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Scleroconjunctival Suture in Cataract Extraction
NOTES, CASES, INSTRUMENTS SCLEROCONJUNCTIVAL S U T U R E IN C A T A R A C T EXTRACTION. F . H.
VERHOEFF,
M.D.
BOSTON.
In 1916, I published a short paper^ in which I incidentally described a new method of wound suture in cataract operations. In 1923 Dr. Derby^ and in 1924 Dr. Howard" reported their ex periences with this method, and in the May issue of this J O U R N A L Dr. Derby describes a modification of it which he believes to be superior to the original method. This modification had pre viously occurred to me, and in 1917, I gave it a thoro trial because it obvious ly possessed the advantage now noted by Dr. Derby, namely the ease and rapidity with which the wound could be closed by simply pulling the threads taut. At that time I used this rhodification in every case of cataract ex traction for four months and then abandoned it because I found that it had a serious disadvantage. This lay in the fact that when the suture was tied it not infrequently pulled too strongly on the conjunctival flap and caused more or less overriding of the lips of the wound thus delaying the re formation of the anterior chamber. This was evidently due to the facts that the two needles could not always be inserted in the sclera with sufficient accuracy and that, in addition, the needle holes sometimes stretched open too widely when the suture was tied. I therefore returned to my original method and have since employed it in every case. . \ s an objection to this method Dr. Derby states; that in order to prevent opening of the wound I employ an as sistant to hold the conjunctival flap down while the threads are being pulled thru it, preliminary to tying the suture. Within the past year or two, however, I have obviated this objec tion. I have found that by pulling one thread outward and slightly downward with one hand, and at the same time pulling the other thread inward and downward with the other hand, the 886
flap comes promptly in perfect position and closes the wound. This little de tail as well as others are difficult to ex plain without actual demonstration up on a patient, but greatly facilitate the operation. I t is very important that the needle holes in the conjunctival flap correspond exactly in position to those in the sclera, otherwise the con junctival flap may be displaced sidewise. I find that the simplest way to get the loops of thread out of the way before the cataract incision is made, is first to pull the threads taut and then insert a strabismus hook under the flap and pull out the two loops to the extent desired. It is not necessary or desirable to have the loops so large as shown in the illustrations of Dr. Howard's and Dr. Derby's. In tying the suture, I employ a "granny" knot, be cause this will remain tied sufficiently long, and if it becomes untied in three or four days removal of the suture is simpli fied. The use of this suture need not in crease the time of the operation more than two minutes. While I do not think that this method of wound suture is a perfect solution of our problem, I have found it so advantageous that I never dis pense with it. Since employing it I have not lost an eye from postopera tive expulsive hemorrhage, resulting from paroxysms of coughing or vomit ing, and I can recall only two cases of infection. In cases of loss of vitreous I think its value, while great, has been overestimated. T h e suture is especial ly effective when the corneal section is small. In the case of patients who are known to be subject to paroxysmal at tacks of coughing, for several years I have employed three conjunctival flaps instead of one. T h e suture for the middle one is inserted as usual, but the other two are simply inserted in the sclera, laid out of the way over the forehead, and not passed thru the flaps until after the extraction has been com pleted. Dexterous operators might find it advantageous to employ two flaps as a routine method. When a suture is employed, it is of course especially important that the
NOTES, CASES AND INSTRUMENTS
operative field be made as sterile as possible. I therefore paint the exposed skin in the operative field with tincture of iodin ( 2 % ) and place a sterile gauze mask over the nose and mouth of the patient. Removal of the suture is a simple matter if properly done. I generally remove it in about a week, but in unruly patients have allowed it to remain over two weeks or until it came out spontaneously. For anes thesia I employ a 2 0 % solution of co cain containing one-sixteenth of one per cent, zinc sulphat, applied by means of a cotton tipped tooth pick. (The zinc sulphat is added to maintain
887
sterility of the solution as regards pathogenic microorganisms.) The cot ton is held in contact with the flap for about half a minute. T h e upper lid is raised by the left middle finger and the free ends of the suture grasped with a small forceps held between the left thumb and forefinger. T h e loop is then quickly cut with one quick snip of the scissors blades—not of the points —either thru the knot or just beneath it. T h e remainder of the loop may then easily be pulled out with the for ceps. 82 Commonwealth Av.
REFERENCES. 1. 2. 3.
