. If the iris is floated forward, it may be easily grasped 
 and excised. If, however, the vitreous pushes the iris backward, all 
 attempts to bring it forward with the forceps would terminate in 
 failures and should, therefore, be abandoned. Occasionally we may 
 be able to catch the iris with a blunt hook and to draw it forward. 
 Should that also fail, one has to desist from excising a piece of the iris. 
 If afterward the operative wound becomes ectatic and the eye con- 
 stantly painful because of the increased pressure, and vision is ulti- 
 mately lost, nothing remains to be done except to enucleate the eye. 
 
 If the lens is displaced into the anterior chamber an operation 
 for its removal must be immediately undertaken, as experience has 
 shown that in such cases increase in intra-ocular tension quickly follows. 
 In order to prevent a slipping of the lens backward into the vitreous 
 chamber, the pupil is first contracted with eserin. Then the anterior 
 chamber is opened by an incision with (iraefe's knite at the lower 
 limbus and the lens brought forward with the loop. As the vitreous 
 and anterior chamber openly communicate, the appearance of the 
 vitreous in the wound is the rule in spite of precautions. 
 
 If a cyst of the iris has led to increase of pressure we must not be 
 satisfied with an iridectomy alone, but endeavor to extirpate the 
 entire cyst by suitable incision. 
 
 The operation for increase of pressure in seclusion of the pupil, 
 when the iris has been pushed forward in the form of a hum]), deserves
 
 208 
 
 OPHTHALMIC SURGERY. 
 
 special mention. A formal iridectomy is hardly possible as the root 
 of the iris is often applied extensively against the posterior wall of the 
 cornea. The operation adapted for such cases is transfixion. This 
 is done with a Graefe knife, which is pushed into the anterior chamber 
 through the cornea i mm. to the inner side of the temporal border 
 of the cornea and a counter-puncture made at a symmetrical point. 
 The knife is then pulled out. The points of entrance and exit lie in 
 the horizontal meridian of the cornea, and the^blade of the knife, held 
 
 FIG. in. 
 
 FIG. 112. 
 FIGS, in and 112. Transfixion in seclusion of the pupil. 
 
 parallel to the base of the cornea, penetrates through the projecting iris 
 and produces in it several openings (Figs, in and 112), through which 
 a new communication is established between the anterior and posterior 
 chambers. In most cases the iris assumes its normal position almost 
 at once and the intra-ocular pressure becomes normal. If no new 
 inflammation of the iris follows, a permanent result may be expected. 
 If, however, there is a new outbreak of iritis, which would cause a 
 closure of the openings through a formation of an exudate, it is better 
 to proceed to establish a normally deep chamber and then to perform a 
 regular iridectomy, in order to prevent a recurrence of the increase in 
 pressure.
 
 CHAPTKR XVII 
 PROLAPSE OF THE IRIS. CONJUNCTIVOPLASTY. 
 
 Every Prolapse of the Iris should be Excised. -Attempts at re-posi- 
 tion of a prolapsed iris should be avoided, not only on account of the 
 danger of intraocular infection, but also because of the uselessness of 
 such a procedure. The replaced iris will again prolapse. It is. there- 
 tore, best to excise not only an iris that has protruded through the open- 
 ing ot a perforated ulcer or through a wound due to injury, but also 
 a prolapsed iris following an extraction without iridectomy. 
 
 The Operation. Xot only should that portion protruding from 
 the opening be cut off. but the iri.s should be completely freed from 
 its connection with the wound, in order to avoid the formation of an 
 anterior synechia. with its consequent sequehe. As the prolapsed iris 
 rapidly becomes covered with fibrinous exudation, making its borders 
 indefinable, this exudate must first be pulled off with a forceps, after 
 which the black point or swelling of the prolapse makes its appearance. 
 By means of a conical sound the prolapse is then freed from the edges 
 of the wound in all directions. In doing this it is necessary to avoid 
 wounding the capsule of the lens, which, by obliteration of the anterior 
 chamber, is brought to lie close to the posterior surface of the cornea. 
 The sound is carefully pushed around the whole periphery of the open- 
 ing between the prolapse and the posterior surface of the cornea, so 
 that the iris is loosened on all sides. During this attempt the aqueous 
 humor is continually escaping. The prolapsed iris is then seized with 
 the iris-forceps close to the opening, drawn out a little, and cut off 
 with the de Wecker's scissors close u> tile edge of the wound. As tin- 
 iris usually retains its power of retraction, immediately after the exci- 
 sion, it withdraws itself into the anterior chamber, and produces a 
 well-situated coloboma in place of the- previous prolapse. 
 
 If the edges of the coloboma do not lie in a proper position, and the si/.e 
 of the opening permits, it is advisable to introduce a spatula and replace 
 the iris. As this may be impossible with a small opening, care should 
 be taken to draw out and excise enough of the iri- to allow it to spon- 
 taneously withdraw to a sufficient extent. If. however, 1 he latter does 
 not occur, an attempt must be- made to introduce a blunt tenaculum 
 
 14 2O()
 
 210 OPHTHALMIC SURGERY. 
 
 into the anterior chamber, and, withdrawing it out of the wound 
 between the iris and the posterior corneal wall, pull out the iris caught 
 in the hook, so that a proper excision can be done. After the operation 
 is completed a drop of atropin is instilled in the eye to retract the iris 
 as far as possible and avoid its adhesion to the edges of the wound. 
 The fact that the prolapse has occurred through perforation of an 
 ulcer is not a contraindication to its immediate excision, notwithstand- 
 ing the claim that there is great possibility of an infection of the interior 
 of the eye through replacement of the borders of the coloboma. If the 
 tendency to infection should exist, the prolapse would afford the best 
 channel by which the microorganisms could gain entrance to the eye. 
 
 Excision of a prolapse of the iris may occasionally be difficult and 
 it is necessary to cocainize thoroughly the conjunctival sac by instilla- 
 tion of a 3 per cent, solution. As the eyes are usually much irritated 
 and injected, adrenalin should be used simultaneously, as the cocain 
 develops its greatest effect after contraction of the blood-vessels. Not- 
 withstanding thorough cocainization, the iris often remains extremely 
 sensitive, and in spite of fixation of the eyeball with forceps, especially 
 at that moment when the iris is drawn out and excised, an abrupt 
 movement of the patient may give rise to severe injury of the iris 
 (iridodialysisj. In children the operation should always be done 
 under general anesthesia. This should also be the rule in restless and 
 timorous adults. 
 
 A second danger is the possibility of a wound of the capsule of the 
 lens. This can be readily avoided if the operator takes sufficient 
 precautions in introducing the blunt tenaculum for the purpose of 
 replacing the iris. However, this accident may be caused by restless- 
 ness on the part of the patient during the undermining of the prolapse 
 with the pointed conical sound. If cocain is dropped directly on 
 the prolapsed iris after it is uncovered, its sensitiveness is greatly 
 diminished. 
 
 The wound in the cornea which remains after excision of the pro- 
 lapse, usually closes rapidly; frequently the anterior chamber is re- 
 established on the day after the operation. The smaller the opening, 
 the more readily and surely does the wound close. The conditions 
 for healing are less favorable in large perforations. It is our established 
 rule not to excise a prolapse of the iris if the opening amounts 
 to one-fourth the diameter of the cornea. Naturally, this can 
 not be readily determined in advance. A large prolapse sometimes
 
 PROLAPSE OF THE IRIS. 211 
 
 comes out through a small opening and, with mushroom-like swelling, 
 overlaps the borders of the corneal wound. If the patient has been 
 seen before the prolapse occurred, the operator will not be thus deceived, 
 but it may happen that the real conditions are revealed only at the 
 time of operation upon attempting to undermine the prolapse. 
 When, for example, one-fourth or more of the cornea has been lost by 
 ulceration, the excision of the iris brings the lens-capsule to lie in the 
 wound throughout its extent. As the scar-formation is not as rapid 
 in the cornea as it is in other tissues, the wound may remain open for 
 some time, and during this period the eye is constantly exposed to the 
 danger of infection. If the exposed lens-capsule cannot withstand the 
 intra-ocular pressure, it finally protrudes and ruptures, the lens-sub- 
 stance first appears in the opening and later the hyaloid membrane 
 bursts, allowing the vitreous humor to prolapse. These sequelae 
 are to be feared only in large prolapses, such as occur in destruction of 
 the cornea by acute blennorrhea or serpiginous ulcer. But even with 
 the medium-sized openings, the operator has to be satisfied if a flat 
 cicatrization results with fusion of the lens-capsule and partial or total 
 clouding of the lens. Frequently these cases end with a slowly devel- 
 oping atrophy of the eyeball. Therefore, it is best not to excise the 
 prolapse, which let alone will form the natural means of closing the 
 large wound. The endeavor should be rather to produce merely a 
 flat cicatrix. Therefore, the intra-ocular pressure should be carefully 
 controlled, and if it rises, an immediate iridectomy done. 
 
 In extensive synechia an iridectomy should be performed before 
 the patient leaves the hospital, in order to avoid the danger of increase 
 in pressure and development of a staphyloma. The continuous appli- 
 cation of a pressure-bandage is advisable to produce a flat cicatrix. 
 A typical picture is seen in those patients who have suffered from a well 
 advanced serpiginous ulcer. An extensive synechia of the iris has 
 been produced, either spontaneously or after Saemisch's incision, w r ith 
 a peripheral part of the cornea still transparent. At first the tension 
 is reduced, but finally becomes normal. At the seat of the prolapse 
 there is formed a flat scar. Suddenly the pressure increases, usually 
 with violent pains, and immediately the still soft cicatrix, which is 
 often the seat of hemorrhages, protrudes in the form of a hump. 
 Under such circumstances the performance of iridectomy is difficult, 
 as the anterior chamber is usually obliterated, the iris atrophic, and 
 the eye painful. This almost invariable result can be avoided if a
 
 212 OPHTHALMIC SURGERY. 
 
 broad iridcctomy is executed in the unaffected portion of the cornea 
 as soon as an anterior chamber has been established during the course 
 of cicatrization of the prolapse and before tension rises. 
 
 Conjunctivoplasty is a significant advance in the treatment of 
 large prolapses of the iris which is advocated especially by Kuhnt. 
 By this means it is possible to excise even a large prolapse, to protect 
 the eye from extensive synechia and at the same time close the defect 
 by solid tissue. 
 
 The operation is as follows: After excision of the prolapsed iris, 
 a cleaned ulcer with the perforation lies exposed. Either the edges of 
 the defect are flat and offer a larger surface for 
 adhesion to the conjunctival flap, in which case 
 the edges should be scraped with a sharp curette, 
 to remove the epithelium that has grown over 
 them, or they are perpendicular, in which case the 
 FIG. 113. Con- chances for fusion with the flap are less favor- 
 
 junctivoplasty. Dia- , . . , . ,1111 
 gram showing ap- able. A flap IS now made from the bulbar COn- 
 pear a nee s after i u nctiva by first detaching with the scissors the 
 
 excision of the pro- J _ J 
 
 lapsed part of the iris, conjunctiva at the limbus corresponding to the 
 
 The ulcer in the lower , , i 111^^1^ 
 
 half of the cornea is ulcer, making a second cut parallel to the first 
 free from the iris, a t a distance almost twice as great as the width 
 
 \vhich shows the ordi- . . . 
 
 nary coioboma. To of the ulcer, and uniting the two by a curved inci- 
 
 SJSJftaESU sion <Fig - , II3) - The flap formed ' in this manner 
 
 of the bulbar con- is undermined, and its base removed far enough 
 back to render it freely movable. If the ulcer 
 is at the edge of the cornea, the flap may arise from the border- 
 ing limbus; but if the loss of substance is central, it may be covered 
 either by a flap brought horizontally over the cornea or by one 
 drawn vertically over it. In the former case the detachment of the 
 conjunctiva must be performed above or below, and the base of the 
 flap must lie externally or internally. The latter method is, therefore, 
 to be preferred on account of the abundance of conjunctiva in the 
 superior fold, which readily permits the formation of a flap, while inter- 
 nally and externally there is little conjunctiva to spare. The only 
 objection is the possible danger of limiting the movements of the 
 eyeball by shortening the conjunctival fold to too great an extent. 
 
 After the flap has been rotated to the correct position, so that it well 
 covers the loss of substance, its apex is fastened by a few fine silk-sutures 
 to the bulbar conjunctiva on the side opposite to that on which the base
 
 PROI.APSK 01 Till; IRIS. 21 ^ 
 
 of the flap is attached iFig. 114). As the conjunctiva often shows a 
 tendency to curl, one or more sutures may be introduced through the 
 lateral edges of the flap, in order to keep it well stretched. Naturally, 
 too much dependence cannot be placed upon these sutures, as they 
 frequently cut through as early as the following day. Still, even this 
 short period usually suffices to maintain the flap in its correct position. 
 The wound in the bulbar conjunctiva left by excision of the flap may 
 be permitted to heal by itself, especially if there is difficult}- in covering 
 it by drawing upon the surrounding membrane; 
 or an attempt may be made to at least partly ~"\ 
 
 draw the conjunctiva over the defect with the 
 aid of incisions to relieve tension. 
 
 After the operation both eyes are bandaged 
 
 to insure a proper position of the flap by exclud- i'^'- 114- i>iaram 
 
 , ., .,. . .. . showing the conjunctiva! 
 
 ing the possibility ot ocular movements. Ik-tore t i a]1 turned over the 
 
 applving the dressings, the operator should assure u . Kr . r< n and an ' uhi : (1 1" 
 
 the bulbar conjunctiva in 
 
 himscli that the flap does not shift its position such manner" that the 
 
 ulcer i 
 covered. 
 
 during the upward rotation that accompanie 
 
 closure of the eyelids, and, if necessary, introduce 
 
 an additional suture to prevent this displacement. The bandage should 
 be changed on the following day, as we have to deal frequently with 
 excessive conjunctiva! and lachrymal secretion. Both eyes are kept 
 closed for at least three days. At first the llap appears quite swollen, 
 and some time may elapse before it again assumes the condition of 
 normal conjunctiva. It is generally not necessary to remove the stitches, 
 as they drop out of themselves in a few days. If the loss of substance 
 has occurred in the middle of the cornea, the separation of the flap from 
 its base can be tmdertaken when the eye lias become completely free 
 from congestion and the process of healing is at an end. The results 
 of this operation are in many cases remarkable, but occasionally, in 
 spite of closure of the ulceration, an atrophy of the eyeball finally sets 
 in. Of course the method cannot be blamed for these bad results, as 
 they are caused by severity of the primary changes. 
 
 Conjunctivoplasty is not limited to perforating ulcers, but is valuable 
 in losses of substance from other causes, especially to gaping wounds 
 following injury. 
 
 In transplantation of the cornea, a conjunctiva! flap properly 
 applied over the cornea will retain the transplanted piece in its position 
 during the first few davs. \Yhen tin- piece' has become attached with
 
 214 OPHTHALMIC SURGERY. 
 
 sufficient firmness, the conjunctival flap may be returned to its original 
 position or may be excised. 
 
 De Wecker's method of transplantation is of great value in severe 
 injuries. It consists in undermining the conjunctiva on all sides from 
 the limbus to the insertions of the recti muscles, after which this mov- 
 able conjunctiva is drawn completely over the cornea and closed in 
 purse-string fashion by several sutures. The raw surface of the con- 
 junctiva closes the defect and fuses with the edges of the wound. After 
 completion of the cicatricial process, the conjunctiva may again be 
 detached, after which it returns to its normal position in all directions, 
 with the exception of the point of fusion. A total detachment of the 
 conjunctiva at the limbus is not always necessary; a partial detachment 
 may suffice to draw the conjunctiva over the cornea and attach it to 
 the opposite limbus. 
 
 The cases thus far discussed refer to prolapse of the iris through a 
 wound of the cornea or at the limbus. There remains to be considered 
 the method of procedure in wounds of the sclera with prolapse of 
 portions of the ciliary body or chorioid. If the injury is not too 
 severe, so that there is hope of preserving the eye, the same rule is to 
 be observed as in prolapse of the iris. The prolapsed portion is excised, 
 the operator being satisfied with removal of that part which lies exposed 
 in the wound. For reasons that can readily be understood, we avoid 
 drawing upon the prolapse with the forceps. The wound is closed by 
 sewing the conjunctiva over it. If it is desired to introduce scleral 
 sutures, they must include only the superficial layers of the sclera, so 
 that the needle does not produce a perforation and thus cause a fresh 
 injury of the deeper parts. Scleral sutures are usually not employed, 
 as the pressure necessary to pass the needle through the sclera causes 
 further protrusion of the vitreous which lies in the wound. Scleral 
 sutures are advisable only if the wound gapes; in which case they will 
 prevent the formation of a wide cicatrix that would likely upon con- 
 traction lead to detachment of the retina. Absolute rest of the patient 
 and bandaging of both eyes during the first few days are necessary 
 requisites to promote healing of the wound. If a large part of the ciliary 
 body or of the chorioid has prolapsed, the best course is to enucleate 
 the eyeball at once. By this means the patient is relieved of a long 
 convalescence, which ends with an atrophic bulb that is subject t o re- 
 peated attacks of pain and is a source of danger, causing sympathetic 
 ophthalmia.
 
 PROLAPSE OF THE IRIS. 215 
 
 A natural question is, how long after the occurrence of the pro- 
 lapse may excision be undertaken? The possibility of loosening 
 the prolapsed iris with the conical sound presupposes a loose connection 
 between the iris and the edges of the wound. If cicatrization has 
 advanced too far the undermining with the sound can no longer be 
 carried out. No definite time can be stated. Even after two or three 
 weeks a slight adhesion may be found between the prolapsed iris and 
 the edges of the wound, so that their separation, though difficult, is 
 still possible. When the cicatrization has already led to a firm union, 
 so that an ectatic black scar is seen in place of the prolapse, the manner 
 of the operative interference again depends materially upon the size 
 of the prolapse. The simplest method is to avoid freeing the iris from 
 the corneal scar and to perform a broad iridectomy behind the normal 
 portion of the cornea. In this \vay the pressure is diminished, and by 
 simultaneously applying a pressure-bandage, an attempt is made to 
 produce a flat cicatrix. Although this simple procedure often leads 
 to the desired result, it fails in many cases, for the ectasis of the cicatrix 
 sometimes does not disappear after iridectomy, and the eye may be 
 destroyed by a renewed increase in pressure. 
 
 For these, as well as for all other cases of anterior synechia (especially 
 when the cicatrix is not solid, but dimly transparent or somewhat 
 ectatic), modern ophthalmic surgery has proposed separation of the 
 iris from the cornea, and has devised various methods for its accomp- 
 lishment. 
 
 When the scar is small, and the prolapse the size of a fly's head 
 or slightly larger, it is best to cut off the protruding cicatrix with a lancet 
 applied flat against the cornea. The opening in the cornea is usually 
 too small to permit the introduction of iris-forceps for the withdrawal 
 and excision of the iris. The latter is better accomplished by means 
 of a blunt hook. After its excision, either the iris is drawn back spon- 
 taneously into its proper position, or it may be pushed back with the 
 blunt tenaculum, as the introduction of a spatula through the small 
 opening is impossible. The small wound cicatrizes in a short time, 
 and the anterior chamber is usually established on the following day. 
 
