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A Lid Retractor for Cataract Surgery*
NOTES, CASES, INSTRUMENTS
108
Fig. 1 (Spencer). Fixation light for slitlamp.
while the foreign body is being removed. The light, "A," which is a small electri cian's trouble light (obtainable at most any hardware store) is attached to the frame of the slitlamp head rest. In this case the two
A LID RETRACTOR FOR CATARACT SURGERY* ISADORE GlVNER, M . D . New York NORMAN S. JAFFE,
Brooklyn,
M.D.
N.Y.
AND
BERNARD M. TESCHNER,
M.D.
New York A controversial but important considera tion in intraocular surgery is the control of the lids. There are numerous methods avail able to us but all have limitations. These ♦From the Department of Ophthalmology, New York City Hospital. These retractors may be ob tained from the Storz Instrument Company, Saint Louis 10, Missouri.
ordinary penlight batteries of the light "A," have been replaced by a low-voltage element, which is wired to a small rheostat and trans former so that the light can be plugged into the 110-120 volt city current. It is wise to use a relatively high-voltage light blub (10 or 12 watts), the filament of which will then only produce a faint glow; this makes steady fixation possible even when the bulb is close to the eye. The light slips into one or the other of the two removable housings, "B and B'," which slide up and down on each side of the frame and are mounted with set-screws. The semiflexible cable holding the bulb is long enough so that the bulb can be ad justed to any position from either side of the frame; it is seldom necessary to change it from one side to the other. The idea for this is not entirely original but was developed following a lecture de livered in San Francisco by Professor Lindner of Vienna. He spoke of using a tiny movable light for controlling the pa tient's eye movement during slitlamp exami nation of the fundus. 135 Montevista Avenue. shortcomings will be discussed and a sugges tion as to what we believe a more desirable method will be presented. Adequate exposure of the operative field is essential in all surgery. There are several factors which alter the degree of exposure in ophthalmic surgery—namely, a deep-set eye or a relatively short palpebral fissure. Expo sure might be inadequate, in many cases, even after lateral canthotomy. Prominent globes may occur as a familial characteristic, in high myopia, or in exophthalmos. Here the exposure is always adequate but the problem is the means of obtaining lid retrac tion without causing pressure on the globe. There are three commonly employed meth ods of lid retraction in ophthalmic surgery: 1. Speculum. Though convenient, this has limitations. In spite of the definite pressure exerted by this instrument on the globe, it is
NOTES, CASES, INSTRUMENTS
109
still the most commonly used method. Spaeth1 quence. If the vertical width of the tarsus is considers it a dangerous instrument. Friden- small, the danger is less. If large, the danger berg2 included it among the dangerous trau- is more, since the upper edge presses more matisms to the eye from faulty instrumenta posteriorly on the globe and in a more per pendicular direction. tion. In addition, the use of lid sutures requires While it is true that the pressure exerted on deep-set or normally situated globes is not further injections for anesthesia and conse great, there is a definite amount of pressure. quently will show other factors such as lid This assumes hazardous proportions in pro swelling, pain of another injection, and so truding globes and dislocated lenses. The forth. speculum is definitely contraindicated in 3. Lid retractor for upper lid and assist these conditions. ant's finger for lower lid. Here, an assistant The main source of pressure is from the elevates the upper lid with a Desmarres re weight of the central or screw end of the tractor and depresses the lower lid with his speculum which is the most dependent part of fingers. This is a most satisfactory method. the instrument and exerts pressure on the There is no pressure exerted on the globe lateral aspect of the globe. Some surgeons and the exposure is adequate. Spaeth recom try to minimize this by inserting cotton pledg mends this method. ets between this end of the instrument and There are certain objections, however. If the skin surface of the lateral orbital margin. one assistant is available both his hands are While this is of some aid in the normally occupied with this all important task. A situated globe, it is still dangerous in the pro lapse in attention may prove disastrous. The truding globe. surgeon must occupy himself with duties Another shortcoming which has been ex ordinarily assumed by his assistant, thus his perienced by all surgeons is that the specu attention is often removed from the opera lum is not quickly removable in times of tive site. danger. Finally, if the lips of the speculum Most of these objections are minimized if are not easily placed between the lid and the there is a second assistant. However, the eyeball after lid akinesia, it should not be hands of the assistant effecting retraction used in that case. and the retractor itself may interfere with Many of the above objections are done the surgeon, since it is situated in the upper away with in retractors such as suggested by part of the globe and limbus where most of the surgery takes place. While the principles Guyton. 2. Lid sutures. Many of those who object employed here are good, there is still much to the speculum because of the shortcomings to be desired. already cited utilize lid sutures. The expo Another method of retraction has been one sure is as good or better and the lids are similar to what we propose but the retractors closed more easily at the conclusion of sur are kept in place by screws tightening the ap gery. However, it is often not realized that position of the retractor to the lid. In our the very dangers they seek to avoid are pres experience the tightening not infrequently ent in this method. causes a squeezing out of meibomian secre When traction is placed on the lid margin tion and theoretically adds to the possibility in a direction away from the globe, the lid of local infection if any latent organism finds folds to form a V the apex of which is at the its habitat therein. tarsolevator junction. Thus the upper edge We have used with great success and con of the tarsus is turned inward and exerts venience separate upper and lower lid re pressure on the globe. Again, in cases of tractors (figs. 1, 2, and 3). protruding globes, this is of serious conse The curved end of the retractor fits be-
110
NOTES, CASES, INSTRUMENTS
hind the tarsus. The retraction is in the di rect line of action of the lids. The retractor is sufficiently broad so as to eliminate notch type of retraction as with lid sutures. The
above to the towel draping the patient's head and below to the sheet over the patient's body and chest. The retractors are simple in de sign, require no spring or lock, and are made of stainless steel. They may be bent
Fig. 1 (Givner, Jaffe, and Teschner). Frontal view of lid retractor. Width is sufficient to eliminate notch-type retraction.