VerhoefF, F . H. Improved F o r c e p s for I n l r a c a p s u l a r Cataract E x t r a c t i o n s . Archives o f Ophthalmology, 1916, v. X L V , p. 479. Derby, G. S. Modern Aids to Cataract E x t r a c t i o n , T r a n s . Ophth. Section, A. M. Α., 1923. Howard, H. J . Conclusions Concerning a Scleroconjunctival S u t u r e in Cataract E x t r a c tion, Ibid., 1924.
B A B B I T M E T A L IN T H E L E N S WITHOUT LENTICULAR OPACITY.
of Ohio, I was requested to examine this claimant who, "was injured in October 1922 while chipping babbit, a piece having struck him in the eye." DONALD J . L Y L E , M . D . The medical report shows "linear cut C I N C I N N A T I , OHIO. of cornea of right eye, near center, in The diagnosis of an intraocular for fected ulcer following." eign body is made from the history of The man was examined by me May the injury: the presence of a wound 17, 1924. T h e orbit, globe and lids entrance; by seeing the foreign body were normal. There was a central, in the eye by means of light, with linear, corneal scar of his right eye in lenses, loups and ophthalmoscopy: the vertical axis about two millimeters and, if the foreign body is in the lens long and one wide. There was a thread or has passed thru it, by lenticular like white opacity in this scar which opacities: and by X-ray, and trans does not disturb the surface contour of illumination. the cornea enough to distort the images It is well to examine an eye under of an ophthalmometer. T h e iris mar a mydriatic and to have an X-ray of all gin in the left lower quadrant was torn suspicious cases, as occasionally the and adherent to the anterior surface of presence of an intraocular foreign body the lens and surrounded by some may be overlooked. For illustration opaque products of tissue reaction or I wish to report the case of a man who infection. Above this, nearly in the has had a piece of babbit metal in his horizontal plane and imbedded in the eye since Oct. 30, 1922, the date of in substance of the lens was seen a highly jury, which neither the injured man refractive, silvery looking object, evi nor his attending oculist knew was dently a piece of bright metal. An X-ray showed the presence of an present, tho it could readily be seen in the lens under inydriasis. T h e most opaque body 2 by 1 by 1 mm. and lo interesting unusual feature is that cated it as shown by accompanying there is very little if any opacity sur chart. rounding the foreign body, the vision This object, no doubt, was a piece of not being impaired by its presence. babbit which, being free from infection In May, 1924, as special eye ex and of nonirritating chemical nature aminer for the Industrial Commission had lodged in the lens without causing
VERHOEFF,
M.D.
BOSTON.
In 1916, I published a short paper^ in which I incidentally described a new method of wound suture in cataract operations. In 1923 Dr. Derby^ and in 1924 Dr. Howard" reported their ex periences with this method, and in the May issue of this J O U R N A L Dr. Derby describes a modification of it which he believes to be superior to the original method. This modification had pre viously occurred to me, and in 1917, I gave it a thoro trial because it obvious ly possessed the advantage now noted by Dr. Derby, namely the ease and rapidity with which the wound could be closed by simply pulling the threads taut. At that time I used this rhodification in every case of cataract ex traction for four months and then abandoned it because I found that it had a serious disadvantage. This lay in the fact that when the suture was tied it not infrequently pulled too strongly on the conjunctival flap and caused more or less overriding of the lips of the wound thus delaying the re formation of the anterior chamber. This was evidently due to the facts that the two needles could not always be inserted in the sclera with sufficient accuracy and that, in addition, the needle holes sometimes stretched open too widely when the suture was tied. I therefore returned to my original method and have since employed it in every case. . \ s an objection to this method Dr. Derby states; that in order to prevent opening of the wound I employ an as sistant to hold the conjunctival flap down while the threads are being pulled thru it, preliminary to tying the suture. Within the past year or two, however, I have obviated this objec tion. I have found that by pulling one thread outward and slightly downward with one hand, and at the same time pulling the other thread inward and downward with the other hand, the 886