 When the ectatic cicatrix is large, it is removed with the lancet 
 as before, and the iris is more readily excised as it can be drawn out 
 with the forceps. After this has been done, the defect is covered with 
 a conjunctival flap as already described, the conjunctiva replacing the 
 cicatrix.
 
 CHAPTER XVIII. 
 CORNEAL TRANSPLANTATION. KERATOPLASTY. 
 
 Transplantation of the cornea consists in the removal of the cica- 
 trix and its replacement by healthy corneal tissue. Fuchs was the first 
 to recommend that the fistulous or ectatic cicatrix be excised with a 
 corneal trephine, and that the defect be covered with a piece of cornea 
 removed by a trephine from a freshly enucleated eye. Before cover- 
 ing the defect, the iris must be freed from its adhesions to the cornea. 
 If the patients are not of a tranquil nature, it is necessary to perform 
 the operation under general anesthesia, in order to avoid any increase 
 of intraocular pressure by straining. The opening is made with a 
 small trephine-crown. The cutting edge of the trephine should 
 project very little, in order to avoid going too deep and injuring the 
 capsule of the lens. The eye is held by forceps, and the trephine 
 placed with slight pressure upon the cornea in the region of the cicatrix. 
 The assistant then presses upon the button of the trephine. After 
 a few rotations the instrument must be raised to determine the depth 
 of the cut, and to observe finally if the instrument has perforated. As 
 the scars are thin, perforation often occurs with unexpected rapidity. 
 After the aqueous humor has escaped, if the circumscribed piece is 
 not cut through in its entire circumference, rather than to re-apply the 
 trephine, it is better to raise the flap with forceps at its cut end and care- 
 fully separate it at the periphery with a lancet. This is not difficult, as 
 a rather deep furrow will have been made. On the posterior wall of 
 the excised piece may be seen adhering the remnants of the pigmented 
 epithelium, in accordance with the circumstance that the excised cica- 
 trix is nothing more than the iris which has undergone cicatricial 
 change. 
 
 Carefully avoiding the capsule of the lens, which lies exposed in the 
 opening, the operator then proceeds with the forceps to draw the iris 
 out a trifle on all sides, and to excise it with de Wecker's scissors. 
 In doing this there is the danger of producing an iridodialysis, especially 
 if the iris is short on one side. This is most likely to occur when the 
 iris is roughly drawn out with the forceps. It is, therefore, better to 
 
 216
 
 CORNEAL TRANSPLANTATION. 217 
 
 break up adhesions with a blunt tenaculum and thus free the iris, 
 whereupon it will usually withdraw itself from the scar, or it may be 
 pushed away with the spatula. .The defect is then covered with a 
 piece of cornea of the same size, removed with the same trephine from 
 a freshly enucleated human eye. If the lens does not protrude it is 
 sufficient to insert the piece without further fixation. It must not be 
 forgotten to note which side corresponds with the outer surface i.e., 
 which side is covered with epithelium. When the flap is placed in the 
 proper position, the upper lid is drawn down carefully over the eye, 
 and a bandage is applied to both eyes and is not removed for two 
 days. It is possible that the flap may then be found in the conjunctival 
 sac even though it may originally have lain in the correct position. But 
 in the large majority of cases it remains fixed. 
 
 It may be seen, however, during the operation, that the flap shows no 
 tendency to remain over the opening. This is especially the case if 
 the lens or the hyaloid membrane protrudes, the latter in case the lens 
 is wanting. Under these circumstances the flap must be fixed in 
 position by a flap of conjunctiva, as already described, this conjunctiva 
 serving the purpose of pressing the corneal flap upon its foundation 
 during the first few days. The conjunctival flap must not be too small. 
 A scanty flap cannot be sufficiently stretched, and, as it always has the 
 tendency to slip off from the bulging cornea, it may even lead to a dis- 
 location of the corneal flap. The conjunctival piece should be at least 
 half again as wide as the corneal flap. Moreover, as the conjunctiva 
 retracts when cut through, it is necessary in planning the conjunctival 
 incision to circumscribe a strip fully twice as wide as the diameter of 
 the corneal flap. The conjunctiva in these cases lies upon a surface 
 completely covered with epithelium. There is, therefore, no adhesion 
 between the two, and if the sutures have not spontaneously cut through, 
 in the meantime, the conjunctival flap may be loosened in a few days 
 and returned to its original position or excised. In every case of cor- 
 neal transplantation both eyes should be kept bandaged for at least 
 four days, and the patient should remain in bed. The transplanted 
 flap becomes cloudy in the course of time, but it retains its firmness. 
 By means of this operation, therefore, not only is the dangerously 
 yielding and leaking scar removed and replaced by solid tissue, but 
 also the iris has been freed from adhesions. 
 
 Partial keratoplasty consists in removing, by means of the trephine, 
 a flap of cornea which does not include its whole thickness, sparing
 
 2l8 OPHTHALMIC SURGERY. 
 
 Descemet's membrane at least. This method has been perfected 
 especially by v. Hippel. It is suitable only for those cases in which 
 the cicatricial clouding of the cornea that is to be replaced by a trans- 
 parent piece does not include the whole thickness of the cornea. By 
 means of the trephine (the crown of which should never exceed 4 mm. 
 in diameter) a groove is cut to the required depth. The flap is then 
 carefully cut out with the aid of forceps and a lancet applied flat, the 
 result being that the transparent posterior layer of the cornea lies 
 exposed in the defect. A corneal segment of the same size is then ex- 
 cised in its whole thickness from a suitable freshly-enucleated human eye. 
 The defect is covered with this piece. The eyes are carefully closed 
 and bandaged, the bandage being changed in three days. It can be 
 entirely dispensed with in nine days. The adhesion of the transplanted 
 piece usually occurs promptly, but the expectation that the flap will 
 remain transparent is almost never realized. A complete cloudiness 
 gradually develops. 
 
 Total Keratoplasty. In this operation the scar is excised for the 
 whole thickness of the cornea and is replaced by a transparent flap. 
 In this case also the flap usually adheres well, but the cloudiness becomes- 
 complete in a short time. From an optical point of view, therefore, 
 these operations are at present almost worthless. They are employed 
 only to replace a fistulous or ectatic part of the cornea. 
 
 The trephine of v. Hippel contains a drum at its upper end, in 
 which a clock-work arrangement is introduced. On the cover of the 
 drum is placed a button; by pressing on this button with the finger, the 
 crown of the trephine is set into rapid rotation. This crown can be 
 varied in height, thus regulating at will the depth of the incision. The 
 trephine contains a set of crowns of varying size. 
 
 It is evident that the operation for removal of an ectatic cicatrix with 
 the trephine can only be applied to scars of small circumference; i.e., 
 with a maximum diameter of 4 mm. If a large piece is trephined 
 from the cornea, the transplanted flap usually will not hold, and the 
 large opening will have to be covered later by a conjunctival flap. 
 Therefore, for large ectatic scars there remains only the original simple 
 method of producing a flattening of the scar by a broad iridectomy 
 and subsequent pressure-bandage. Ectatic cicatrices should be 
 removed by operative means, as they not only carry with them the dan- 
 ger of increased pressure, but also afford a portal of entry for infection 
 of the eye. But increase in pressure may also occur in cases of anterior
 
 CORNEAL TRANSPLANTATION. 2 19 
 
 synechia, in which the corneal scar is not only flat but also solid, espe- 
 cially if a considerable portion rather than a small tip of the iris is 
 adherent to the scar. 
 
 Operations for Anterior Synechia. It is difficult to give a general 
 rule for operative interference in anterior synechia a flat cicatrix 
 being naturally implied. It has already been explained that an ectatic 
 scar should be subjected to operation under all circumstances. But 
 there occurs the question, should an operation be performed in every 
 case of anterior synechia with flat solid cicatrix? By no means is this 
 our belief. In deciding, the following are considered indications: 
 (i) If the fusion is extensive, so that a large part of the pupillary border 
 is adherent to the cicatrix. (2) If signs of increased pressure are pres- 
 ent even though they occur but intermittently. (3) If the cicatrix, 
 although originally flat, threatens to yield to the intra-ocular pressure 
 (beginning protrusion). (4) If dislocation of the pupil, as a result of 
 distortion of the iris, hides the pupillary opening completely behind 
 the cicatrix. The latter may occur in a peripheral adhesion of the iris, 
 when the pupil is so distorted that only the irregular refracting border 
 of the cornea can be used for visual purposes. The same visual dis- 
 turbance occurs when the pupil is directly covered by a central corneal 
 cicatrix. In the fourth indication, the operation is demanded upon 
 essentially optical grounds. While we were formerly well satisfied 
 with iridectomy in all these cases, we now prefer a temporary resec- 
 tion of the cicatrix with the aid of the trephine a method which was 
 first recommended by Sachs. As the scar is solid, it does not require 
 to be replaced by a piece removed from another cornea. 
 
 In order to avoid the danger of delayed healing of the excised flap 
 of cornea, it is only separated in a little more than half its circum- 
 ference by placing the trephine obliquely upon the cornea. In 
 this way an assistant may lift the flap like a lid with a sharp tenaculum, 
 while through the opening thus produced the operator enters the 
 anterior chamber with the forceps or a tenaculum, draws the iris care- 
 fully out o n all sides and excises it. The base of the flap is so placed 
 that the iris can be most readily reached through the opening produced 
 by lifting the flap. In most cases, therefore, this base will lie toward 
 the center; that is, toward the pupil. After the iris is completely freed, 
 the flap is returned to its original position, in which it is firmly held 
 by the pressure of the upper lid when the eye is closed. A light com- 
 press and bandage may be used to support the lid. By the use of
 
 220 OPHTHALMIC SURGERY. 
 
 atropin an attempt is made to retract the iris as far as possible from 
 its former point of adhesion. The anterior chamber will be re-estab- 
 lished on the next day, but it is advisable to keep the eye bandaged 
 for at least one week. The corneal cicatrix, which was formerly 
 somewhat thin and had already become slightly ectatic, is often observed 
 to become flat and solid after this operation. After detachment of 
 the iris from the cicatrix, the former withdraws, and the pupil returns 
 to its position behind the center of the cornea. Therefore, by this 
 means not only have the optical disturbances been remedied, but also 
 the anterior synechia is removed. When the eye has become entirely 
 free from inflammation, and healing is complete, a tattooing of the scar 
 may be performed. 
 
 The only danger in trephining the cornea lies in an injury to the 
 lens. Sometimes, unfortunately, this cannot be avoided, as, for in- 
 stance, when the lens-capsule is adherent to the scar, and the capsule is 
 cut when the corneal cicatrix is incised. But in these very cases the 
 injury to the lens is not so important, as this structure is usually 
 cloudy and, in young persons, frequently shrunken. The most dreaded 
 sequel occurs after the escape of the lens-substance, when the delicate 
 hyaloid membrane appears in the wound and ruptures, leading to 
 prolapse of the vitreous humor and preventing continuance of the 
 operation. 
 
 If the adhesion of the iris consists merely of a fine filament which, 
 for example, unites the anterior surface of the iris with a solid corneal 
 cicatrix, a division of this attachment is certainly not necessary. The 
 same holds true of an adhesion between a small part of the pupillary 
 border and the cornea, provided that the cicatrix itself is in good condi- 
 tion. Moreover, these are the cases in which the anterior synechia can 
 be divided by the simpler means of the discission needle or the Graefe's 
 knife. 
 
 In cases of anterior synechia produced by the iris healing in an oper- 
 ation-cicatrix, the mode of procedure cannot be governed by any 
 general fixed rules. The point of view to be taken may perhaps be 
 more readily comprehended from several examples: After an iridec- 
 tomy for glaucoma, in which one or both sides of the excision have be- 
 come adherent to the wound, no additional interference is called for if 
 tension is normal and the operative cicatrix remains flat, presenting 
 at most a dark coloration of the scar due to the adhesion of the iris. 
 If fresh attacks of increased pressure arise, it would be a mistake to
 
 CORNEAL TRANSPLANTATION. 221 
 
 proceed immediately to the performance of a second iridectomy, .as 
 the latter, being carried out inferiorly, would exert an unfavorable 
 influence upon the visual function. Here, however, it is necessary 
 to remove the adhesion of the iris. 
 
 The first method of operation consists in making with a lancet 
 an incision corresponding to the adherent side of the coloboma; this 
 incision should be as near the periphery as possible. Then the iris is 
 drawn out with the iris-forceps and excised, whereupon it either spon- 
 taneously returns to its proper position or is replaced with a spatula. 
 
 The second method takes into consideration the possibility of an 
 injury to the lens, and is, therefore, safer. An incision is made in the 
 region of the iris-adhesion similar to that of an anterior sclerotomy. 
 A Graefe knife is introduced on one side of the adhesion, and is brought 
 out of the anterior chamber on the other side of the adhesion, and 
 makes a scleral cut as near the periphery as possible, so that the iris is 
 thereby severed from its adhesion. The incision need not be com- 
 pleted. Especially when a prolapse of the vitreous humor is to be feared, 
 the flap should not be completely cut through, in order to avoid a gap- 
 ing wound. If the iris does not retract after the incision, this method 
 also permits the operator to draw the iris out with tenaculum or forceps 
 to excise it to its proper position. 
 
 Operation for cystic scars after iridectomy for glaucoma 
 is at present much under debate. Some authorities consider these 
 cicatrices with their porous and nitrating properties favorable occur- 
 rences in glaucomatous eyes, and do not remove them unless forced to 
 do so. Others maintain that it is better to free the iris and produce a 
 flat cicatrix, thus protecting the eye from other dangers that may 
 arise from cystic scars, especially the danger of spontaneous late 
 infection.
 
 CHAPTER XIX. 
 
 EXTRACTION OF FOREIGN BODIES FROM THE INTERIOR 
 
 OF THE EYE. 
 
 The extraction of foreign bodies from the interior of the eye is 
 usually a most delicate operation, particularly if attempted weeks 
 or months after the original injury. There is no typical operative 
 method that may guide the less skillful, and, as many of the most 
 important structures of the eye are directly or indirectly affected in 
 any form of operation, these may readily receive more injury than aid 
 from the operator of limited experience. 
 
 Diagnosis. In many cases one can recognize at first glance a 
 perforation of the eyeball by a foreign body and determine the pres- 
 ence of the latter within the eye, but in others it may be difficult to 
 find the point of entrance and to discover the foreign body itself. 
 It frequently happens that a patient will complain of diminution in 
 visual power without known cause and with positive denial of any 
 injury, while the skilled eye of the physician, warned by the finding 
 of a unilateral-partial cataract, will examine the eye with a magnifying 
 glass and at once discover a positive sign of previous penetrating wound 
 in the form of a fine linear corneal cicatrix. If the media is sufficiently 
 transparent to permit an ophthalmoscopic examination, the splinter 
 will be found in the vitreous or retina. Naturally even the most 
 experienced surgeon may in some cases only succeed after prolonged 
 efforts. 
 
 Often a vain search is made for the cicatrix. A fine narrow splinter 
 with sharp edges, penetrating the sclera at the limbus or through the 
 bulbar conjunctiva, will leave behind not the slightest trace of a 
 visible cicatrix. The diagnosis will then depend upon the exami- 
 nation with the ophthalmoscope, the sideroscope and the Rontgen rays. 
 An advanced cataract may render impossible the illumination of the 
 eye-ground and the consequent discovery of the foreign bcdy. Again, 
 the lens may remain transparent in spite of a perforating injury; 
 namely, if the perforation has occurred through the sclera without 
 injuring the lens. However, the diagnosis may be rendered difficult 
 
 222
 
 EXTRACTION OF FOREIGN BODIES. 223 
 
 through the presence of dense vitreous turbidity, which is usually 
 greatest around a foreign body lodged posteriorly in the eyeball. Or 
 the difficulty in diagnosis may be due to the separation of the retina, 
 which occurs frequently in such injuries. An exact and complete 
 diagnosis, including the localization of the splinter, is most readily 
 made when the opportunity is afforded of examining the patient im- 
 mediately after the injury. Under these conditions, even if the lens 
 is pierced, it is frequently possible, in spite of beginning lenticular 
 turbidity, to find the splinter by means of the ophthalmoscope in the 
 vitreous or in the retina. 
 
 The position of the foreign body does not always correspond to the 
 direction indicated by the corneal w r ound and the turbidity of the lens. 
 It frequently happens that the splinter has been deprived of its momen- 
 tum through resistance of the cornea and lens, and simply falls to the 
 bottom of the vitreous chamber. On the other hand, it may have been 
 projected as far as the retina without penetrating the latter, and may 
 have sunk downward from the point of impact. It is, therefore, always 
 advisable to examine first the fundus, especially in the direction of the 
 corneal and lenticular wounds. Here there may be discovered a 
 wound in the retina and chorioid, appearing as a glistening, white spot 
 (the exposed sclera), which may even assume the form of the foreign 
 body; or there may at least be seen a hemorrhage corresponding to the 
 point of impact. 
 
 In most cases the foreign body is a splinter of metal, which is ren- 
 dered conspicuous by its metallic luster, as its outer surface reflects 
 light strongly. In recent cases, air-bubbles may not infrequently, 
 be seen in the vitreous or around the foreign body. If a dense opacity 
 of the vitreous lies in front of the foreign body, the position of the 
 latter is betrayed by a conspicuous whitish luster. In presence of iron- 
 splinters within the eye, the sideroscope renders valuable assistance; 
 it not only indicates the presence of small particles, but also at the 
 same time allows an incidental localization, manifested by a marked 
 deviation of the magnetic needle upon approaching the position of the 
 fragment. 
 
 However, the deviation of the magnetic needle does not always 
 indicate the presence of a splinter within the eyeball. We have 
 recently seen an illustrative case in which a patient declared that he 
 had been wounded by a splinter while hammering on iron two months 
 previously. The splinter penetrated the lower lid about 8 mm.
 
 224 OPHTHALMIC SURGERY. 
 
 below the edge of the lid. The wound bled slightly, and it was on y 
 after the lapse of some time that the patient noticed a gradual dimi- 
 nution in the visual power of this eye, without having experienced any 
 inflammation. When the patient was seen for the first time, there was 
 found a delicate scar in the skin of the lower lid about 3 mm. in length. 
 No cicatrix could be found on the eye by the minutest examination, 
 but the vision was about one-fourth normal. By means of the ophthal- 
 moscope, floating vitreous opacities could be seen, which were fixed 
 below and moved about freely in the upper part of the eyeball. Upon 
 looking downward, the red reflex was lost entirely, on account of 
 increasing density of the opacities. As the visual field was much 
 limited in its upper part, a separation of the retina in this region seemed 
 probable. The splinter could not be seen. The patient was placed 
 in front of the sideroscope. Upon approaching it, the needle was 
 immediately affected, and showed a marked deviation. This occurred 
 with almost the same intensity in all positions of the eyeball, but 
 was greatest when the patient was brought near, with the eye directed 
 upward. But in front of the large magnet even the strongest currents 
 did not draw out the splinter, and the patient did not have the slightest 
 pain. This was more remarkable, since the presence of a large splinter 
 had been assumed from the size of the palpebral cicatrix and the 
 deviation of the sideroscope. However, examination with the Ront- 
 gen rays showed that actually a splinter 5 mm. long was lodged in the 
 orbit outside of the eyeball. In its course through the orbit the splinter 
 either had perforated the sclera twice, or had slit up the envelope of the 
 eyeball below, and had thus produced the intra-ocular changes. 
 