Fig. 2 (Givner, Jaffe, and Teschner). Side view of lid retractor. The length of the short arm is equal to that of the tarsus, thus eliminating any possibility of bending of the tarus. The space be tween the long arm and short arm is sufficient to accommodate the eyelid.
curved part of the retractor is approximately the same length as the tarsus thereby elimi nating any bending or folding of the tarsus. The blades completely enclose the tarsus. There is absolutely no pressure on the globe. The exposure exceeds that obtained with the speculum and lid sutures. No assistant is required to hold the retractors. A heavy (No. 1) black silk is tied to the end of the rectractor and this is clamped
Fig. 3 (Givner, Jaffe, and Teschner). Separate upper and lower lid retractors in place. Note the space between lids and globe. There is adequate exposure and no evidence of pressure on the globe at any point.
if necessary to accommodate the curve of the supraorbital margin. They are indispensable in cases with protruding globes or where only one assistant is available. We have found them to be the most de sirable method of retraction. 108 East 66th Street (21). 309 Sterling Place (17).
REFERENCES
1. Spaeth, E. B.: Principles and Practice of Ophthalmic Surgery. Philadelphia, Lea, 1944, p. 618. 2. Fridenberg, P.: Sect. Ophth., N.Y. Acad. Med., May 17,1936.
108
Fig. 1 (Spencer). Fixation light for slitlamp.
while the foreign body is being removed. The light, "A," which is a small electri cian's trouble light (obtainable at most any hardware store) is attached to the frame of the slitlamp head rest. In this case the two
A LID RETRACTOR FOR CATARACT SURGERY* ISADORE GlVNER, M . D . New York NORMAN S. JAFFE,
Brooklyn,
M.D.
N.Y.
AND
BERNARD M. TESCHNER,
M.D.
New York A controversial but important considera tion in intraocular surgery is the control of the lids. There are numerous methods avail able to us but all have limitations. These ♦From the Department of Ophthalmology, New York City Hospital. These retractors may be ob tained from the Storz Instrument Company, Saint Louis 10, Missouri.
ordinary penlight batteries of the light "A," have been replaced by a low-voltage element, which is wired to a small rheostat and trans former so that the light can be plugged into the 110-120 volt city current. It is wise to use a relatively high-voltage light blub (10 or 12 watts), the filament of which will then only produce a faint glow; this makes steady fixation possible even when the bulb is close to the eye. The light slips into one or the other of the two removable housings, "B and B'," which slide up and down on each side of the frame and are mounted with set-screws. The semiflexible cable holding the bulb is long enough so that the bulb can be ad justed to any position from either side of the frame; it is seldom necessary to change it from one side to the other. The idea for this is not entirely original but was developed following a lecture de livered in San Francisco by Professor Lindner of Vienna. He spoke of using a tiny movable light for controlling the pa tient's eye movement during slitlamp exami nation of the fundus. 135 Montevista Avenue. shortcomings will be discussed and a sugges tion as to what we believe a more desirable method will be presented. Adequate exposure of the operative field is essential in all surgery. There are several factors which alter the degree of exposure in ophthalmic surgery—namely, a deep-set eye or a relatively short palpebral fissure. Expo sure might be inadequate, in many cases, even after lateral canthotomy. Prominent globes may occur as a familial characteristic, in high myopia, or in exophthalmos. Here the exposure is always adequate but the problem is the means of obtaining lid retrac tion without causing pressure on the globe. There are three commonly employed meth ods of lid retraction in ophthalmic surgery: 1. Speculum. Though convenient, this has limitations. In spite of the definite pressure exerted by this instrument on the globe, it is
NOTES, CASES, INSTRUMENTS
109
still the most commonly used method. Spaeth1 quence. If the vertical width of the tarsus is considers it a dangerous instrument. Friden- small, the danger is less. If large, the danger berg2 included it among the dangerous trau- is more, since the upper edge presses more matisms to the eye from faulty instrumenta posteriorly on the globe and in a more per pendicular direction. tion. In addition, the use of lid sutures requires While it is true that the pressure exerted on deep-set or normally situated globes is not further injections for anesthesia and conse great, there is a definite amount of pressure. quently will show other factors such as lid This assumes hazardous proportions in pro swelling, pain of another injection, and so truding globes and dislocated lenses. The forth. speculum is definitely contraindicated in 3. Lid retractor