flap comes promptly in perfect position and closes the wound. This little de tail as well as others are difficult to ex plain without actual demonstration up on a patient, but greatly facilitate the operation. I t is very important that the needle holes in the conjunctival flap correspond exactly in position to those in the sclera, otherwise the con junctival flap may be displaced sidewise. I find that the simplest way to get the loops of thread out of the way before the cataract incision is made, is first to pull the threads taut and then insert a strabismus hook under the flap and pull out the two loops to the extent desired. It is not necessary or desirable to have the loops so large as shown in the illustrations of Dr. Howard's and Dr. Derby's. In tying the suture, I employ a "granny" knot, be cause this will remain tied sufficiently long, and if it becomes untied in three or four days removal of the suture is simpli fied. The use of this suture need not in crease the time of the operation more than two minutes. While I do not think that this method of wound suture is a perfect solution of our problem, I have found it so advantageous that I never dis pense with it. Since employing it I have not lost an eye from postopera tive expulsive hemorrhage, resulting from paroxysms of coughing or vomit ing, and I can recall only two cases of infection. In cases of loss of vitreous I think its value, while great, has been overestimated. T h e suture is especial ly effective when the corneal section is small. In the case of patients who are known to be subject to paroxysmal at tacks of coughing, for several years I have employed three conjunctival flaps instead of one. T h e suture for the middle one is inserted as usual, but the other two are simply inserted in the sclera, laid out of the way over the forehead, and not passed thru the flaps until after the extraction has been com pleted. Dexterous operators might find it advantageous to employ two flaps as a routine method. When a suture is employed, it is of course especially important that the
NOTES, CASES AND INSTRUMENTS
operative field be made as sterile as possible. I therefore paint the exposed skin in the operative field with tincture of iodin ( 2 % ) and place a sterile gauze mask over the nose and mouth of the patient. Removal of the suture is a simple matter if properly done. I generally remove it in about a week, but in unruly patients have allowed it to remain over two weeks or until it came out spontaneously. For anes thesia I employ a 2 0 % solution of co cain containing one-sixteenth of one per cent, zinc sulphat, applied by means of a cotton tipped tooth pick. (The zinc sulphat is added to maintain
887
sterility of the solution as regards pathogenic microorganisms.) The cot ton is held in contact with the flap for about half a minute. T h e upper lid is raised by the left middle finger and the free ends of the suture grasped with a small forceps held between the left thumb and forefinger. T h e loop is then quickly cut with one quick snip of the scissors blades—not of the points —either thru the knot or just beneath it. T h e remainder of the loop may then easily be pulled out with the for ceps. 82 Commonwealth Av.
REFERENCES. 1. 2. 3.
VerhoefF, F . H. Improved F o r c e p s for I n l r a c a p s u l a r Cataract E x t r a c t i o n s . Archives o f Ophthalmology, 1916, v. X L V , p. 479. Derby, G. S. Modern Aids to Cataract E x t r a c t i o n , T r a n s . Ophth. Section, A. M. Α., 1923. Howard, H. J . Conclusions Concerning a Scleroconjunctival S u t u r e in Cataract E x t r a c tion, Ibid., 1924.
B A B B I T M E T A L IN T H E L E N S WITHOUT LENTICULAR OPACITY.
of Ohio, I was requested to examine this claimant who, "was injured in October 1922 while chipping babbit, a piece having struck him in the eye." DONALD J . L Y L E , M . D . The medical report shows "linear cut C I N C I N N A T I , OHIO. of cornea of right eye, near center, in The diagnosis of an intraocular for fected ulcer following." eign body is made from the history of The man was examined by me May the injury: the presence of a wound 17, 1924. T h e orbit, globe and lids entrance; by seeing the foreign body were normal. There was a central, in the eye by means of light, with linear, corneal scar of his right eye in lenses, loups and ophthalmoscopy: the vertical axis about two millimeters and, if the foreign body is in the lens long and one wide. There was a thread or has passed thru it, by lenticular like white opacity in this scar which opacities: and by X-ray, and trans does not disturb the surface contour of illumination. the cornea enough to distort the images It is well to examine an eye under of an ophthalmometer. T h e iris mar a mydriatic and to have an X-ray of all gin in the left lower quadrant was torn suspicious cases, as occasionally the and adherent to the anterior surface of presence of an intraocular foreign body the lens and surrounded by some may be overlooked. For illustration opaque products of tissue reaction or I wish to report the case of a man who infection. Above this, nearly in the has had a piece of babbit metal in his horizontal plane and imbedded in the eye since Oct. 30, 1922, the date of in substance of the lens was seen a highly jury, which neither the injured man refractive, silvery looking object, evi nor his attending oculist knew was dently a piece of bright metal. An X-ray showed the presence of an present, tho it could readily be seen in the lens under inydriasis. T h e most opaque body 2 by 1 by 1 mm. and lo interesting unusual feature is that cated it as shown by accompanying there is very little if any opacity sur chart. rounding the foreign body, the vision This object, no doubt, was a piece of not being impaired by its presence. babbit which, being free from infection In May, 1924, as special eye ex and of nonirritating chemical nature aminer for the Industrial Commission had lodged in the lens without causing