 The extraction of iron splinters by the magnet operation will 
 first be described. When the iron splinter is found in the vitreous 
 chamber or in the retina, the method employed exclusively in our clinic 
 consists in first drawing this splinter into the anterior chamber by 
 means of the large magnet (Haab) . This operation must be carefully 
 performed, in order that the eye shall not receive disastrous injury. 
 There are two means at our command to lessen the attractive power 
 of the large magnet on the eye, either by employing a weak current 
 so that the iron core is given but slight magnetic pull, or by keeping 
 the eye at some distance from the pole of the magnet. The object 
 is to use the least possible magnetic force necessary to draw the splinter 
 gently around the edge of the lens, first behind the iris and then 
 through the pupil into the anterior chamber. If the position of the
 
 EXTRACTION OF FOREIGN BODIES. 225 
 
 splinter has been determined, it is not difficult to rotate the eye into 
 the proper position. For example, if the splinter lies in the lower 
 part of the vitreous chamber, the eye will be directed downward upon 
 approaching the magnet, so that the latter is brought approximately 
 opposite the center of the cornea. If the injury has occurred recently, 
 the splinter will very soon follow the magnet, and will appear behind 
 the iris, causing a protrusion of the latter. If the injury is of longer 
 duration, it may take some time before the splinter yields to the traction 
 of the magnet. If it is seen that the extraction cannot be accom- 
 plished with mild currents, the strength of the latter is gradually 
 increased. But if the patient experiences pain even with a mild current 
 this is an indication that the splinter is yielding, and is perhaps in 
 contact with the ciliary body; greater care must then be taken in the 
 operation. If the foreign body has become firmly lodged in the 
 posterior eye-ground by means of inflammatory bands, even the large 
 magnet may not be sufficient to dislodge it, especially if the splinter 
 is very small. It may then be necessary to subject the patient to the 
 magnet repeatedly, and each time for a longer period, before we 
 succeed in drawing the splinter gradually from its bed. 
 
 Having been drawn into the anterior chamber, the splinter may be 
 pulled by force of the magnet to the posterior wall of the cornea, where 
 it remains hanging; or it may fall upon the iris or into the angle of the 
 chamber, where, if sufficiently small, it may entirely disappear from 
 view. To remove the splinter from the anterior chamber, an incision 
 is made with the lancet, usually below, and of sufficient size so that an 
 instrument, such as forceps or the end of a small magnet, may readily 
 be introduced without compressing the iris or cornea. It is best to 
 attempt to combine the incision and the extraction of the foreign body 
 in one act. The assistant by means of the small magnet holds the 
 splinter against the center of the posterior corneal wall, while the 
 operator introduces the lancet. At the moment when the operator 
 begins to withdraw the lancet from the eye, the assistant moves the 
 magnet downward along the outer surface of the cornea, so that the 
 splinter makes its exit from the wound along the outer surface of the 
 lancet simultaneously with the latter. 
 
 A negative result from the examination with the sideroscope is not 
 always to be accepted as a certainty that no' steel is in the eyeball or 
 orbit; a slight deviation may frequently have no significance, especially 
 in large cities, where the magnetic needle is always in a state of unrest.
 
 226 OPHTHALMIC SURGERY. 
 
 Penetrating wounds of the eyeball are often made with splinters 
 of other materials, such as wood, stone and especially copper, which 
 may penetrate the eye from an explosion of percussion caps. If these 
 splinters lodged in the posterior section of the eyeball, until recently 
 the eye was usually looked upon as lost; and if it was certain that such 
 an intra-ocular foreign body was present, an enucleation was imme- 
 diately performed. Examination with the Rontgen rays has since 
 effected a great change in the treatment of these cases, and has made it 
 possible to save many eyes that were formerly regarded as lost. Without 
 a previous examination with the Rontgen rays, no operation should 
 be undertaken in any case where there is suspicion of an intra-ocular 
 foreign body, with perhaps the exception of an iron splinter. By this 
 examination there is also given us accurate information concerning the 
 position of the splinter. 
 
 Summary In concluding these observations, it may be said in 
 general that the presence of small wounds caused by the impact of 
 foreign bodies usually points to the likelihood of these bodies having 
 entered the eye; while in patients showing large wounds the injury is 
 caused by larger pieces which rebound and do not remain in the eye. 
 For example, if a recent injury of the cornea is found in the form of a 
 small perforating wound, and if the history is obtained that a small 
 splinter had come in contact with the eye, such circumstances will 
 allow the presumption that there is a foreign body within the eye. 
 If it is not found lying in the anterior chamber, the search for a per- 
 foration of the iris, lens-capsule, etc., will not be in vain. On the 
 other hand, a larger piece, flying against the eye with its fine point, 
 might wound the cornea, iris and lens-capsule and then drop away. 
 In this case the patient's statement concerning the size of the splinter 
 is of importance. 
 
 Unfortunately, the result with the small magnet is often unsatis- 
 factory. It is not sufficiently strong to exert its magnetic power 
 through the cornea and to direct the splinter at will. If the attempt 
 just described is not successful, the splinter may be drawn out of the 
 anterior chamber through the wound by means of the magnet. The 
 tip of the magnet is introduced through the wound into the anterior 
 chamber and brought close to the foreign body, so that the force is 
 sufficient to attract the splinter. As the various terminals of the mag- 
 net are relatively thick, it is less injurious to grasp the foreign body 
 directly with a pair of forceps and thus withdraw it. Occasionally
 
 EXTRACTION OF FOREIGN BODIES. 227 
 
 the splinter can be removed with the aid of Daviel's curette. This 
 instrument is introduced behind the foreign body, presses it against 
 the posterior corneal wall, and renders its extraction easy along the 
 channel formed by the curette. In all these procedures care must be 
 taken not to allow the splinter to disappear behind the iris, either by 
 falling downward or by being pushed upward behind the pupil by the 
 use of an instrument. In order to bring again to view the foreign 
 body, recourse must usually be had again to the large magnet, espe- 
 cially if a minute splinter has disappeared below into the bottom of the 
 chamber. The iris is to be excised only, if severely injured by the 
 accident, or, as rarely occurs, it has been badly contused during the 
 operation. If the foreign body has perforated the lens and the wound 
 in the capsule becomes closed by the iris, the opacity in the lens may 
 remain slight and stationary. In this case that part of the iris which 
 covers the wound in the capsule should be carefully avoided during 
 the operation. 
 
 Extraction from the vitreous through the anterior chamber is contra- 
 indicated only if the foreign body has penetrated the sclera behind 
 the lens, so that the latter has remained completely transparent. In 
 this case the splinter is withdrawn directly through the original wound 
 by means of the large magnet, applied as described. If necessary, 
 the wound can be enlarged to a sufficient size. Only by gross care- 
 lessness on the part of the operator will parts of the chorioid and 
 retina be withdrawn with the foreign body. If the magnet is made 
 sufficiently weak, the splinter can slowly be brought into the wound 
 whence it may be readily extracted. 
 
 Some operators believe that extraction through an opening in the 
 sclera, preferably between the external and inferior recti muscles, with 
 the magnet-point between the lips of the wound, but not entered into 
 the vitreous, is a safer procedure than removal of the foreign body 
 around the lens into the anterior chamber. This is the method largely 
 followed in America, the position of the metal being accurately deter- 
 mined by means of the Roentgen-rays before operation. 
 
 Prognosis. The smaller the splinter, the more favorable is the prog- 
 nosis for the future of the eye. Large splinters render the prognosis 
 bad, because of the immediate injury to important parts of the eye, and 
 the subsequent inflammation that occurs. Even though their extraction 
 may have been performed smoothly, separation of the retina or chronic 
 iridocyclitis may follow, usually necessitating enucleation of the eye.
 
 228 OPHTHALMIC SURGERY. 
 
 Foreign bodies other than iron that lodge in the anterior section 
 
 of the eye, may in exceptional cases be extracted through the original 
 wound in the cornea, after its enlargement by means of scissors. 
 Only peripheral wounds, however, are suitable for this procedure. 
 Wounds near the center of the cornea if similarly treated would later 
 produce still greater disturbance of vision through the larger cicatrix 
 resulting from the incision, and it is, therefore, the best procedure to 
 make a lancet-incision elsewhere of sufficient size to permit the intro- 
 duction of forceps. This incision may be difficult if the wound pro- 
 duced by the foreign body has not yet closed, permitting escape of the 
 aqueous and shallowing of the anterior chamber. But even then a 
 correct incision can be made between the cornea and iris without 
 wounding the latter, especially if a Graefe knife is used and is slowly 
 introduced between both membranes. If the splinter in the anterior 
 chamber is large and warped, care must be taken during its with- 
 drawal not to wound the iris or capsule of the lens. The incision into 
 the anterior chamber is best made below or externally, from which 
 directions instruments can be most readily introduced into the eye. 
 
 The extraction from the vitreous chamber of foreign bodies not 
 composed of iron is incomparably more complicated. Such substances 
 are usually splinters of copper or grains of shot. Before operating for 
 their removal, they must be accurately localized, using the Roentgen 
 rays for this purpose. On account of their weight, most of these for- 
 eign bodies fall to the bottom of the vitreous chamber, where they 
 immediately become fixed by exudate. They can most readily be 
 recovered, if they lie externally and below. The operative procedure 
 is as follows: After an incision into the conjunctiva and uncovering 
 of the sclera, a meridional opening, at least 6 to 8 mm. long, is made 
 in the neighborhood of the foreign body, the cut extending through 
 the sclera into the vitreous humor. With double tenacula the assistant 
 raises and separates the edges of the wound, in order to facilitate an 
 examination of the interior of the eye. During this procedure the 
 loss of vitreous humor can readily be avoided. It is best to have the 
 patient in condition of profound anesthesia. 
 
 If the incision corresponds with the position of the foreign body, 
 the latter will appear in the wound and can be removed with forceps. 
 But if it has not appeared in the wound, the attempt to find it in the 
 vitreous chamber is usually hopeless. The immediate neighborhood 
 of the wound must be carefully explored with the iris-forceps, in the
 
 EXTRACTION OF FOREIGN BODIES. 22Q 
 
 hope of locating the foreign body. Occasionally, the use of Sach's 
 lamp will be of material assistance in the operation. If the lamp 
 is placed by an assistant laterally against the cornea, without exerting 
 pressure on the eye, the open incision and the whole vitreous space is 
 illuminated and transparent, so that in fortunate cases the foreign 
 body is recognized as a dark structure, and can be grasped and with- 
 drawn with the forceps. After the extraction it is necessary to suture 
 the scleral wound accurately through the superficial layers, and to 
 sew the conjunctiva over it. The patient should be kept in bed for 
 several days. The prognosis even in successful cases is bad on 
 account of detachment of the retina. 
 
 If the extraction of the foreign body has not been accomplished, 
 it is best to proceed at once to the enucleation. The consent of the 
 patient to this operation should be obtained beforehand, telling him 
 that the other procedure is merely an attempt to save the eye through 
 search for and extraction of the foreign body. Non-magnetic foreign 
 bodies situated in the neighborhood of the macula give no hope of 
 extraction with preservation of the eye. 
 
 In all recent injuries, whether the splinter is of iron or of other 
 material, immediate operation should be undertaken. It is other- 
 wise, however, with old injuries. We know that splinters of iron 
 are not well borne, but cause a gradual disintegration of the eye through 
 an incidious inflammation and sidcrosis. As extraction with the 
 magnet is usually successful even in these old cases, the operation is 
 always performed, especially when there are already signs of a dele- 
 terious influence exerted by the foreign body. The case is different 
 with non-magnetic bodies in the posterior segment of the eye. Of these 
 copper splinters are least well borne, and the attempt to remove them 
 should be made in every case. I kit if such foreign body is securely 
 lodged without signs of irritation or inflammation, the operation should 
 be avoided on account of its unfavorable prognosis, and only under 
 taken if threatening phenomena arise.
 
 CHAPTER XX. 
 
 MINOR CORNEAL OPERATIONS. PTERYGIUM. THE 
 OPHTHALMIC ASSISTANT. ANESTHESIA. 
 
 THE OPERATIVE THERAPY OF SERPIGINOUS ULCER. 
 
 Small serpiginous ulcers may be combated by subconjunctival 
 injections of a i-iooo corrosive sublimate solution, using TO" cc. 
 Should no further progress of the ulcer be observed on the following 
 day this treatment may be continued, but if the infiltration tends to 
 spread, the thermocautery is to be immediately employed, since 
 every millimeter of tissue is valuable, as the affected area is situated at 
 or near the center of the cornea. The cautery is applied to the entire 
 ulcer, paying especial attention to its yellow, infiltrated, progressing 
 borders. A simultaneous puncture of the anterior chamber has a 
 favorable influence on the course of the disease, and should therefore 
 not be neglected in view of the insignificance of the procedure. It makes 
 no difference whether or not the hypopyon is thereby removed from the 
 eye. If the ulcer has penetrated deeply, the opening of the anterior 
 chamber may be accomplished after first thoroughly cauterizing the 
 whole ulcer by burning through the cornea in a punctiform spot, so 
 that the aqueous humor trickles out slowly. The slight perforation 
 soon closes and an adhesion of the iris is not to be feared, if the opening 
 is in the region of the pupil. 
 
 Serpiginous ulcers that have affected more than one-third of the 
 cornea are not longer amenable to this form of treatment, as the exten- 
 sive destruction of the cornea in its whole thickness leads to perforation 
 before completion of the cauterization, thus bringing this interference 
 to a close. It is in these cases, and only in these cases, that we follow 
 another procedure, i.e. splitting the cornea according to the Saemisch 
 method. The cocainized eye is held with the forceps below, and the 
 cornea is then split in the region of the serpiginous ulcer with a Graefe 
 knife. In performing this operation, the knife with the cutting edge 
 directed forward, is introduced into the healthy part of the cornea close 
 to one edge of the ulcer, and is brought out at the opposite edge, so 
 that the ulcer is cut through. The blade of the instrument must be 
 
 230
 
 MINOR CORNEAL OPERATIONS. 23! 
 
 rather parallel to the cornea, in order that the lens will not be injured, 
 as would occur if held more perpendicular and the point thus directed 
 backward. By a slow, sawing motion, the cornea is then split in the 
 region of the ulcer from behind forward. It is best to direct the incision 
 so that it passes through the extending, yellow, infiltrated part of the 
 border. The aqueous humor escapes rapidly through the incision, 
 and the hypopyon is frequently forced into the wound, whence it can 
 readily be extracted in a compact mass by a pair of forceps. 
 
 The opening into the anterior chamber must not be allowed to close 
 until the ulcer has become clean and retrogressive. The reopening of 
 the incision in the succeeding days is not difficult, and may be 
 accomplished by slightly depressing one lip of the w r ound with a spatula. 
 The splitting of the cornea does not always have the desired effect, and 
 the serpiginous ulcer progresses further and destroys the whole cornea. 
 However, a favorable result usually follows, but the operation has the 
 disadvantage of causing extensive attachments between the cornea 
 and the iris. These adhesions cannot be avoided, but we select the 
 Saemisch section only in advanced serpiginous ulcers to preserve an eye 
 that would probably otherwise be entirely ruined by the infection. 
 
 Before the patient leaves the hospital, a broad iridectomy is per- 
 formed behind the transparent part of the cornea, to prevent the other- 
 wise certain onset of increased pressure, which would completely do 
 away with the visual power and cause the patient other inconveniences 
 through the transformation of the flat cicatrix into a staphyloma. 
 Serpiginous ulcers are frequently associated with purulent disease of 
 the lachrymal canal, and an important part of the treatment of the 
 corneal affection is the immediate removal of the diseased sac. 
 
 OPERATION FOR PTERYGIUM. 
 
 Transplantation of the pterygium is the simplest and at the same 
 time the most reliable method. After well cocainizing the eye, the 
 lids are opened with a spring-speculum, and the 
 patient is told to look toward the side opposite to 
 the pterygium. The operator then grasps the neck 
 of the pterygium with toothed forceps, stretches it 
 somewhat, and applies a lancet flat against the Hg. 115. Trans] .lantu- 
 
 11 i / \ /T-" \ l ' on f pterygium. 
 
 cornea completely separating the head (a) (r ig. 115) 
 
 from the corneal tissue, with which it is firmly united. This peeling 
 
 off must be done carefully, so that none of the advancing part of the
 
 332 OPHTHALMIC SURGERY. 
 
 pterygium is left on the cornea. When the head is once free, the 
 remaining loosely connected portion of the growth is separated as 
 far as the border of the cornea and for a short distance on to the 
 sclera. The border of the pterygium, lying at the apex of the loosened 
 conjunctiva, is excised with the scissors, and the 
 pterygium with its apex (a) turned inward so that 
 its raw surface is directed forward and its two 
 borders (ab, ac] diverge toward the cornea (Fig. 
 Fig. 1 1 6. Transplan- u6). By two or three suitable sutures the borders 
 
 tation of ptervgium su- . , , . i 
 
 tures in pcstion are now united, taking care that no wound re- 
 
 mains at the limbus. The first suture is therefore 
 introduced vertically in the neighborhood of the limbus, it being 
 advisable to include with the needle a few superficial fibers of the 
 sclera between the two edges. A projection is formed on the conjunc- 
 tiva by the transplanted pterygium, but in a short time it completely 
 disappears. 
 
 Arlt's method for the removal of pterygium is also used frequently. 
 The pterygium is held with toothed forceps at its neck, where it can be 
 slightly lifted from the underlying part. The 
 separation is the same as previously described. 
 While none of the advancing head should be 
 left on the cornea, no normal corneal layers 
 should be unnecessarily removed by cutting too 
 deeply, as this would produce a more extensive 
 scar. After separation of the pterygium, two 
 convergent incisions (c b u, b d) are made in its 
 body (see Fig. 117). A rhomboidal piece is 
 
 i . j . . , , i j , ,. Fig. 117. Arlt's method of 
 
 thus excised, consisting of the head and part of operation for pretygium. 
 the body. The conjunctiva opening is accur- 
 ately closed by two sutures which are introduced in a vertical posi- 
 tion. The wound in the cornea heals by cicatrization, causing a 
 permanent opacity. The complete and accurate closure of the wound 
 in the conjunctive is of great importance, otherwise the conjunctiva 
 will again be drawn on to the cornea by the cicatricial tissue. 
 
 TATTOOING THE CORNEA. 
 
