A Method of Preventing Loss of Vitreous

A Method of Preventing Loss of Vitreous

AMERICAN JOURNAL OF OPHTHALMOLOGY Vol. 5 FEBRUARY, 1922 No. 2 A METHOD OF PREVENTING LOSS OF VITREOUS. F. FRISCH, M. D. A T L A N T I C CITY, X ...

401KB Sizes 0 Downloads 70 Views

AMERICAN JOURNAL OF OPHTHALMOLOGY Vol. 5

FEBRUARY, 1922

No. 2

A METHOD OF PREVENTING LOSS OF VITREOUS. F. FRISCH, M.

D.

A T L A N T I C CITY, X . J .

By previously placing a suture, with a knot on it, the corneal_ incision can be instantly and completely closed to meet any emergency that may arise during operation.

In order to have a suture prevent or aid in stopping already escaping vitre­ ous, it is necessary to be able to act instantaneously. As a rule it takes too long to pick up two ends of a thread, when vitreous is threatening to escape. For ten years I have studied the vari-

Fig. 1. Suture applied before making incision for cataract operation, drawn aside to be out of the way of the knife, which has been introduced, mak­ ing the puncture and counter puncture.

ous sutures devised for cataract opera­ tions, and tried many of them myself, with and without modifications, on animal and human eyes. Several methods answer the purpose very well after operation is completed, when no necessity exists for closing the gaping wound rapidly. The suture described here has been developed after hun­ dreds of experiments on animal eyes, and since then its efficiency has been proved in a number of cataract opera­ tions on the human eye, when loss of vitreous seemed imminent. Kalt says: "Once the suture is tied, one is master of the situation." With the suture described here, one is master of the situation, even before tying it. When the wound

is gaping or vitreous already escaping, it is only necessary to pull on the long end of the thread and hold it until pa­ tient stops squeezing or the situation is otherwise controlled. E-ven the speculum may be removed safely or the lids closed. To prepare the suture, white silk spool thread, size B and 25 cm. long, is passed thru the eye of the smallest curved needle which will take that size thread. The usual short self threading needles answer the purpose very well. A loop like a single bow knot is tied 10 cm. from one end and drawn out so that a loop remains only 1 mm. long. This loop, or knot, will prevent the thread from slipping thru a hole made in the cornea by the needle. A loop can be eliminated after the operation by pulling on both ends of the thread, but there is no harm in tying the suture right over the loop if it does not pull out readily. The needle is inserted into the cor­ nea 1.5 mm. to the temporal side and 2.5 mm. below the upper corneal margin, emerging about 1.2 mm. above insertion, without entering the an­ terior chamber, and the thread pulled thru until the knot is in contact with the cornea. This suture can be placed lower if the operator prefers to have the incision terminate high in the cor­ nea. Now the needle is inserted into the conjunctiva 4 mm. above the limbus, emerging 1.5 mm. above. With a strabismus hook the thread between the corneal and conjunctival insertions is pulled up to form a loop 12 to 15 mm. long so that the thread can not obstruct the escaping- cataract. The 81

82

F. PRISCH

operator is now ready for the incision. The end of the thread which has passed thru the conjunctiva is longer, i. e., farther away from the knot than the other shorter end, which should be laid out of the way across the nose, and not touched until ready to tie the suture after the operation. At any time during the operation, if necessary to do so, the wound can be closed rapidly by simply pulling in any direction on one end, i. e., the long end of the thread. The wound can be held closed until the patient gets thru squeezing or the situation is otherwise under control, and the toilet of the wound completed after the suture is tied. The speculum may be removed, the lids closed or opened, the iris re­ placed, and if the capsule has been opened, the remaining debris may be scooped out or removed by irrigation. In dislocated lenses, the loop, or Reisinger hooks, may be introduced and the wound held closed until the escap­ ing lens shuts off the escaping vitreous, and after the lens is out the wound can be immediately closed again by simply pulling on one end of the thread. If the operation has progressed without incident, and the operator is ready to tie the suture, the knot can be elimi­ nated by pulling on short end of the thread also, or it can be pulled away from cornea. But no harm results from leaving the knot in contact with cornea, and tying the suture right over it, on account of the elastic pull of the conjunctiva. Four years ago I operated on 18 cataracts with thru and thru corneal sutures, i. e., both sutures passing thru

the whole thickness of cornea, which I generally removed on the fourth day. Then I had two particularly unruly pa­ tients who squeezed so that I left the sutures in eight days, and in each case a severe iridocyclitis developed. This suggested that an ideal suture should be tolerated at least a week without detrimental results, and that it should be elastic. The suture described here has frequently been left in 10 to 20 days without reaction, or until it cuts thru the conjunctiva or cornea, and there is no reason for removing it for at least a week. When one or both eyes are left open protected by a wire mask, the suture generally cuts thru about the fourth day. Scissors are so easily slipped under it, that it is not necessary to mention the suture to the patient until after it is out. Summary: Instantaneous control of gaping wound of escaping vitreous. No possible escape of vitreous after the cataract is out, even before suture has been tied. When necessary to resort to loop or spoon, the wound can be held firmly closed until the escaping cataract closes wound, and again immediately after it is out. This is best accomplished by an assistant holding the long end of the thread in one hand and controlling the size of loop with a small strabismus hook in the other hand. While hold­ ing the wound closed by pulling on the long end of the thread, the other end is picked up, and the suture tied. This procedure does not prolong the operation because the suture can be inserted while waiting for anesthesia of the iris.