for upper lid and assist these conditions. ant's finger for lower lid. Here, an assistant The main source of pressure is from the elevates the upper lid with a Desmarres re weight of the central or screw end of the tractor and depresses the lower lid with his speculum which is the most dependent part of fingers. This is a most satisfactory method. the instrument and exerts pressure on the There is no pressure exerted on the globe lateral aspect of the globe. Some surgeons and the exposure is adequate. Spaeth recom try to minimize this by inserting cotton pledg mends this method. ets between this end of the instrument and There are certain objections, however. If the skin surface of the lateral orbital margin. one assistant is available both his hands are While this is of some aid in the normally occupied with this all important task. A situated globe, it is still dangerous in the pro lapse in attention may prove disastrous. The truding globe. surgeon must occupy himself with duties Another shortcoming which has been ex ordinarily assumed by his assistant, thus his perienced by all surgeons is that the specu attention is often removed from the opera lum is not quickly removable in times of tive site. danger. Finally, if the lips of the speculum Most of these objections are minimized if are not easily placed between the lid and the there is a second assistant. However, the eyeball after lid akinesia, it should not be hands of the assistant effecting retraction used in that case. and the retractor itself may interfere with Many of the above objections are done the surgeon, since it is situated in the upper away with in retractors such as suggested by part of the globe and limbus where most of the surgery takes place. While the principles Guyton. 2. Lid sutures. Many of those who object employed here are good, there is still much to the speculum because of the shortcomings to be desired. already cited utilize lid sutures. The expo Another method of retraction has been one sure is as good or better and the lids are similar to what we propose but the retractors closed more easily at the conclusion of sur are kept in place by screws tightening the ap gery. However, it is often not realized that position of the retractor to the lid. In our the very dangers they seek to avoid are pres experience the tightening not infrequently ent in this method. causes a squeezing out of meibomian secre When traction is placed on the lid margin tion and theoretically adds to the possibility in a direction away from the globe, the lid of local infection if any latent organism finds folds to form a V the apex of which is at the its habitat therein. tarsolevator junction. Thus the upper edge We have used with great success and con of the tarsus is turned inward and exerts venience separate upper and lower lid re pressure on the globe. Again, in cases of tractors (figs. 1, 2, and 3). protruding globes, this is of serious conse The curved end of the retractor fits be-
110
NOTES, CASES, INSTRUMENTS
hind the tarsus. The retraction is in the di rect line of action of the lids. The retractor is sufficiently broad so as to eliminate notch type of retraction as with lid sutures. The
above to the towel draping the patient's head and below to the sheet over the patient's body and chest. The retractors are simple in de sign, require no spring or lock, and are made of stainless steel. They may be bent
Fig. 1 (Givner, Jaffe, and Teschner). Frontal view of lid retractor. Width is sufficient to eliminate notch-type retraction.
Fig. 2 (Givner, Jaffe, and Teschner). Side view of lid retractor. The length of the short arm is equal to that of the tarsus, thus eliminating any possibility of bending of the tarus. The space be tween the long arm and short arm is sufficient to accommodate the eyelid.
curved part of the retractor is approximately the same length as the tarsus thereby elimi nating any bending or folding of the tarsus. The blades completely enclose the tarsus. There is absolutely no pressure on the globe. The exposure exceeds that obtained with the speculum and lid sutures. No assistant is required to hold the retractors. A heavy (No. 1) black silk is tied to the end of the rectractor and this is clamped
Fig. 3 (Givner, Jaffe, and Teschner). Separate upper and lower lid retractors in place. Note the space between lids and globe. There is adequate exposure and no evidence of pressure on the globe at any point.
if necessary to accommodate the curve of the supraorbital margin. They are indispensable in cases with protruding globes or where only one assistant is available. We have found them to be the most de sirable method of retraction. 108 East 66th Street (21). 309 Sterling Place (17).
REFERENCES
1. Spaeth, E. B.: Principles and Practice of Ophthalmic Surgery. Philadelphia, Lea, 1944, p. 618. 2. Fridenberg, P.: Sect. Ophth., N.Y. Acad. Med., May 17,1936.