 Only solid, flat scars of the cornea are suitable for tattooing. If 
 there is a tendency to ectasis or if the scar is thinned, tattooing is 
 to be avoided. India ink is the only pigment applicable for the pur-
 
 MINOR CORXEAL OPERATIONS. 233 
 
 pose. It is introduced into the corneal scar by pricking either with a 
 cluster of needles, or with a single, broad needle, provided with a 
 groove for holding the coloring matter. In order to produce the 
 best results, the tattooing must usually be done in several sittings. 
 Thorough cocainization is always necessary. To hold the eye steady, 
 the conjunctiva should be grasped with slightly roughened forceps, as 
 toothed forceps produce slight wounds which become impregnated with 
 the pigment. 
 
 Tattooing with the cluster of needles is to be preferred to that done 
 with the grooved needle. The latter is better suited, however, for 
 accurate definition of the border. With the cluster of needles which 
 are put in vertically, the operator produces simultaneously a series of 
 closely-placed points, and, therefore, works more rapidly. There is 
 also less danger of perforating the cornea than with the grooved needle, 
 which has to be applied in a slanting direction to prevent perforation. 
 If the latter should accidently be produced and the pigment enters 
 the anterior chamber, it must be opened with a lancet and washed out. 
 
 Froehlich's method is an excellent procedure for imitating a beauti- 
 ful, round, black pupil. It is recommended for very large and thick, 
 flat scars. With a v. Hippel trephine a superficial furrow is cut, corre- 
 sponding in position and size to the pupil of the other eye. Then, with 
 a lancet applied on the flat, the superficial layers of the cicatrix, con- 
 taining epithelium and a few lamellae, are removed in the form of a 
 disk. The exposed base is scarified in all directions with the cutting 
 edge of the lancet and the ink is rubbed in well. In this way a pro- 
 nounced and uniformly black pupil is produced, which closely resembles 
 a true pupil. The surroundings are then tattooed by pricking with 
 the cluster of needles until the desired shade is produced. 
 
 OPERATION FOR CORNEAL STAPHYLOMA. 
 
 The method of Beer-Wecker is employed for the removal of a 
 complete corneal staphyloma. The conjunctiva is detached completely 
 around the limbus, as in the operation for enucleation, is thoroughly 
 undermined, and a purse-string suture introduced which is at first 
 left loose. The epithelium on the limbus and the border of the staphy- 
 loma is then carefully denuded, in order to produce a raw surface to 
 which the conjunctiva can adhere when drawn over it. The staphy- 
 loma is then cut away; in doing this the lower half is first separated by
 
 234 OPHTHALMIC SURGERY. 
 
 means of a Gracfe knife in the same manner as for a cataract-operation. 
 The flap thus formed is held by forceps and the upper half is separated 
 with the scissors. A narrow band should be left above and below, 
 through which sutures are introduced and left loose. Before tying the 
 sutures, the lens is allowed to escape from the eye by opening the lens- 
 capsule; after which the sutures are rapidly draw r n together to avoid loss 
 of the vitreous humor. Then the wound in the conjunctiva is closed 
 by drawing upon the purse-string suture. 
 
 In a recent staphyloma with thin walls an attempt may be made 
 to produce a flat scar by simply splitting the staphyloma. In this 
 operation it is best to make a bow-shaped incision like that for cataract, 
 so that the flap is formed from the wall of the staphyloma. By retrac- 
 tion of the flap, the wound is made to gape, which effect may be increased 
 by excising a narrow edge from the flap. The lens is removed by rup- 
 ture of the anterior capsule. Then by means of a compress and ban- 
 dage, a flat cicatrix may be produced. 
 
 The incision of a staphyloma has only one advantage over enuclea- 
 tion, namely, that the patient is left with a freely movable stump, 
 upon which an artificial eye can be well fitted. On the other hand, 
 the operation has the disadvantage of not guarding against sympathetic 
 ophthalmia. It is, therefore, evident that enucleation should be 
 preferred in all cases in which there is suspicion of sympathetic oph- 
 thalmia or in which the latter may readily develop. 
 
 EXPRESSION OF TRACHOMA-GRANULES. 
 
 This operation is performed under cocain-anesthesia. After repeated 
 instillation of the cocain-solution into the conjunctival sac, a sub-con- 
 junctival injection of a i per cent, cocain-solution is made beneath that 
 part of the conjunctiva upon which the expression is to be commenced. 
 The conjunctiva over the granules is then superficially scarified 
 with a Graefe knife, so that the granules may readily make their exit 
 through the slight incisions thus produced. In order to gain comfort- 
 able access to the upper fold, the lid is everted. Moreover, the sub- 
 conjunctival injection causes a marked swelling and protrusion of the 
 fold. For expression of the granulations we employ either Knapp's 
 roller-forceps or Kuhnt's expresser. 
 
 In using Knapp's roller-forceps, the conjunctival fold is grasped 
 between the two branches, one end of the roller-forceps being introduced
 
 MINOR CORXEAL OPERATIONS. 235 
 
 above between the scleral conjunctiva and that of the lid, while the 
 other end is placed upon the anterior surface of the tarsus. The 
 instrument is pressed together rather forcibly and is drawn slowly 
 along the conjunctiva. During this procedure the ridged rollers pass 
 over the conjunctiva and express the granulations. The traction 
 should not be made rapidly, as this may produce more marked lesions 
 of the conjunctiva in the form of lacerations, and give rise to fresh 
 scar-formation. The more carefully the operation is done, the less 
 painful will it be and less injurious to the conjunctiva. The consider- 
 able bleeding which follows is combated by active sponging with a 
 weak bichlorid-solution. 
 
 In a similar manner the lower lid is freed of its granulations. With 
 Knapp's roller it is more difficult to strip the semi unar fold, and especi- 
 ally to squeeze out isolated granulations, without including and com- 
 pressing the surrounding conjunctiva. For these cases it is best to 
 employ simply a small forceps, the narrow branches of which can readily 
 grasp and express isolated granulations. If a group of granulations 
 is found on a sharply circumscribed area of the upper fold or elsew r here, 
 we usually excise this part of the conjunctiva. On the other hand, 
 we prefer the method of expression in those cases in which the granular 
 formation, though sharply circumscribed, includes the whole length 
 of the fold. In order to extract the granulations from the tarsal con- 
 junctiva, the tarsus itself must be seized between the branches of the 
 roller-forceps. 
 
 With Kuhnt's expressor the granulations are pressed out of the 
 conjunctiva without pulling on the latter. The advantage of this " 
 instrument, therefore, lies in the avoidance of the lesions which occasion- 
 ally follow^ laceration of the conjunctiva. Kuhnt recommends the 
 instrument especially for advanced, felty trachoma, as in these cases tin- 
 conjunctiva of the transitional fold is easily lacerated and wounded by 
 the rolling, on account of the felty change. The unpleasant result of 
 this injury would be a marked contraction of the conjunctival sac. 
 With Kuhnt's expressor all pulling and lacerating of the conjunctiva 
 is avoided, and the granulations are pressed out of their beds like 
 comedones. 
 
 After expression, cold compresses should be applied diligently 
 for several hours. After an interval of about two days, the further 
 medical treatment of the conjunctival disease may be commenced, i.e., 
 touching with 2 per cent, silver-nitrate solution.
 
 236 OPHTHALMIC SURGERY. 
 
 THE OPHTHALMIC ASSISTANT. 
 
 In order to obtain free access to the eye with the instruments during 
 operations, the lids must be adequately opened. In those operations 
 in which the eyeball is not cut into or is incised only to a slight extent, 
 we employ the spring-speculum. It is, therefore, used in strabismus- 
 operations, in pterygium-operations, discissions, puncture of the 
 anterior chamber, etc. On the other hand, we dispense with the use 
 of the speculum in iridectomy for glaucoma and in cataract-operations. 
 Even those operators who regularly use the lid-speculum designate 
 it as " an instrument dangerous to the eye, but indispensable" (Terrien). 
 The first attribute is correct, but not the second. The lid-speculum 
 will cause no injury in a patient who is quiet and who does not twitch, 
 especially if the assistant holds it carefully in his hand and directs it so 
 that there is no pressure exerted on the eye. In any case, the lid- 
 speculum often becomes a great hindrance; indeed, with a small palpe- 
 bral fissure it may render impossible, for example, an upward incision. 
 The injury produced by introduction of the lid-speculum may even 
 amount to a catastrophe if the patient strains, the wound begins to 
 gape, and the vitreous humor presents itself. In addition, it may 
 then become very difficult to free the lids from the instrument. In 
 Mueller's lid-speculum, the branches are turned around by closure of 
 the speculum so that the lids free themselves. If the operator can 
 command the services of even a half-experienced assistant, this is 
 certainly to be preferred over the lid-speculum. . 
 
 The work of the assistant consists in separating the lids and 
 holding the palpebral fissure open only during the short periods that 
 the operator works on the eye. In the intervals, while the instruments 
 are being changed, the eye washed out, etc., the lids are released so 
 that they cover the eye. 
 
 In opening the palpebral fissure (see p. 125), the assistant applies 
 the thumb of the right hand to the edge of the superior lid, 
 raising it and at the same time pushes the lower lid down with a finger 
 of the left hand laid on its edge. The upper lid is at the same time 
 somewhat drawn away from the globe, so that its border does not 
 get into the wound if the eye should be suddenly rotated upward or if 
 the lid should suddenly slip. The lower lid should be pushed down- 
 ward in such manner that it does not roll outward. The extent of 
 separation of the lids depends upon the operative procedure to be 
 undertaken.
 
 MINOR CORXEAL OPERATIONS. 237 
 
 The work of the assistant during a cataract-operation may be 
 detailed as follows: During the incision, the palpebral fissure is held 
 open as just described. When the operator has completed the incision, 
 the assistant lets the upper lid slide down, in such a manner that it 
 does not make the wound gape. It must, therefore, be brought down 
 at a certain distance from the cornea in the sagittal plane. This is 
 best accomplished by drawing the external canthus somewhat down- 
 ward, whereby the upper lid performs the desired movement. The 
 lower lid must not be released until the upper lid covers the wound. 
 
 In performing the iridectomy the palpebral fissure is opened in the 
 same way, and the assistant need only see that the finger which holds 
 the upper lid is not placed in the way of the operator (see Fig. 60 of 
 
 
 Fig. 118. Assistance. The operator grasps the upper lid by its cilia, draws it slightly 
 away from the eyeball, and guides it downward over the wound, while the spoon is inserted 
 under the lid to keep it away from the surface of the globe. 
 
 the cataract-operation, p. 125). As the operator must introduce 
 the forceps into the wound from above, the assistant places his finger 
 on the lid either internally or externally. 
 
 In opening the anterior capsule, the operator himself raises the 
 upper lid with the left hand. The assistant holds the lower lid with 
 one hand, and at the same time takes a Daviel spoon in the other hand, 
 which is held against the border of the upper lid. If the lid should 
 slip through the fault of the operator or from the twitching of the 
 patient, it will fall upon the spoon, and will thus slide over the wound 
 without turning the latter back. At the critical moment the operator 
 can help himself without much chance of failure, by slipping the 
 rapidly closed capsule forceps under the upper lid and thus drawing 
 it down. Fig. 118 shows how the operator himself may draw down the
 
 238 OPHTHALMIC SURGERY. 
 
 lid by its cilia, while the spoon in the assistant's hand is ready to 
 slip under the lid and hold it away from the eye. 
 
 Control of the lower lid always requires great care. Even though 
 the patient twitches but slightly, the lower lid should never remain 
 without fixation after the upper lid is raised. If the lower lid is left 
 free, and the patient makes it tense through innervation of the palpebral 
 muscle, the lid will be pressed against the globe and will cause the 
 wound to gape and open. The vitreous humor may even be expressed 
 in this way. 
 
 If the operator contemplates removing the lens in its capsule, 
 on account of thickening of the latter, he should allow the assistant to 
 hold both lids, so that he himself may take in his left hand the spatula 
 with which the scleral edge of the wound is somewhat depressed to 
 favor the escape of the lens. 
 
 During expression of the cataract the operator, while raising the 
 upper lid with either hand performs w r ith the lower lid the massage- 
 movements that have been described for expressing the lens. The 
 assistant holds the Daviel spoon, prepared to introduce it under the 
 upper lid, if necessary, and to extract the lens when it protrudes to the 
 extent of one-half. In performing this latter act, the spoon is placed 
 against the equator of the lens and thus lifts it out. 
 
 During reposition of the iris the operator raises the upper lid 
 and the assistant holds the lower. If the patients are quiet and do 
 not twitch, the assistant's task is an easy one. Of course, the assistant 
 must never press the lids against the eye. In protruding eyes the 
 opening of the lids requires special care. The lids must not be pushed 
 far backward, but must be opened merely enough for the requirements 
 of the operator. The work of the assistant is much more difficult 
 in the case of a patient who strains. But it is just in such cases that 
 the value of a good assistant is fully appreciated. Skillful separation 
 of the lids in the correct manner and at the right time often prevents 
 the otherwise certain prolapse of the vitreous humor. 
 
 In unruly patients it may be quite impossible to proceed in the 
 manner described. The upper lid must then be elevated by inserting 
 a Desmarres elevator. All pressure on the eye, however, must be 
 carefully avoided. This elevator is permitted to remain in place 
 during the whole operation, while the lower lid must also be fixed at 
 the same time, for reasons that have been mentioned. The only 
 disadvantage of the elevator is that it stands in the way of instruments
 
 MINOR CORXEAL OPERATIONS. 239 
 
 that are to be introduced from above. The spring-speculum, however, 
 must never be used in restless patients. 
 
 If a prolapse of the vitreous occurs, the lids must not be aimlessly 
 released, as is often done by frightened assistants. On the contrary, 
 the upper lid still firmly held must be cautiously lowered over the 
 gaping wound, while the operator inserts under the lid for its guidance 
 the instrument which he happens to have in his hand. This may be a 
 closed pair of Wecker's scissors, the capsule-forceps, the spatula, the 
 spoon, or even the handle of the Graefe knife. The lower lid may be 
 released by the assistant only after the upper lid has covered the 
 wound. Otherwise the patient will raise the flap still further with 
 his lower lid, and will thus express the vitreous. In patients who are 
 known beforehand to be restless and likely to twitch, the opening of 
 the lids may be materially facilitated by performing an extensive 
 canthotomy immediately before the operation. 
 
 Occasionally it may also fall to the lot of the assistant to hold the 
 eye with fixation-forceps. As repeatedly stated, fixation is only 
 employed in cataract-operation while making the incision. In non- 
 congested and well-cocainized eyes, the iridectomy is usually accom- 
 panied by so little pain that the patients are perfectly quiet during its 
 performance. After opening the eyeball by a long incision, the use of 
 fixation-forceps, even with the greatest care, causes a gaping of the 
 wound. The fixation-forceps should only be employed when abso- 
 lutely necessary. Especially in the cataract-operation their use can 
 only be forced by unreasonable patients. In such cases the assistant 
 applies the forceps to the limbus exactly at the lower edge of the cornea, 
 and draws the eye slightly down. The forceps also keep the lower 
 lid away from the globe. The iridectomy may under these circum- 
 stances become difficult. 
 
 If the upper lid is held up by the Daviel spoon, the eyeball must 
 be carefully drawn downward a little with the forceps; otherwise, it- 
 may be impossible in the small space to draw out the iris with the 
 forceps. On the other hand it may be easier to slip into the anterior 
 chamber from the side with a properly bent, blunt tenaculum, and 
 thus draw out and excise a fold of iris from the pupillary border. Like- 
 wise the opening of the anterior lens-capsule must then be performed 
 with a sharp tenaculum that has been bent in the required direction. 
 The otherwise painful excision of the iris in inflammatory glaucoma, 
 injuries, prolapse of the iris, etc., may be rendered considerably less
 
 240 OPHTHALMIC SURGERY. 
 
 painful by dropping a little cocain-solution on the exposed iris after the 
 anterior chamber is opened. However, in certain cases the eye must 
 be held with the forceps in order to be quite safe, and this we do almost 
 regularly in excision of a prolapsed iris in an inflamed eye. During 
 reposition of the iris it may be necessary to draw the eye downward 
 with the forceps, because the patient will not voluntarily look down. 
 In this case it is best for the operator himself to hold the eye in the 
 required position. 
 
 As already mentioned, the eye must be held fast in all procedures 
 with cutting or puncturing instruments, e.g., during the incision, 
 during discission, etc. Occasionally an exception can be made in 
 very quiet patients who will turn their eyes in the required direction. 
 For example, if the conjunctiva tears away during the incision, and if 
 the patient looks in the right direction, there is no objection to com- 
 pleting the incision without further fixation. A discission, the incision 
 in a linear extraction, or a puncture may exceptionally be performed 
 without fixation. 
 
 Beside proper fixation, the position of the operator's fingers is 
 important. The support of the operator's hand must also be at a 
 safe point. For this purpose, the fourth finger of the hands usually 
 rests in a suitable position on the head of the patient. In incisions 
 from the external side the operator's hand is supported on the temple 
 or malar bone. In incisions from below, the hand is supported on the 
 cheek; and in incisions from above, on the forehead. The operator is 
 not then taken unaware by an unexpected movement of the patient's 
 head. The incision directed downward is the more readily accom- 
 plished because every patient shows a tendency to avoid the instru- 
 ment by an upward movement of the eye, and it is usually much easier 
 to look upward than downward. 
 
 It was, therefore, repeatedly recommended to perform all ophthalmic 
 operations, including cataract-extraction, by the inferior incision, 
 and in fact, special methods were devised for this purpose, but, as 
 iridectomy must be performed in most cases, operators soon adhered 
 to the upward cut. In fact, in the establishment of a broad coloboma 
 for glaucoma, it is of importance that the coloboma be covered by the 
 upper lid. The lower operations are therefore limited to those cases 
 in which it is known beforehand that a coloboma will not be necessary, 
 such as puncture of the cornea, linear extraction and similar opera- 
 tions. There are, however, certain cases which are especially suitable
 
 MINOR CORXEAL OPERATIONS. 241 
 
 for the inferior operation. In cataract-patients an accompanying 
 ptosis may cause the pupillary region to be covered by the upper lid, an 
 amyotrophic ptosis being not uncommon in old persons. This is an 
 indication for the inferior operation with a narrow coloboma, avoiding 
 the periphery of the iris. 
 
 Auxiliary minor assistance may be serviceable during an opera- 
 tion. It is the duty of the assistant to remove the blood from the con- 
 junctival sac by sponging. The sponges should be kept in sterilized, 
 physiologic saline solution. The sponge is well squeezed out and one 
 end is formed into a point. This end is inserted into the internal 
 angle of the eye so that it absorbs the blood from the point outward; 
 or the end may be drawn from the internal angle outward along the 
 inferior transitional fold, taking the blood with it. Direct sponging 
 of the operation-wound in the eye is to be avoided as much as possible. 
 With marked hemorrhage into the anterior chamber it will serve the 
 purpose very well if the assistant strokes the blood out of the anterior 
 chamber, while the operator stands ready with the instrument to 
 perform rapidly the next operation (iridectomy or opening of the 
 capsule) as soon as he can obtain a clear view of the chamber. 
 
 If necessary, the assistant should turn the conjunctival flap back 
 with a spatula, in case it should get in the way of the operator. He 
 should stroke the iris back into its place, if, during an extraction 
 without iridectomy, the border of the pupil should become stretched 
 against the lens as it makes its exit. Occasionally it may be necessary 
 for the assistant to cut off the iris with the deWecker scissors, if 
 the operator, for example, in the excision of a prolapsed iris, holds and 
 directs the eye with one hand while the other hand draws out the iris. 
 
 ANESTHESIA. 
 
 In all ophthalmic operations there is an advantage in being able to 
 operate under local anesthesia. \\e use it on the most extensive 
 scale, and endeavor to make it suffice wherever possible in the place of 
 general anesthesia. In most operations on the eyeball itself, the 
 co-operation of the patient in bringing the eye into the proper position 
 will make the procedure much less difficult and will render unnecessary 
 the dangerous fixation of the eye during many operations. General 
 anesthesia not only robs us of this factor, which is important for the 
 faultless accomplishment of many operations, but also draws in its 
 train another series of baneful influences which are important in 
 
 16
 
 242 OPHTHALMIC SURGERY. 
 
 patients subjected to any eye operation. Among these latter may be 
 mentioned the dulled consciousness, the restlessness of the patient 
 upon awakening, the often violent vomiting, etc. 
 
 General anesthesia is therefore confined to the following cases: 
 
 1. Children who do not as yet possess sufficient intelligence to keep 
 quiet and conduct themselves sensibly. 
 
 2. More extensive operations in the orbit and on the lids, especially 
 if the parts subjected to operation are sensitive on account of inflam- 
 matory conditions, such as exenteration, enucleation of inflamed eyes, 
 more extensive plastic operations and similar procedures. 
 
 3. Severe operations on the eye itself, if local anesthesia is refused 
 (especially in inflammatory glaucoma, excision of prolapsed iris in 
 marked inflammatory conditions, etc.) or if the patient is not suitable 
 for local anesthesia on account of other circumstances, such a pro- 
 nounced blepharospasm, dementia, great irritability, etc. 
 
 Cocain-anesthesia in operations on the eye itself is usually effected 
 by a 3 per cent, solution, which is dropped into the eye several times 
 during a period of ten minutes. The eye must be kept closed during 
 this process of cocainization. If it remains open, the cocain may 
 readily produce a dryness of the cornea with epithelial changes, which 
 may not only impede the operation on account of cloudiness of the 
 cornea, but may also cause the patient pain after the operation. If 
 the eye is injected, a few drops of adrenalin-solution should be 
 instilled in the eye. The last application should be made just before 
 the operation, as the constriction of the vessels caused by the adrenalin 
 soon disappears and is replaced by a vascular relaxation which might 
 cause considerable bleeding during the operation. 
 
 The advantages of cocain surpass those of all its substitutes. Its 
 constricting influence on the vessels is an excellent property, which 
 is of great value in every operation. The dilatation of the pupil which 
 it causes is undesirable only in glaucoma-operations, but can usually 
 be prevented by a preceding instillation of eserin. Recently we have 
 substituted for cocain in these cases a 3 per cent, solution of alypin, 
 which must be supplemented by adrenalin, as it does not possess any 
 vaso -constrictor properties. We also prefer alypin for sounding, for 
 extraction of foreign bodies from the surface of the cornea, etc., as it 
 does not cause the patient the inconvenience of pupillary dilatation. 
 
 To produce a more profound anesthesia of the deeper parts of the 
 eye, we drop some cocain-solution into the anterior chamber
 
 MINOR CORNEAL OPERATIONS. 243 
 
 after it is opened in cases in which manipulation of the iris will pre- 
 sumably be painful, as in inflamed eyes. For this purpose only a 
 sterilized solution can be used. For operations on the lids a sub- 
 cutaneous injection of a i per cent, cocain-solution will usually 
 suffice. The injected fluid must be suitably distributed throughout 
 the field of operation. 
 
 The addition of adrenalin (3 to 5 drops) to the cocain-solution 
 will reduce the bleeding to a minimum. More accurate directions 
 have been given with the various operations, so that the best effect 
 can be produced with the least quantities. Aimless injection in one 
 place with neglect of other parts of the operative field will not produce 
 the desired result. The dose of cocain which we employ in most 
 operations is a minimal one, amounting at most to one Pravaz syringe- 
 ful (o.oi gm. cocain), so that poisoning need not be feared in the 
 most sensitive individuals. Only in enucleation is as much as 0.03 
 gram allotted, a quantity which is also far below the maximum dose. 
 
 In place of general chloroform or ether narcosis, the general anes- 
 thesia with scopolamin and morphin is recommended, carried out 
 according to the following prescription. These solutions should be 
 freshly prepared each time: 
 
 9 
 
 Scopolamin. hydrobromat, o.oi 
 
 Aq. destillat 30 .o 
 9 
 
 Morphin. hydrochlr., 0.075 
 
 Aq. destillat 9.0 
 
 Three hours before the operation one cc of each solution is 
 injected under the skin of the upper arm, first injecting one solution, 
 and then, without withdrawing the needle, making the other injection 
 in the same place, but in another direction. Even after these injections 
 the patient will become somnolent, quiet and so insensible of pain 
 that the operation can often be performed in this stage with the aid 
 of simultaneous cocainization of the eye. But if the desired effect 
 is not obtained, the same dose of each solution must again be injected 
 fifteen minutes before the operation. Thereupon the patient can be 
 subjected to the operation in a completely relaxed condition, if at the 
 same time the eye is made insensible by cocain. The advantage of 
 this method is that the patient sleeps quietly for several hours after
 
 244 OPHTHALMIC SURGERY. 
 
 the operation, does not vomit and exhibits no restlessness upon awaken- 
 ing. Moreover, after carrying out these methods, a general narcosis 
 can be rapidly produced by a few drops of ether or chloroform. 
 
 Bandaging After Operations on the Eye. We employ Fuchs' 
 lattice in men, and Snellen's cup in women, the cup being attached by 
 strips of adhesive. The latter is not advisable for men, because the 
 plaster will not adhere to the bearded skin. In children and restless 
 patients bandages are applied, and with the aid of starch a stiff dress- 
 ing is produced, which will also sufficiently protect the eye against 
 careless contact. The application of pressure-bandages has been 
 described in connection with the operations in which they are indicated.
 
 INDEX. 
 
 Accidents during anterior sclerotomy, 195 
 cataract extraction, 140 
 cataract expression, 146 
 discission, 160 
 
 iridectomy for glaucoma, 187 
 trephining of cornea, 216 
 Accumulation of blood after excision of 
 
 lachrymal sac, 13 
 Acute dacryocystitis, 20 
 
 iritis, puncture of cornea in, 206 
 Adrenalin, 242 
 
 in cyclodialysis, 201 
 in enucleation, 103 
 in operations upon lachrymal appa- 
 ratus, 15 
 
 in probing of lachrymo-nasal duct, 29 
 Adults, young, linear extraction for 
 
 cataract in, 164 
 
 Advancement of extraocular muscles, 86 
 after-treatment, 91 
 contraindication, 92 
 dressing, 91 
 
 fixation of muscle to limbus, 91 
 incision, 86 
 
 means of influencing effect of, 96 
 stretching of muscle, 87 
 sutures, 87 
 of rectus internus, indications for, 
 
 101 
 Advantages of capsule-forceps in opening 
 
 anterior lens-capsule, 134 
 Fuchs's method of tarsorrhaphy, 68 
 Graefe knife in iridectomy for 
 
 glaucoma, 184 
 lancet in iridectomy of glaucoma, 
 
 184 
 After-results of anesthesia-hemostasis of 
 
 lachrymal apparatus, 16 
 After-treatment of advancement of extra- 
 ocular muscles, 91 
 conjunctivoplasty, 213 
 corneal transplantation, 217 
 excision of iris, 210 
 expression of trachoma granules, 235 
 
 in 
 
 After-treatment of Hess's operation for 
 
 ptosis, 74 
 
 Saemisch section, 231 
 simple extraction, 157 
 Age limit for muscle-operations, 102 
 Air-bubbles in anterior chamber 
 
 extraction, 153 
 Alypin, 242 
 
 as corneal anesthetic, 168 
 in iridectomy for glaucoma, 184 
 Anatomy of lachrymal sac, i 
 AnePs syringe, 28 
 
 Anesthesia in advancement of extra- 
 ocular muscles, 86 
 enucleation, 103, 107 
 Hess's operation for ptosis, 75 
 of lachrymal apparatus, 15 
 lachrymo-nasal duct, 28 
 ophthalmic surgery, 241 
 optico-ciliary neurotomy, 112 
 tenotomy of rectus internus, 85 
 Angle at which lancet is held in making 
 incision in iridectomy for glau- 
 coma, 181 
 
 Anterior lachrymal crest, i, 17 
 lens-capsule, incision of, 159 
 
 opening, 131 
 sclerotomy, 193 
 
 accidents during, 195 
 faulty position of incision, 195 
 indications, 196 
 intralamellar incision in, 195 
 iridodialysis in, 196 
 results of, 196 
 
 synechia following cataract extrac- 
 tion, 142 
 
 operations for, 219 
 Apparatus, lachrymal, i 
 Appearance of vitreous prior to removal 
 
 of lens in extraction, 149 
 Applicability of strabismus operation, 92 
 Application of iridotomy, 170 
 Aqueous, escape of, during discission 
 
 through cornea, 161 
 Arlt's median tarsorrhaphy, 70 
 operation for pterygium, 232 
 
 245
 
 246 
 
 INDEX. 
 
 Assistance, auxiliary minor, 241 
 Assistant, duties of ophthalmic, 236 
 
 in extraction without iridectomy, 157 
 Astigmatism following cataract extrac- 
 tion, 141 
 
 Atrophic iris in glaucoma, 188 
 Atropin after excision of iris, 210 
 Attached iris in glaucoma, liberation of, 
 
 190 
 Auxiliary minor assistance, 241 
 
 B 
 
 Backward luxation of lens during extrac- 
 tion, 155 
 Ball, introduction of glass or gold, in 
 
 eye, in 
 Bandage, binocular, 139 
 
 in conjunctivoplasty, 213 
 corneal transplantation, 217 
 iridotomy, 171 
 
 Bandaging after operations, 244 
 Beer-Wecker operation for corneal staph- 
 
 yloma, 233 
 Best method of operating in total 
 
 symblepharon, 122 
 Bilateral ectropion, 52 
 Binocular handage after extraction, 139 
 Black cataract, 146 
 Blood, accumulation of, after excision of 
 
 lachrymal sac, 13 
 Blunt hook in iridectomy for glaucoma, 
 
 188 
 Bodies, foreign, in the eye-ball, extraction 
 
 of, 222 
 
 enucleation for, 229 
 other than iron, 228 
 in vitreous, removal by posterior 
 
 sclerotomy, 199 
 
 Bowman's operation of discission, 169 
 slitting the canaliculus, 26 
 probes, 27 
 
 Buediner's operation, 117 
 Bulging of vitreous as an indication of 
 prolapse, 153 
 
 Canaliculus, dilatation of, 24 
 
 slitting of, 26 
 
 Canthal ligament, internal, 4 
 Canthoplasty, 61 
 
 indications for, 62 
 
 Kuhnt's method, 63 
 
 sutures in, 62 
 
 technic 62 
 
 Canthotomy, 63, 113 
 Capsule-forceps, 131 
 
 Capsule, lens, wound of, 210 
 
 opening of, in extraction without 
 
 iridectomy, 157 
 
 Capsulotomy in secondary cataract, 1 70 
 Care of iris in linear extraction of soft 
 
 cataract, 177 
 Cataract, black, 146 
 
 in children, discission for, 163 
 congenital, discission for, 163 
 expression of, 134, 146 
 extraction of senile, 124 
 accidents during, 140 
 backward luxation of lens, 155 
 collapse of cornea, 155 
 complications of, 140 
 explosive hemorrhage in, 155 
 hemorrhage attending, 141 
 incision, 127 
 without iridectomy, 156 
 following iridectomy for glaucoma, 
 
 191 
 
 knife, Graefe, 127 
 operations, 124, 159 
 partial, discission for, 163 
 secondary, operations for, 159, 169 
 
 discission in, 169 
 soft, linear extraction for, 174 
 Causes of difficulty in expression of 
 
 cataract, 145 
 
 penetrating wounds of eye-ball, 226 
 prolapse of vitreous during extrac- 
 tion, 148 
 
 secondary glaucoma, 207 
 turning down of corneal flap after 
 
 extraction, 154 
 Cavity, orbital, exenteration of, 112 
 
 opening of, 17 
 
 Changing of dressing in enucleation, 107 
 in excision of lachrymal sac, 13 
 in operation for cicatricial ectropion, 
 
 57 
 Children, muscle-operations in, 102 
 
 new-born, probing in, 29 
 Chloroform, 243 
 Chorioid, prolapse of, in scleral wounds, 
 
 214 
 
 Chronic epiphora, 30 
 Crystalline lens, backward luxation of, 
 
 155 
 
 operations, 124 
 
 subluxation, in iridectomy for glau- 
 coma, 191 
 
 Cicatricial ectropion, 52 
 operation for, 
 dressing, 56 
 insertion of sutures, 53
 
 INDEX. 
 
 247 
 
 Cicatricial ectropion, results, 54 
 skin-grafts in, 55 
 technic, 52 
 Cicatrix in cases of foreign body in 
 
 eyeball, 222 
 Cilia forceps, 41 
 Ciliary body, prolapse of, in scleral 
 
 wounds, 214 
 
 Closure, complete, of palpebral fissure, 69 
 of the wound after advancement 
 
 of extraocular muscles, 90 
 after enucleation, 107 
 Everbusch's operation for ptosis, 80 
 tenotomy of rectus internus, 84 
 Cocain-anesthesia, 242 
 Cocain in advancement of extraocular 
 
 muscles, 86 
 enucleation, 103, 107 
 iridectomy for glaucoma, 188 
 operations upon the lachrymal appa- 
 ratus, 15 
 
 probing lachrymo-nasal duct, 28 
 tenotomy, 85 
 
 Coloboma in optical iridectomy, 165 
 Collapse of cornea during cataract 
 
 extraction, 155 
 
 eye-ball due to fluid vitreous, 154 
 Combination of Dieffenbach's and Bue- 
 
 diner's operation, 117 
 Combined discission, 170 
 Comparative value of several operations 
 
 for ptosis, 82 
 
 Complete closure of palpebral fissure, 69 
 symblepharon, 121 
 
 Rogman's operation, 121 
 
 unpedicled flap operation, 123 
 
 operations, dressing, 123 
 Complications of anterior sclerotomy, 195 
 cataract extraction, 140 
 cyclodialysis, 202 
 discission, 160 
 
 discission through sclera, 172, 174 
 enucleation, 108 
 excision of iris, 210 
 excision of lachrymal sac, 17 
 expression of cataract, 146 
 Graefe's operation for senile entro- 
 
 pion, 60 
 
 Hotz-Anagnostakis operation, 35 
 iridectomy in cataract extraction, 144 
 for glaucoma, 187 
 
 in secondary glaucoma, 207 
 iridotomy, 171 
 Kuhnt-Szymanowski operation for 
 
 senile ectropin, 51 
 linear extraction for soft cataract, 177 
 
 Complications of operations for cicatricial 
 
 ectropion. 54 
 
 for secondary cataract, 169 
 reposition of iris in iridectomy for 
 
 glaucoma, 189 
 tenotomy, 101 
 
 Congenital cataract, discission for, 163 
 Conical probe, 24 
 Conjunctiva, laceration of, in iridectomy 
 
 for glaucoma, 187 
 suturing of, in cyclodialysis, 202 
 tearing of, during cataract extraction, 
 
 140 
 transplantation of, De Wecker's 
 
 method of, 214 
 
 Conjunctival flap in conjunctivoplasty,2i2 
 in corneal transplantation, 217 
 in extraction operation, 129 
 position of, after extraction, 139 
 suture after advancement of extra - 
 
 ocular muscles, 90 
 Conjunctivoplasty, 212 
 after-treatment, 213 
 indications for, 212 
 Contingencies in expression of cataract, 
 
 146 
 
 Contraindication to advancement, 92 
 for Everbusch's operation for ptosis, 
 
 81 
 
 for Hess's operation for ptosis, 76 
 for probing lachrymo-nasal duct, 31 
 Convergent strabismus, indications for 
 
 operations in, 98 
 Cornea, collapse of, during cataract 
 
 extraction, 155 
 discission through, 159 
 infection of, following cataract ex- 
 traction, 142 
 paracentesis of, 205 
 splitting of, 230 
 tattooing of, 168, 232 
 trephining of, for anterior synechia, 
 
 219 
 Corneal erosion in excision of lachrymal 
 
 sac, 13 
 
 operations, minor, 230 
 staphyloma, operations for, 233 
 transplantation, 216 
 partial, 217 
 total, 218 
 
 Von Hippel's 218 
 trephine, 216 
 of Von Hippel, 218 
 ulcers, 230 
 
 corneal puncture in, 206 
 wound in excision of iris, 210
 
 248 
 
 INDEX. 
 
 Cortical substance, removal of, in extrac- 
 tion without iridectomy, 157 
 
 Crest, anterior lachrymal, i 
 
 Counteracting sutures in tenotomy, 95 
 indications for, 100 
 
 Counter-puncture in extraction opera- 
 tion, 127 
 
 Crest, anterior lachrymal, 17 
 
 Crucial incision in opening anterior lens- 
 capsule, 161 
 
 Cup-bandage, Snellen's 244 
 
 Curette, Daviel's, in foreign bodies in 
 eyeball, 227 
 
 Curettement in excision of lachrymal sac, 
 12 
 
 Cyclodialysis (Heine), 199 
 complications of, 202 
 dressing in, 202 
 indications for, 203 
 results of, 203 
 
 Cystic scars after iridectomy for glau- 
 coma, 221 
 
 Cyst of iris as cause of secondary 
 glaucoma, 207 
 
 Cystotome, 131 
 
 D 
 
 Dacryocystitis, 20 
 
 Dangers of excision of iris, 209 
 
 probing of lachrymo-nasal duct, 27 
 trephining of cornea for anterior 
 
 synechia, 220 
 Daviel's spoon in expression of cataract- 
 
 ous lens, 136 
 in foreign bodies, 227 
 Deep fascia in excision of lachrymal sac, 4 
 Deepening of the anterior chamber as a 
 sign of prolapse of vitreous, 153 
 Descemet's membrane, detachment of, in 
 
 cyclodialysis, 202 
 Desmarres' elevator, 238 
 
 spoon, 152 
 Detachment of Descemet's membrane 
 
 in cyclodialysis, 202 
 retina, posterior sclerotomy for, 198 
 following prolapse of vitreous, 155 
 conjunctiva in enucleation, 103 
 Details of cyclodialysis, 199 
 
 incision for cataract extraction, 127 
 incision in iridectomy for glaucoma, 
 
 180 
 De Wecker's method of transplantation 
 
 of the conjunctiva, 214 
 pince-ciseaux, 129 
 Diagnosis of foreign bodies in eye-ball. 
 
 Dieffenbach's operation on eyelids, 115 
 
 results of, 117 
 
 Difficulties attending anterior sclerot- 
 omy, 194 
 enucleation, 108 
 excision of lachrymal sac, 17 
 expressing cataractous lens, 146 
 iridectomy for secondary glau- 
 coma, 207 
 linear extraction of soft cataract, 
 
 177 
 
 Dilaceration of secondary cataract, 169 
 Dilatation of the canaliculus, 24 
 
 lachrymal sac, 20 
 Diminution of vision in foreign bodies in 
 
 eye-ball, 222 
 
 Direction of lachrymal canaliculus, 24 
 Directions for making incision in cataract 
 
 extraction, 142 
 
 opening capsule in cataract extrac- 
 tion, 145 
 Disadvantages of Beer-Wecker operation 
 
 for corneal staphyloma, 234 
 extraction without iridectomy, 156 
 Fuchs's method of tarsorrhaphy, 68 
 lancet in incision in iridectomy for 
 
 'glaucoma, 185 
 
 Panas's operation for trichiasis, 38 
 precorneal iridotomy, 165 
 Discission, 159 
 
 accidents during, 160 
 
 Bowman's 169 
 
 combined, 170 
 
 for congenital cataract, 163 
 
 through cornea, 159 
 
 for high myopia, 162 
 
 indications for, in high grade 
 
 myopia, 162 
 needles, 159 
 for partial cataract, 163 
 prolapse of vitreous in, 162 
 through sclera, complication, 174 
 through sclera in secondary cata- 
 ract, 172 
 
 in secondary cataract, 169 
 for totally opaque lenses, 163 
 of a transparent lens, 161 
 with two needles, 169 
 Disk, Fritsch's movable stenopaeic, 167 
 Dislocation of lens, effects of, in extrac- 
 tion, 147 
 Dissection in Everbusch's operation for 
 
 ptosis, 77 
 
 Hess's operation for ptosis, 71 
 lachrymal structures, 2 
 Distichiasis, operations for, 32
 
 IXDEX. 
 
 249 
 
 Divergent strabismus, indications for 
 operations in, 99 
 
 Division of muscles in enucleation, 104, 
 
 105, 107 
 
 optic nerve in enucleation, 106 
 straight eye-muscles in enucleation, 
 104 
 
 Dose of cocain, 243 
 
 Double tenaculum, Reisinger's, 150, 151 
 
 Douching of lachrymal sac, 28 
 
 Drainage in incision of lachrymal sac, 13 
 
 Dressing after operations, 244 
 
 in advancement of extraocular 
 
 muscle, 91 
 
 conjunctivoplasty, 213 
 cyclodialysis, 202 
 
 Dieff enbach-Buediner operation , 1 1 8 
 enucleation, 107 
 excision of lachrymal gland, 24 
 excision of lachrymal sac, 13 
 extraction, 139 
 
 Hess's operation for ptosis, 73 
 Hotz-Anagnostakis operation, 35 
 iridotomy, 117 
 
 Kuhnt-Szymanowski operation, 50 
 linear extraction of soft cataract, 177 
 operation for cicatricial ectropion, 56 
 operations for total symblepharon, 
 123 
 
 Ducts, lachrymal, 7 
 
 lachrymo-nasal, probing of, 27 
 
 Duties of ophthalmic assistant, 157, 236 
 
 Ectasia of sclera as cause of secondary 
 
 glaucoma, 207 
 as contraindication of advancement, 
 
 92 
 
 Ectropion, 42 
 bilateral, 52 
 cicatricial, 52 
 following excision of lachrymal sac, 
 
 20 
 
 of lower lid, 26 
 operations for, 42 
 paralytic, 52 
 senile, 43 
 spastic, 42 
 Effects of adhesions in optical iridec- 
 
 tomy, 1 68 
 
 dislocation of lens in extraction, 147 
 failure to open lens-capsule, 147 
 produced by advancement of rectus 
 
 externus, 96 
 
 Electrolytic epilation in trichiasis, 41 
 Elevator, Desmarres', 238 
 
 Employment of capsule-forceps in open- 
 ing capsule, 145 
 Entropion, 58 
 
 operations for, 58 
 senile, 59 
 spastic, 58 
 Enucleation, 103 
 
 complications of, 108 
 detachment of conjunctiva in, 103 
 division of straight eye-muscles in, 
 
 104 
 
 division of vertical muscles, 105 
 dressing in, 107 
 for foreign bodies, 229 
 in glaucoma, 192 
 indications for, no 
 insertion of scissors, 105 
 in prolapse of ciliary body and 
 
 chorioid, 214 
 
 resection of optic nerve in, 1 10 
 severance of optic nerve, 106 
 Epilation in trichiasis, 41 
 Epiphora, chronic, 30 
 Erosion of the cornea in excision of 
 
 lachrymal sac, 13 
 Escape of aqueous during discission 
 
 through cornea, 161 
 Eserin in iridectomy for glaucoma, 184 
 
 after simple extraction, 157 
 Ether, 243 
 
 Everbusch's operation for ptosis, 77 
 closure of the wound, 80 
 contraindications, 81 
 indications, 77 
 result of, 80 
 sutures, 78 
 Eversion of inferior lachrymal puncture, 
 
 26 
 of lid in excision of palpebral 
 
 lachrymal gland, 22 
 Evisceration of the eye-ball, in 
 Examination in cases of foreign body in 
 
 eye -ball, 222 
 
 Excision of corneal cicatrix, 216 
 iris, 209 
 
 in iridectomy for glaucoma, 185 
 after prolapse, indications, 215 
 
 time for, 215 
 lachrymal sac, i 
 
 incomplete, 14, 18 
 palpebral lachrymal gland. 22 
 portion of lid for senile ectropion, 44 
 prolapsed iris after simple extrac- 
 tion, 158 
 
 in optical iridectomy, 165 
 for senile entropion, 59
 
 2^0 
 
 INDEX. 
 
 Excision of tarsus in Kuhnt-Szyma- 
 
 nowski operation, 46 
 Exenteration of orbital cavity, 113 
 
 indications for, 113 
 
 Exophthalmos following tenotomy, 101 
 Expression of cataract, 134, 146 
 
 trachoma granules, 234 
 Expressor, Kuhnt's, 235 
 Expulsive hemorrhage in cataract ex- 
 traction, 155 
 
 in iridectomy for glaucoma, 190 
 Extensive ruptures of eye, operation in, 
 
 no 
 
 synechia, iridectomy in, 211 
 Extent of effect produced by advance- 
 ment of rectus externus, 96 
 External rectus, tenotomy of, 86, 96 
 
 tarsorrhaphy, 65 
 Extirpation of lachrymal sac, i 
 
 palpebral lachrymal gland, 22 
 Extraction of cataractous lens in its 
 
 capsule, 150 
 foreign bodies from the interior of 
 
 the eye, 222 
 through an opening in the sclera, 
 
 227 
 
 other than iron, 228 
 iron splinters by magnet operation, 
 
 224 
 
 linear, for soft cataract, 174 
 senile cataract, 124 
 accidents, 140 
 
 anterior synechia following, 142 
 astigmatism in, 141 
 black cataract, 146 
 collapse of cornea, 155 
 complications, 140 
 counter-puncture, 127 
 Daviel's spoon, 136 
 dressing, 139 
 duties of assistant, 237 
 expression of lens, 134, 146 
 expulsive hemorrhage, 155 
 faulty incision, 140 
 gaping of wound, 141 
 hemorrhage attending, 141 
 hemorrhage after iridectomy, 144 
 incision, 127 
 
 infection of cornea following, 142 
 intralamellar incision. 143 
 iridectomy in, 129 
 iridodialysis in, 144 
 length of incision, 142 
 luxation of lens, 147 
 luxation backward of lens, 155 
 massage after extraction, 137 
 
 Extraction of senile cataract, accidents 
 opening of anterior lens-cap- 
 sule, 131, 145 
 position of conjunctiva! flap after, 
 
 J 39 
 
 prolapse of vitreous, 148 
 reposition of iris after, 138 
 technic of, 124 
 toilet of eye after, 138 
 without iridectomy, 156 
 Eye, extraction of foreign bodies from 
 
 interior of, 222 
 toilet of, after extraction, 138 
 Eye-ball, collapse of, due to fluid vitreous, 
 
 154 
 
 foreign bodes in, prognosis of, 227 
 enucleation of, 103 
 Evisceration of, in 
 Mules's operation, in 
 optico-ciliary neurotomy operation, 
 
 112 
 
 penetrating wounds of, 226 
 summary of wounds of, 226 
 Eyelids, operations on, 32 
 
 plastic operations, Dieffenbach's, 
 
 US 
 plastic operations, Dieffenbach-Bue- 
 
 diner's, 117 
 plastic operations with pedicled 
 
 flaps, 115 
 
 plastic operations on, Fricke's, 115 
 Eye-muscles, operations on, 84 
 
 Factors, influencing length of incision in 
 
 senile cataract, 142 
 Failure to open lens-capsule, effects of, 
 
 M7 
 
 False passage in probing lachrymo- 
 nasal duct, 27 
 
 Fascia, in excision of lachrymal sac, 3, n 
 tarso-orbital, 23 
 
 Faulty incision in cataract extraction, 140 
 position of incision in anterior 
 sclerotomy, 195 
 
 Firm bandage after iridotomy, 171 
 
 First method of operating for anterior 
 
 synechia, 221 
 
 step in Kuhnt-Szymanowski oper- 
 ation, 44 
 
 Fistula following excision of lachrymal 
 
 sac, 19 
 lachrymal, 30 
 
 Fixation forceps used in cataract extrac- 
 tion, 124 
 of muscle to the limbus, 91
 
 INDEX. 
 
 251 
 
 Fixing-suture in Fuchs's method of tar- 
 
 sorrhaphy, 67 
 Flap, conjunctival, in conjunctivoplasty, 
 
 212 
 
 in corneal transplantation, 217 
 in extraction operation, 129, 139 
 Flaps, pedicled, in eye-lid operations, 115 
 skin-graft, in operation for cica- 
 tricial ectropion, 55 
 Flarer's operation for trichiasis, 38 
 Fluid vitreous, 154 
 Forceps, capsule, 131 
 
 fixation, used in cataract extraction, 
 
 124 
 
 iris, 129 
 
 Knapp's roller, 234 
 Foreign bodies in eye-ball, diagnosis of, 
 
 222 
 extraction of, from the interior of 
 
 the eye, 222 
 extraction through an opening in 
 
 sclera, 227 
 enucleation, 229 
 other than iron, 228 
 prognosis of, 227 
 in vitreous, removal by posterior scle- 
 
 rotomy, 199 
 Fourth step in Kuhnt-Szymanowski 
 
 operation, 48 
 
 Fricke's operation on eye-lids, 115 
 Fritsch's movable stenopaeic disk, 167 
 Froehlich's method of tattooing the 
 
 cornea, 233 
 
 Fuchs's keratoplasty, 216 
 lattice bandage, 244 
 method of tarsorrhaphy, 65 
 advantage, 68 
 
 disadvantage of, 68 
 
 sutures in, 67 
 
 preliminary treatment in patients 
 subject to hemorrhage, 155 
 
 Gaping of wound in cataract extraction, 
 
 141 
 
 as a sign of prolapse of vitreous, 154 
 Gaillard's suture for spastic entropion, 58 
 General anesthesia in ophthalmic oper- 
 ations, 242 
 Gland, palpebral lachrymal, excision of, 
 
 22 
 
 Glass ball in eye, introduction of, in 
 Glaucoma, 180 
 
 anterior sclerotomy (De Wecker), 
 
 193 
 atrophic iris in, 188 
 
 Glaucoma, cyclodialysis in, 203 
 enucleation in, 192 
 iridectomy for, 180 
 cataract following, 191 
 cystic scars after, 221 
 expulsive hemorrhage in, 190 
 Graefe knife in, 184 
 indications for, 187 
 spontaneous rupture of lens-capsule 
 
 in. 191 
 
 subluxation of lens in, 191 
 liberation of attached iris in, 190 
 posterior sclerotomy, 196 
 secondary, iridectomy in, 206 
 secondary, operations for, 205 
 time for operation in, 189 
 Gold ball in eye, introduction of, in 
 Graefe knife, 127 
 
 in anterior sclerotomy, 193 
 
 Beer-Wecker operation for corneal 
 
 staphyloma, 234 
 iridectomy for glaucoma, 184 
 operations anterior synechia, 221 
 operation for secondary cataract, 
 
 170 
 
 posterior sclerotomy, 196 
 Saemisch section, 230 
 transfixion for seclusion of the 
 
 pupil, 208 
 Graefe's operation for senile entropion, 
 
 ?9 
 
 incision, 59 
 results, 60 
 Granules, trachoma, expression of, 234 
 
 H 
 
 Haab's large magnet, 224 
 
 Hand used in making incision in cataract 
 
 extraction, 144 
 Heine's cyclodialysis, 199 
 Hemorrhage after iridotomy, 171 
 
 after division of optic nerve, no 
 attending cataract extraction, 141 
 during iridectomy in cataract extrac- 
 tion, 144 
 
 during iridectomy for glaucoma, 189 
 expulsive, in cataract extraction, 155 
 expulsive, in iridectomy for glau- 
 coma, 190 
 following prolapse of vitreous, 1 54 
 
 in cyclodialysis, 201 
 Hemostasis of lachrymal apparatus, 15 
 Hernia lentis, 191 
 
 of vitreous, 153 
 Hess's operation for ptosis, 71 
 after treatment. 74
 
 INDEX. 
 
 Ness's anesthesia, 75 
 
 contraindications for, 76 
 
 dissection, 71 
 
 dressing in, 73 
 
 incision, 71 
 
 indications, 75 
 
 results, 75 
 
 sutures in, 71 
 High myopia, indications for discission 
 
 in, 162 
 
 Hollow probes, 30 
 Hook, blunt, in iridectomy for glaucoma, 
 
 188 
 
 Hooks in excision of lachrymal sac, 12 
 Horizontal incision in iridotomy, 172 
 
 sutures in operation for cicatricial 
 
 ectropion, 53 
 Hotz-Anagnostakis operation, 32 
 
 complications of, 35 
 
 dressing in, 35 
 
 incision, 32 
 
 results, 36 
 
 sutures in, 34 
 
 technic of, 32 
 
 Ideal indication for optical iridectomy, 
 
 1 66 
 Importance of Graefe knife in iridectomy 
 
 for glaucoma, 184 
 Improper position of incision in anterior 
 
 sclerotomy, 195 
 Incision in advancement of extraocular 
 
 muscles, 86 
 
 of anterior lens-capsule, 159 
 in anterior sclerotomy (DeWecker's), 
 
 193 
 in capsule of Tenon as an adjunct 
 
 to tenotomy, 94 
 in cyclodialysis (Heine), 199 
 in Everbusch's operation for ptosis, 
 
 77 
 
 for extirpation of lachrymal sac, 2 
 in extraction of senile cataract, 
 
 127 
 
 for foreign bodies, 228 
 with the Graefe knife in iridectomy 
 
 for glaucoma, 184 
 Graefe's operation for senile entro- 
 
 pion, 59 
 
 in Hess's operation for ptosis, 71 
 in Hotz-Anagnostakis operation for 
 
 ptosis, 32 
 
 inferior, in cataract-extraction, 240 
 intermarginal, in Kuhnt-Szyma- 
 
 nowski operation, 46 
 
 in 
 
 Incision, intralamellar, in anterior scie- 
 
 rotomy, 194, 195 
 intralamellar, in cataract extraction, 
 
 143 
 
 intralamellar, in iridectomy for glau- 
 coma, 185, 187 
 
 for iridectomy in glaucoma, 180 
 
 in iridotomy, 171 
 
 with lancet in iridectomy for glau- 
 coma, 185 
 
 in linear extraction for soft cataracts, 
 
 174 
 
 length of, in cataract extraction, 142 
 in operation for cicatricial ectropion, 
 
 52 
 
 in optical iridectomy, 165 
 in Panas's operation for trichiasis, 36 
 in paracentesis of cornea, 205 
 in posterior sclerotomy, 197 
 in simple extraction, 157 
 in tarsorrhaphy, 66 
 Incomplete excision of lachrymal sac, 18 
 
 results of, 14 
 
 Incorrect position of incision in iridec- 
 tomy for glaucoma, 187 
 India ink in tattooing of cornea, 232 
 Indications for advancement of rectus 
 
 internus, 101 
 anterior sclerotomy, 196 
 canthoplasty, 62 
 conjunctivoplasty, 212, 213 
 counteracting suture, 100 
 cyclodialysis, 203 
 
 discission in high-grade myopia, 162 
 discission through sclera, 172 
 enucleation, no 
 
 Everbusch's operation for ptosis, 77 
 excision of iris, 209 
 
 after prolapse, 215 
 exenteration of orbital cavity, 113 
 extraction without iridectomy, 156 
 Graefe knife in iridectomy for 
 
 glaucoma, 184 
 iridectomy in glaucoma, 187 
 iridotomy, 170 
 
 Kuhnt's method of canthoplasty, 63 
 operation in convergent strabismus, 
 
 98 
 for divergent strabismus, 99 
 
 in secondary glaucoma, 205 
 optical iridectomy, 164 
 optico-ciliary neurotomy, 112 
 posterior sclerotomy, 198 
 probing lachrymo-nasal duct, 27, 29 
 prolapse of vitreous, 152 
 ptosis operation, 75
 
 Indication- for roection of lachrymal 
 
 sac. jo 
 
 slitting lachrvmal cana'iculus. 2(1 
 supporting: suuiri 1 . 100 
 tarsorrhaphy. 65. oX 
 Infection of cornea follo,viiiL, r cataract 
 
 extraction. 142 
 Inferior inci.-ion in cataract-extraction, 
 
 240 
 
 lachrymal puncture, cversioti of. _ ; 
 Influence of small wound in expres.-ion of 
 
 cataract. 140 
 Injection of cocain in cnuclcalion. 707 
 
 <>f cocain volution into the anu-rior 
 
 chamber. 242 
 subcon junctival. in serpi.^inous 
 
 ulcer. 2^0 
 injury to lachrymal canaliculus during 
 
 dilatation. 25 
 
 lachrymal sac during excision, 17 
 to lens during iridectomy for t^lau 
 
 coma. 1X7 
 
 to lens in trephining the cornea. 220 
 to the lens-capsule in iridectomy for 
 
 glaucoma, i SS 
 
 Ink. India, in tattooing of cornea, 2^2 
 Insertion of an unpedicled tlap without 
 incision in total symhlepharon, 
 
 scissors m enuclcation. 105 
 sutures in advancement of extra- 
 ocular muscles. Sj 
 Kvcrbusch's operation for ptosis, 
 
 7- s 
 (iraefc's operation for senile en 
 
 tropion. 60 
 
 I less's operation for ptosis, 71 
 I lot/.-. \naLmostakis operalion. ^2 
 operation for cicatricial ec tropion. 
 
 53 
 Instruments for iridectomy in extraction, 
 
 I2t, 
 
 extraction. 127 
 Interior of eye. extraction of foreign 
 
 bodies from. 222 
 Intermanrinal incision in Kuhnt-S/.yma- 
 
 nowski operation. 4^1 
 in tarsorrhaphv. 06 
 Internal canthal ligament. 4 
 palpeliral ligament, i 
 rectus. indications for advancement 
 of. 1 01 
 
 Internal rectus. tenotomy of. >>4 
 
 tarsorrliapliy, (xt 
 Intralamellar incision in anterior >clen> 
 
 tolliy. K;4. K;5 
 
 cataract extraction. 14^ 
 iriilectomy lor glaucoma. iN>. \^~ 
 Introduction of Ljla.-o or LTold liall> in eye. 
 
 i i i 
 
 knife-needle in discission. i>(; 
 l'ai, r en>techer's sutun-s for pbi>. 
 
 70 
 suture> in I ; uchs's meth.od , i| tarsor- 
 
 rhaphy. 07 
 \\"elier's loop. I 50 
 Iridectomy after prolapse, indication.- 
 
 for. 215 
 
 dutie> of assistant in. -'^7 
 glaucoma. iSo 
 I'ataract folIowin.Lr. K;I 
 cocain in. i SS 
 complications of. i ti~ 
 complications during reposition oi 
 
 iris. i<S<; 
 
 disadvantages of lancet. 1X5 
 excision of iris in. 1X5 
 expulsive hemorrhage in. K^O 
 ( iraefe knife in. 184 
 hemorrhage duriiiLT. iS<; 
 inci>ion tor. iSo 
 indications for. 1X7 
 intralamellar incision. 1X5 
 lancet in. i So 
 operation lor cystic >car> alter. 
 
 22 I 
 
 pain during. iSS 
 
 prolapse of vitreous in. i go 
 
 repi isilion of iris in. i So 
 
 spontaneous ruture of lens-cap>ule 
 i 'i ' 
 
 suhluxation of lens. \<>\ 
 
 ser| n'd nous ulcer. 2^ i 
 
 in cataract extraction, i 21; 
 
 ci implicalic in> oi. i | j 
 
 exten-ivc svne( hia. 2 i i 
 
 sccondarv Lrlaui i >ma. Jof> 
 
 complications of. 207 
 
 oplical. 104 
 
 preliminary. 15'' 
 Iridodialysis in anterior srlerolomy, KjC) 
 
 duriii'j; iridectomy in cataract extrac 
 lion. 14 | 
 
 !< iv planet ima. i Sj 
 Iridotomy in secondary cataract. 170 
 
 applic atii >n <>\ . i 70 
 
 precorncal. 10; 
 Iris, atrophic. in u'laucoma. i SS
 
 2 54 
 
 INDEX. 
 
 Iris, attached in glaucoma, liberation of, 
 
 190 
 care of, in linear extraction of soft 
 
 cataract, 177 
 cyst of, as a cause of secondary 
 
 glaucoma, 207 
 excision of, 209 
 forceps, 129 
 
 in iridectomy for glaucoma, 185 
 operations on, 164 
 prolapse, after simple extraction, 158 
 prolapse of, conjunctivoplasty in, 212 
 in extraction without iridectomy, 
 
 156 
 
 operation for, 209 
 reposition of, after extraction, 138 
 in iridectomy for glaucoma, 186 
 scissors, 129 
 
 time for excision after prolapse, 215 
 transfixion of, in iridectomy for 
 
 glaucoma, 187 
 
 Iritis, acute, corneal puncture in, 206 
 Iron splinters in eye, 224 
 
 J 
 
 Jaesche-Arlt operation, 39 
 
 K 
 
 Keratitis profunda, corneal puncture, in, 
 
 206 
 
 Keratoplasty, 216 
 partial, 217 
 total, 218 
 
 Knapp's roller forceps, 234 
 Knife, Graefe cataract, 127 
 in anterior sclerotomy, 193 
 iridectomy for glaucoma, 184 
 operations for anterior synechia, 
 
 221 
 
 posterior sclerotomy, 196 
 Saemisch section, 230 
 transfixion for seclusion of pupil, 
 
 208 
 
 Weber's 27 
 Knots in sutures in excision of lachrymal 
 
 sac, 13 
 
 Kuhnt's conjunctivoplasty, 212 
 expressor, 235 
 method of canthoplasty, 63 
 operation for senile ectropion, 44 
 Miiller's modification of, 52 
 Kuhnt-Szymanowski operation for senile 
 
 ectropion, 44 
 complications of, 51 
 dressing, 50 
 ectropion, results of, 51 
 technic, 44 
 
 Laceration of conjunctiva in iridectomy 
 
 for glaucoma, 187 
 Lachrymal apparatus, i 
 anesthesia of, 15 
 hemostasia of, 15 
 canaliculus, dilatation of, 24 
 dilatation of, injury during, 25 
 slitting of, 26 
 crest, anterior, i, 17 
 ducts, 7 
 fistula, 30 
 
 gland, palpebral, excision of, 22 
 sac, anatomy of, i 
 
 acute inflammation of, 20 
 dissection, 2 
 douching of, 28 
 excision of, i 
 complications, 17 
 difficulties in, 17 
 ectropion following, 20 
 fistula following, 19 
 incomplete, 14, 18 
 indications for, 20 
 injury of sac during, 17 
 persistent suppuration after, 18 
 ultimate result, 21 
 great dilatation of, 20 
 tuberculous disease, 20 
 passages, test for permeability of, 30 
 probing, 24 
 
 punctum, inferior, eversion of, 26 
 Lachrymo-nasal duct, probing of, 27 
 contraindications, 31 
 indications for, 29 
 in new-born, 29 
 Lamp, Sach's, 229 
 
 Lancet in iridectomy for glaucoma, 180 
 Large magnet, Haab's, 224 
 Last step in Kuhnt-Szymanowski oper 
 
 ation, 49 
 
 Lattice bandage, Fuchs's, 244 
 Length of incision in cataract extraction, 
 
 142 
 
 for excision of lachrymal sac, 2 
 in anterior sclerotomy, 194 
 Lens-capsule, anterior, incision of, 131, 
 
 159 
 
 effects of failure to open, 147 
 spontaneous rupture in iridectomy 
 
 for glaucoma, 191 
 Lens, backward luxation of, 155 
 
 discission for totally opaque, 163 
 
 transparent, 161 
 
 expression of cataractous, 134, 146
 
 INDEX. 
 
 255 
 
 Lens, injury to, during iridectomy for 
 
 glaucoma, 187 
 in trephining cornea, 220 
 luxation of, affecting expression in 
 
 cataract extraction, 147 
 operations, 124 
 removal of, in extraction of soft 
 
 cataract, 176 
 
 shrunken, in children, 164 
 subluxation of, in iridectomy for 
 
 glaucoma, 191 
 
 swelling of, corneal puncture in, 206 
 wound of capsule, in excision of iris, 
 
 210 
 
 Lentis, hernia, 191 
 Liberation of attached iris in glaucoma, 
 
 190 
 Lid, excision of portion of, for senile 
 
 ectropion, 44 
 lower, ectropion, 26 
 shortening of, for senile ectropion, 44 
 operations on, 32 
 speculum, 236 
 Ligament, internal canthal, 4 
 
 palpebral, i 
 Linear extraction, 169 
 for soft cataract, 174 
 for total cataract in young adults, 164 
 Local anesthesia in ophthalmic operations, 
 
 241 
 
 Loop, Weber's, 150 
 Lower lid, ectropion, 26 
 
 operations on, for trichiasis, 38 
 spastic ectropion of, 42 
 Luxation of lens as cause of secondary 
 
 glaucoma, 207 
 effects of, in extraction, 147 
 
 M 
 
 Magnet, Haab's large, 224 
 operation, 224 
 small, in foreign bodies in eye-ball, 
 
 226 
 Malignant growths of eye, operation for, 
 
 in, 113 
 
 Manifestations of prolapse of vitreous, 153 
 Manner of making incision in cataract 
 
 extraction 142 
 Massage after expression of cataractous 
 
 lens, 137 
 Means of determining whether optical 
 
 iridectomy w T ill improve vision, 
 
 167 
 
 influencing effect of advancement, 96 
 Membrane, Descemet's, detachment of, 
 
 in cyclodialysis, 202 
 
 Median tarsorrhaphy (V. Arlt), 70 
 Method, De Wecker's, of transplantation 
 of the conjunctiva, 214 
 
 of Dieffenbach, 115 
 
 for extirpation of lachrymal sac, i 
 
 Flarer's, 38 
 
 Fricke's, 115 
 
 Froehlich's, of tattooing the cornea, 
 
 2 33 
 
 Fuchs's, of tarsorrhaphy, 65 
 Hotz-Anagnostakis, 32 
 inserting Graefe cataract-knife in 
 
 extraction, 127 
 
 Reisinger's double tenaculum, 151 
 scissors in enucleation, 105 
 introducing Weber's loop, 150 
 Jaesche-Arlt, 39 
 Kuhnt's, of canthoplasty, 63 
 Motais', for ptosis, 83 
 of operating for anterior synechia, 
 
 221 
 
 Panas's, for ptosis, 83 
 for trichiasis, 36 
 of procedure when capsule of lens is 
 
 thickened, in extraction, 145 
 Rogman's, 121 
 
 Von Hippel's of keratoplasty, 218 
 Minor assistance, auxiliary, 241 
 
 corneal operations, 230 
 Misplacement of incision in anterior 
 
 sclerotomy, 195 
 
 Motais' operation for ptosis, 83 
 Movable stenopaeic disk, Fritsch's, 167 
 Mueller's lid speculum, 236 
 Mules's operation, in 
 Miiller's modification of Kuhnt's oper- 
 ation, 52 
 
 tear -sac speculum, 3 
 Muscles in excision of lachrymal sac, 3 
 Muscle-operations in children, 102 
 Muscles, operations on, 84 
 Myopia, indications for discission, 162 
 
 N 
 
 Naso-lachrymal duct, probing of, 27 
 Needles, discission with two, 169 
 in excision of lachrymal sac, 12 
 in tattooing the cornea, 233 
 Nerve, optic, resection of, in enucleation, 
 
 no 
 
 Neurotomy, optico-ciliary, 112 
 New-born children, probing in, 29 
 
 O 
 
 Object of precorneal iridotomy, 165 
 tarsorrhaphy, 65
 
 256 
 
 INDEX. 
 
 Opening anterior lens-capsule, in extrac- 
 tion, 131, 145 _ 
 duties of assistant in, 237 
 in extraction without iridectomy, 157 
 linear extraction for soft cataract, 
 
 175 
 
 of orbital cavity, 17 
 Operations, advancement. 86 
 anesthesia in, 241 
 
 anterior sclerotomy in glaucoma, 193 
 anterior synechia, 219 
 Arlt's for pterygium, 232 
 bandaging after, 244 
 Beer-Wecker, for corneal staphy 
 
 loma, 233 
 
 bilateral ectropion, 52 
 Bowman's discission, 169 
 canthoplasty, 61 
 
 canthoplasty, Kuhnt's method, 63 
 canthotomy, 63 
 cataract, 124 
 linear extraction for, 174 
 chrystalline lens, 124 
 complete closure of palpebral fissure, 
 
 6 9 
 
 symblepharon, 121 
 Rogman's, 121 
 
 cicatricial ectropion, 52 
 
 congenital cataract, 163 
 
 conjunctivoplasty, 212 
 
 convergent strabismus, indications 
 for, 98 
 
 corneal staphyloma, 233 
 
 corneal transplantation, 216 
 
 cyclodialysis (Heine), 199 
 
 cystic scars after iridectomy for 
 glaucoma, 221 
 
 detachment of retina, 198 
 
 De Wecker's anterior sclerotomy in 
 glaucoma, 193 
 
 De Wecker's method of transplan- 
 tation of the conjunctiva, 214 
 
 Dieffenbach-Buediner, 117 
 
 discission, 159 
 
 discission through sclera, 172 
 
 divergent strabismus, indications for, 
 
 99 
 
 dressing after, 244 
 ectropion, 42 
 entropion, 58 
 enucleation, 103 
 for foreign, bodies, 229 
 in glaucoma, 192 
 Everbusch's, for ptosis, 77 
 evisceration of the eyeball, in 
 excision of iris, 209 
 
 Operations, exenterationof orbital cavity, 
 
 "3 
 
 expression of trachoma granules, 
 
 234 
 
 extraction of foreign bodies from 
 interior of the eye, 222 
 
 other than iron, 228 
 
 through an opening in the sclera. 
 227 
 
 of lens in its capsule, 150 
 
 senile cataract, 124 
 
 without iridectomy, 157 
 eyelids, 32 
 
 plastic, Dieffenbach's, 115 
 
 Dieffenbach-Buediner, 117 
 
 Fricke's, 115 
 
 with pedicled flaps, 115 
 eye-muscles, 84 
 Flarer's, for trichiasis, 38 
 Fuchs's method of tarsorrhaphy, 65 
 glaucoma, 180 
 
 time, 189 
 
 Graefe's, for senile entropion, 59 
 Haab large magnet, 224 
 Heine's, 199 
 Hess's for ptosis. 71 
 Hotz-Anagnostakis, 32 
 incision of anterior lens-capsule, 
 
 159 
 
 internal tarsorrhaphy, 69 
 iridectomy in extraction, 129 
 for glaucoma, 180 
 iridotomy linear extraction, 169 
 keratoplasty, 216 
 Kuhnt's conjunctivoplasty, 212 
 Kuhnt's, Miiller's modification, of, 
 
 5 2 
 
 Kuhnt's, for senile ectropion, 44 
 
 lengthening palpebral fissure, 61 
 
 liberation of attached iris in glau- 
 coma, 190 
 
 linear extraction for soft, 174 
 
 lower eyelid for trichiasis, 38 
 
 magnet, 224 
 
 median tarsorrhaphy, 70 
 
 minor corneal, 230 
 
 Motais', for ptosis, 83 
 
 Mules's, in 
 
 muscle, simultaneous, 97 
 
 optical iridectomy, 164 
 
 optico-ciliary neurotomy, 112 
 
 Pagenstecher's sutures for ptosis. 
 76 
 
 Panas's, for ptosis, 83 
 for trichiasis, 36 
 
 paracentesis of cornea, 205
 
 INDEX. 
 
 Operations, paralytic ectropion, 52 
 plastic, for trichiasis, 40 
 posterior sclerotomy in glaucoma, 
 
 196 
 
 precorneal iridotomy, 165 
 preliminary iridectomy, 156 
 prolapse of iris, 209 
 pterygium, 231 
 ptosis, 71 
 summary, 82 
 
 removal of partial cataract, 163 
 Rogman's, for complete symble- 
 
 pharon. 121 
 
 Sach's, for anterior synechia, 219 
 Saemisch section, 230 
 seclusion of pupil, 208 
 secondary cataracts, 159, 169 
 secondary glaucoma, 205 
 senile ectropion, 43 
 
 Kuhnt-Szymanowski, 44 
 serpiginous ulcers, 230 
 shortening of lid for senile ectropion, 
 
 44 
 
 simple extraction, 156 
 
 simultaneous muscle, 97 
 
 spastic ectropion, 42 
 
 spastic entropion, 58 
 
 strabismus. 84 
 
 applicability of, 92 
 
 symblepharon, 120 
 
 tarsorrhaphy, 65 
 
 tattooing of cornea, 232 
 
 tenotomy, 85 
 
 total cataract in young adults, 164 
 
 transfixion, 208 
 
 transplantation of cornea, 216 
 
 transplantation for pterygium, 231 
 
 trichiasis, 32 
 
 Hotz-Anagnostakis, 32 
 
 Jaesche-Arlt, 39 
 
 Panas's, 36 
 
 Von Hippel's corneal transplanta- 
 tion, 218 
 
 Ophthalmic assistant, duties of, 236 
 Ophthalmoscope examination in cases of 
 
 foreign body in eyeball, 222 
 Optic nerve, resection of, in enucleation, 
 no 
 
 iridectomy, 164 
 
 indications for, 168 
 
 results of, 168 
 Optico-ciliary neurotomy, 112 
 
 anesthesia, 112 
 
 indications, 112 
 
 Orbicularis muscle in excision of lach- 
 rymal sac, 3 
 
 17 
 
 Orbital cavity, exenteration of, 113 
 opening of, 1 7 
 
 fat in excision of lachrymal sac, 12 
 lachrymal gland, excision of, 24 
 
 Pagenstecher's sutures for ptosis, 76 
 Pain during iridectomy for glaucoma, 188 
 Painful amaurotic eye, operation in, no 
 Palpebral fissure, complete closure of, 69 
 operation for lengthening, 61 
 lachrymal gland, excision of, 22 
 dressing after, 24 
 results, 24 
 technic, 22 
 ligament, internal, i 
 Panas's operation for ptosis, 83 
 for trichiasis, 36 
 disadvantages, 38 
 incision, 36 
 results, 38 
 sutures in, 37 
 technic, 36 
 
 Panophthalmitis, operation in, in 
 Paracentesis of cornea, 205 
 Paralytic ectropion, 52 
 
 squint, operations for, 101 
 Partial cataract, discission for, 163 
 kerataplasty, 217 
 trichiasis, 39 
 Passing of probes in new-born children. 
 
 29 
 
 Pedicled flaps in eyelid operations, 115 
 Penetrating wounds of eyeball, 226 
 Percentage of prolapse of iris in extrac- 
 tion without iridectomy, 156 
 Perforation of sclera in posterior scle- 
 rotomy, 197 
 Permeability of lachrymal passages, test 
 
 for, 30 
 Persistent suppuration after excision of 
 
 lachrymal sac, 18 
 
 Phenomena indicating prolapse of vitre- 
 ous, 153 
 
 Pince-ciseaux, De Wecker's, 129 
 Plastic operations on eyelids, Dieffen- 
 
 bach's, 115 
 
 Dieffenbach-Buediner, 117 
 Fricke's, 115 
 with pedicled flaps, 115 
 for symblepharon, 120 
 for trichiasis, 40 
 Pointed tenaculum used to open anterior 
 
 lens-capsule, 134 
 
 Position of conjunctiva! flap after extrac- 
 tion, 139
 
 258 
 
 INDEX. 
 
 Position of eye after strabismus opera- 
 tions, 94 
 faulty, of incision in anterior scler- 
 
 otomy, 195 
 
 foreign body in eyeball, 223 
 incision for iridectomy in glaucoma, 
 
 1 80 
 knife during incision for extraction, 
 
 128, 143 
 
 Possibility of recurrence of trichiasis after 
 Hotz-Anagnostakis operation, 
 36 
 
 after Panas's operation, 38 
 Posterior sclerotomy as an adjunct to 
 removal of foreign bodies in 
 vitreous, 199 
 
 for detachment of retina. 198 
 in glaucoma, 196 
 incision, 197 
 indications for, 198 
 Pravaz's syringe, 15 
 Precautions during cyclodialysis, 201 
 Precorneal iridotomy, 165 
 Preliminary iridectomy, 156 
 Preparation of upper lid in tarsorraphy, 
 
 66 
 
 Pressure-bandages, 244 
 Pressure-dressing after iridotomy, 171 
 Prevention of hemorrhage after irido- 
 tomy, 171 
 
 Primary glaucoma, cyclodialysis in, 203 
 Principal value of posterior sclerotomy, 
 
 198 
 Procedure in old injuries from foreign 
 
 bodies, 229 
 Prognosis for foreign bodies in eyeball, 
 
 227 
 
 Progressive corneal ulcers, corneal punc- 
 ture in, 206 
 Prolapse of chorioid in scleral wounds, 
 
 treatment of, 214 
 ciliary body in scleral wounds, 
 
 treatment, 214 
 Prolapse of iris in anterior sclerotomy, 
 
 196 
 
 conjunctivoplasty in, 212 
 excision of, after simple extraction, 
 
 157 
 
 operations for, 209 
 percentage of, in extraction without 
 
 iridectomy, 156 
 time for excision after, 215 
 vitreous in cataract extraction, 148 
 as a cause of secondary glaucoma, 
 
 207 
 
 during discission, 162 
 in iridectomy for glaucoma, 190 
 
 Prolapse in linear extraction for soft 
 
 cataract, 179 
 sequela? of, 154 
 Probes, Bowman's, 27 
 conical, 24 
 hollow, 30 
 
 Probing in excision of lachrymal sac, 12 
 lachrymal, 24 
 of lachrymo-nasal duct, 27 
 contraindications, 31 
 indications for, 29 
 in new-born, 29 
 Pterygium, operations for, 231 
 Arlt's, 232 
 transplantation, 231 
 Ptosis following excision of lachrymal 
 
 gland, 24 
 operations for, 71 
 Everbusch's, 77 
 Hess's, 71 
 Motais's, 83 
 Pagenstecher's, 77 
 Panas's, 83 
 summary of, 82 
 Puncture of cornea, 206 
 Pupil, seclusion of, operation for, 208 
 Purposes of iridotomy, 171 
 
 R 
 
 Rays, Rontgen, in foreign bodies in eye- 
 ball, 222 
 Rectus externus, tenotomy of, 86, 96 
 
 internus, advancement of, indica- 
 tions for, 101 
 tenotomy of, 84 
 
 Reisinger's double tenaculum, 150, 151 
 Removal of cortical substance in extrac- 
 tion without iridectomy, 157 
 lens in linear extraction of soft 
 
 cataract, 176 
 partial cataract, 163 
 totally opaque lenses, discission for, 
 
 163 
 
 Repetition of iridotomy, 172 
 puncture of cornea, 206 
 Reposition of iris after extraction of len*. 
 
 138 
 
 in iridectomy for glaucoma, 186 
 
 complications during, 189 
 Resection of lachrymal sac, i 
 
 optic nerve in enucleation, no 
 
 palpebral lachrymal gland, 22 
 Results of anterior sclerotomy, 196 
 
 cyclodialysis, 203 
 
 Dieffenbach's operation on eyelids, 
 117
 
 Kuhm-S/ymano\vski operation for 
 
 senile ectropion. ; i 
 operation for cicatricial ectropion. =14 
 operation for >enile entropion. 60 
 optical iridectomy. i6S 
 I'anas's operation for trichiasis. ^S 
 
 Results ot Kverbusch's operation for Scleral sutures. 24 
 
 ptosis. So wounds, treatment of. 214 
 
 excision ot lachrymal gland. 24 Sclerotomy. anterior, accidents during. 
 
 sac. 21 10.5 
 
 Hess's ptosis operation. 75 in glaucoma, ig^ 
 
 Hotz-Anagnostakis operation. y> indications, igf> 
 
 intralaniellar incision in. ig- 
 iridodialv>is. igo 
 re.-ults of. i go 
 po-ten'or. for detachment of retina. 
 
 igS 
 
 in glaucoma. n><> 
 incision in. 107 
 indication.- for. igS 
 plastic operation for trichiasis. 41 Scopalamin-morphin ane.-the.-ia. 24^ 
 
 probing lachrymo-nasal net. 27 Seclusion of pupil, operation for, 208 
 
 simultaneous tenotomy and advance- Second incision in Kuhnt-Szymanowski 
 
 meiit. 07 operation. 48 
 
 tar-orrhaphy. 68 method of operating for anterior 
 
 Retention of particles of mucous mem- synechia. 221 
 
 brane after excision of lach- step in Kuhm-S/ymanow-ki oper 
 
 rymal sac. 18 ation. 40 
 
 Retina, detachment of. posterior sclero- Secondarv cataract, operation for. 150 
 
 tomy tor. ig8 Bowman's discission. i6g 
 
 following prolapse of vitreou.-. 155 capsulotomv. 170 
 
 Retraction of caruncle following teno- 
 tomy, 101 
 Rogman's operation for complete symble 
 
 pharon. 121 
 
 Roller forceps. Knapp's. 2^4 
 Ront^en ray- in foreign bodies in eye- 
 ball. '222 
 Rules governing excision of iris. 210 
 
 the incision in cataract extraction. 
 
 142 
 
 operations in convergent strabis- 
 mus. 08 
 operations in divergent .-trabi.-mus.gg 
 
 combined discission. 170 
 discission. r6g 
 
 disci.-.-ion through -clera. 172 
 glaucoma, operations for. 205 
 
 iridectomy in. 206 
 transfixion. 208 
 
 jjosterior sclerotomy in glaucoma. 
 
 197 
 
 Rii|)ture. spontaneous, of lens-capsule in 
 iridectomv tor glaucoma, igi 
 
 Senile cataract, extraction of. 124 
 
 ectropion. operations for. 4^ 
 
 excision, 44 
 
 K.uhm's. 44 
 
 Kuhnt-S/ymaiiowski. 44 
 
 .shortening of lid for. 44 
 
 entropion, 4^. 51) 
 
 operations, ;g 
 
 operations for. 51; 
 
 exci.-ion. _;g 
 
 operations. ( iraete's. 50 
 Sec|Uel;e of prolap-e of vitreous. 154 
 
 tenotomv. ici 
 
 Sac. excision of lachrymal, i 
 Sachs' lamp. 221; 
 
 operation for anterior synechia. 2ig 
 
 Saemisch section in serpiginous ulcer. 2 ^o Serpiginous ulcer, iridectomy tor. 2^1 
 
 Scars, cystic, after iridectomy for glau- operati\e therapy ot. 2^0 
 
 coma. 221 Saemisch section in. 2 yO 
 
 Scissors in enucleation. 105 subconjunctival injections in. 2^0 
 
 iris, i2g thermocautery in. 2,^0 
 
 Sclera. discission through, in >Vn>ndary Severaiue of optic nerve in enucleation, 
 
 cataract, 172 IGO 
 
 extraction of foreign bodies through Shorten in-.: of lid for senile ectropion. 
 
 an opening in. 227 44
 
 260 
 
 INDEX. 
 
 Shortness of corneal incision in cataract 
 
 extraction, 141 
 Shrunken lens in children, operation for, 
 
 164 
 
 Sideroscope, 223 
 Sideroscope in foreign bodies in eye-ball, 
 
 222 
 Significance of prolapse of vitreous 
 
 during extraction, 148 
 Signs of prolapse of vitreous, 153 
 Simple extraction, 156 
 Simultaneous advancement of rectus 
 externus and tenotomy of rectus 
 internus of one eye, 97 
 Size of lens influencing expression in 
 
 extraction, 147 
 Skin-graft flaps in operation for cicatri- 
 
 cial ectropion, 55 
 
 Slitting of lachrymal canaliculus, 26 
 indications, 26 
 technic of, 26 
 
 Small magnet in foreign bodies in eye- 
 ball, 226 
 Snellen's cup, 244 
 
 suture for spastic ectropion, 42 
 Soft cataract, linear extraction for, 174 
 Spastic ectropion, 42 
 operations for, 42 
 operations for, Snellen's suture. 42 
 entropion, 58 
 operations for, 58 
 Gaillard's suture, 58 
 Speculum, lid, 236 
 
 Muller's tearsac, 3 
 Spencer Watson operation for partial 
 
 trichiasis, 39 
 Splitting of cornea, 230 
 Spontaneous rupture of lens-capsule in 
 
 iridectomy for glaucoma, 191 
 Spoon, Daviel's, in foreign bodies in 
 
 eye-ball, 227 
 in expression of cataractous lens, 
 
 136 
 
 Desmarres', 152 
 Squint, paralytic, indications for oper 
 
 ation in, 101 
 
 Staphyloma, corneal, operations for, 233 
 Stenopaeic disk, Fritsch's movable, 167 
 Steps in Kuhnt-Syzmanowski operation, 
 
 44 
 
 Steps in enucleation, 103 
 Strabismus, convergent, indications for 
 
 operations in, 98 
 divergent, indications for, 99 
 operations, 84 
 applicability, 92 
 
 Stretching of muscle in advancement, 87 
 Subconjunctival injections for serpigi- 
 
 nous ulcer, 230 
 Subcutaneous injection of cocain-solu- 
 
 tion, 243 
 Subluxation of lens in iridectomy for 
 
 glaucoma, 191 
 Summary of operations for ptosis, 82 
 
 wounds of eye-ball, 226 
 Superficial fascia in excision of lach 
 
 rymal sac, 3 
 Supporting sutures, indications for, 100 
 
 in tenotomy, 93 
 Suppuration, persistent, after excision of 
 
 lachrymal sac, 18 
 Sutures in advancement of extraocular 
 
 muscles, 87 
 in canthoplasty, 62 
 in conjunctivoplasty, 212 
 counteracting, in tenotomy, 95 
 in Dieffenbach-Buediner operation, 
 
 118 
 in Everbusch's operation for ptosis, 
 
 78 
 
 in excision of lachrymal sac, 12 
 in Fuchs's method of tarsorrhaphy, 67 
 Gaillard's, for spastic entropion, 58 
 in Graefe's operation for senile 
 
 entropion, 60 
 
 in Hess's operation for ptosis, 71 
 in Hotz-Anagnostakis operation, 34 
 in Kuhnt's method of canthoplasty 
 
 64 
 
 in Kuhnt-Szymanowski operation, 48 
 in operation for cicatricial ectropion, 
 
 53 
 
 Pagenstecher's, for ptosis, 76 
 in Panas's operation for trichiasis, 37 
 scleral, 214 
 
 Snellen's, for spastic ectropion, 42 
 supporting, in tenotomy, 93 
 after tenotomy of rectus internus, 84 
 Suturing of conjunctiva in cyclodialysis, 
 
 202 
 
 Swelling of lens, corneal puncture in, 206 
 Symblepharon, complete, 121 
 
 operations for, 120 
 
 Sympathetic affections, operations in, no 
 Symptoms of prolapse of vitreous, 153 
 Synechiae, anterior, operations for, 219 
 
 extensive, iridectomy in, 211 
 
 following cataract extraction, 142 
 Syringe, Anel's, 28 
 
 Pravaz's, 15 
 
 Szymanowski operation for senile ectro- 
 pion, 44
 
 INDEX. 
 
 Tampon in enucleation, 109 
 Tarso-orbital faccia, 23 
 Tarsorrhaphy, 65 
 
 external, 65 
 
 Fuchs's method of, 65 
 
 incisions in, 66 
 
 indications for, 65, 68 
 
 internal, 69 
 
 median (v. Arlt), 70 
 
 object of, 65 
 
 results of, 68 
 Tarsus, excision of, in Kuhnt-Szyma- 
 
 nowski operation, 46 
 Tattooing of cornea, 168, 232 
 
 Froehlich's method of, 233 
 Tear-conduction, 29 
 Tearing of conjunctiva during cataract 
 
 extraction, 140 
 
 Tearsac speculum (Miiller's), 3 
 Technic of advancement of extraocular 
 muscles, 86 
 
 anesthesia of lachrymal apparatus, 
 
 15 
 anterior sclerotomy, (De Wecker), 
 
 193 
 
 Arlt's median tarsorrhophy, 70 
 Arlt's operation for pterygium, 232 
 Beer-Wecker operation for corneal 
 
 staphyloma, 233 
 canthoplasty, 61 
 conjunct! voplasty. 212 
 corneal transplantation, 216 
 cyclodialysis (Heine), 199 
 De Wecker's method of transplanta- 
 tion of the conjunctiva, 214 
 Dieffenbach's operation on eyelids, 
 
 "5 
 
 Dieffenbach-Buediner operation, 117 
 
 dilatation of canalicujus, 24 
 
 discission, 159 
 
 for secondary cataract, 1 70 
 
 douching lachrymal sac, 28 
 
 enucleation, 103 
 
 Everbusch's operation for ptosis, 77 
 
 excision of iris, 209 
 
 of lachrymal sac, i 
 
 palpebral lachrymal gland, 22 
 expression of trachoma granules, 
 
 234 
 
 extraction of lens in its capsule, 150 
 senile cataract, 124 
 without iridectomy. 157 
 Graefe's operation for senile entro- 
 pion, 59 
 
 Technic of Fricke's operation, 115 
 Hess's operation for ptosis, 71 
 Hotz-Anagnostakis operation, 32 
 of introduction of Pagenstecher's 
 
 sutures for ptosis, 76 
 iridectomy in cataract extraction, 
 
 129 
 
 iridectomy for glaucoma, 180 
 iridotomy for secondary cataract, 
 
 170 
 
 keratoplasty, 216 
 
 Kuhnt's method of canthoplasty, 63 
 Kuhnt's conjunctiroplasty, 212 
 Kuhnt-Szymanowski operation for 
 
 senile ectropion, 44 
 linear extraction for soft cataract, 
 
 174 
 
 magnet operations, 224 
 opening anterior lens-capsule in 
 
 extraction, 131 
 
 operation for cicatricial ectropion, 52 
 for corneal staphyloma, 233 
 for entropion, 58 
 for symblepharon, 120 
 optical iridectomy, 165 
 optico-ciliary neurotomy, 112 
 Panas's operation for trichiasis, 36 
 paracentesis of cornea, 205 
 partial transplantation of cornea, 217 
 plastic operation for trichiasis, 40 
 posterior sclerotomy in glaucoma, 
 
 196 
 
 precorneal iridotomy, 165 
 probing lachrymo-nasal duct, 27 
 Rogman's operation for symble 
 
 pharon, 121 
 simple extraction, 156 
 slitting the lachrymal canaliculus, 26 
 tarsorrhophy, 65, 69 
 tattooing of cornea, 232 
 rectus externus, 86 
 tenotomy of rectus internus, 84 
 total keratoplasty, 218 
 transfixion for seclusion of pupil, 208 
 transplantation operation for ptery- 
 gium, 231 
 
 Yon Hippel's corneal transplanta- 
 tion, 218 
 
 Tenaculum, pointed, used to open ante- 
 rior lens-capsule, 134 
 Reisinger's double, 150, 151 
 Tenotomy. ^4 
 
 and advancement performed simul- 
 taneously, 97 
 
 counteracting sutures in, 95 
 rectus, externus, 86, 96
 
 262 
 
 INDEX. 
 
 Tenotomy, rectus internus, 84 
 sequelae of, 101 
 supporting sutures, 93 
 
 Test for permeability of lachrymal 
 passages, 30 
 
 Therapy, operative, of serpiginous ulcer, 
 230 
 
 Thermocautery in serpiginous ulcers, 230 
 
 Thickening of capsule of lens in cataract 
 extraction, 145 
 
 Third step in Kuhnt-Szymanowski oper- 
 ation, 48 
 
 Time for excision of iris after prolapse, 
 
 2I 5 
 
 operation in glaucoma, 189 
 Toilet of the eye after extraction, 138 
 Total cataract in young adults, operation 
 
 for, 164 
 
 keratoplasty, 218 
 staphyloma, operation in, in 
 symblepharon, operations for, 121, 
 
 122 
 
 Totally opaque lenses, discission for, 163 
 Trachoma granules, expression of, 234 
 Transfixion of iris in iridectomy for 
 
 glaucoma, 187 
 for seclusion of pupil, 208 
 Transparent lens, discission of, 161 
 Transplantation of conjunctiva, De 
 
 Wecker's method of, 214 
 cornea, 216 
 partial, 217 
 total, 218 
 Von Hippel's, 218 
 for pterygium, 231 
 Trephine, corneal, Von Hippel's 218 
 Trephining of cornea, 216 
 
 for anterior synechia, 219 
 Treatment of expulsive hemorrhage 
 
 during extraction, 155 
 prolapse of vitreous during extrac- 
 tion, 148 
 wounds with prolapse of ciliary 
 
 body or chorioid, 214 
 serpiginous ulcer, 230 
 wounds of eyeball, 226 
 Trichiasis, electrolysis in, 41 
 epilation in, 41 
 operations for, 32 
 Flarer's method, 38 
 Hotz-Anagnostakis method, 32 
 Jaesche-Arlt, 39 
 Panas's method, 36 
 plastic, 40 
 Spencer Watson method, 39 
 
 Tuberculous disease of lachrymal, sac, 20 
 Turning down of corneal flap after 
 
 extraction, 154 
 Turning of the lancet in iridectomy for 
 
 glaucoma, 182 
 
 Two needles, discission with, 169 
 Tying of sutures in Hess's operation for 
 
 ptosis, 72 
 
 U 
 
 Ulcer, serpiginous, operative therapy of, 
 230 
 
 Ulcers, progressive corneal, corneal punc- 
 ture in, 206 
 
 Ultimate result of excision of lachrymal 
 sac, 21 
 
 Undercorrection after tenotomy for con 
 vergent squint, 94 
 
 Unpedicled flap operation in total 
 symblepharon, 123 
 
 Upper lid, spastic ectropion of, 42 
 
 Vertical incision in iridotomy, 171, 172 
 Vision in cases of foreign body in eyeball, 
 
 222 
 Vitreous, extraction of foreign bodies in, 
 
 228 
 
 fluid, 154 
 
 prolapse of, after extraction, 148 
 during discission, 162 
 in iridectomy for glaucoma, 190 
 in linear extraction of soft cata- 
 ract, 179 
 sequelae of, 154 
 removal of foreign bodies in, hypos- 
 
 terior sclerotomy, 199 
 Von Hippel's corneal transplantation, 218 
 trephine, 218 
 
 Watson operation for partial trichiasis, 39 
 Weber's knife, 27 
 
 loop, 150 
 Widening of palpebral fissure following 
 
 tenotomy, 101 
 Withdrawal of the knife in iridectomy 
 
 for glaucoma, 183 
 Wounds in cornea in excision of iris, 210 
 
 eyeball, penetrating, 226 
 
 summary of, 226 
 
 gaping, in cataract extraction, 141 
 
 lens-capsule in excision of iris, 210 
 
 scleral treatment of, 214
 
 UNIVERSITY OF CALIFORNIA LIBRARY 
 
 Los Angeles 
 
 This book is DUE on the last date stamped below. 
 
 Form L9-Series 4939
 
 UC SOUTHERN REGIONAL LIBRARY FACILITY 
 
 A 000414520 7