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A Special Clamp for Holding Lid Sutures in Cataract Operations*
NOTES, CASES, I N S T R U M E N T S
end results compare favorably from a statistical standpoint with those ob tained by other methods. A SPECIAL CLAMP FOR H O L D ING LID SUTURES IN CATARACT OPERATIONS* WARREN D. HORNER, SAN FRANCISCO
957
fulfills these requirements (fig. 1). I t consists of a modified hemostat with closely fitting jaws which will hold silk threads without slipping, throughout its entire grasping surface.
M.D.
The control of the lids by sutures in cataract operations offers certain defi nite advantages. These have been dis cussed by the author in a previous pub lication 1 . An ordinary hemostat was first em ployed to hold the sutures. A hemostat, however, is not designed to grasp threads transversely, hence equal ten sion on the four strands supporting the lid was frequently not maintained, par ticularly when they were properly spaced along the jaws of the clamp. If one converges the four sutures to a common point, an undesirable tendency to "tent" the lid is introduced. The design of a clamp was therefore sought which would overcome this dif ficulty, which would be more easily held than a hemostat, and which would provide a simple means of utilizing a suture in the superior-rectus muscle.
Fig. 1 (Horner). Clamp for holding lid sutures. Inability to look down is so common, particularly following retrobulbar in jection, that a superior-rectus suture is an important aid in cataract extrac tions. The instrument illustrated amply * From the Dept. of Ophthalmology, Uni versity of California Medical School. 1 Horner, W. D. Sutures for lid control in cataract operations. Amer. Jour. Ophth., 1935, v. 18, Jan., p. 33.
Fig. 2 (Homer). Clamp in position. The handle is streamlined and may be comfortably held with either hand. It allows a variety of grips, depending upon the hand of the assistant. The upper blade of the clamp, at its middle, bears a small hook open toward the point of the instrument. This acts as a pulley for the superior-rectus su ture which changes its direction from a vertical pull to the horizontal. A cor rugated plate offers a stop against which the suture is pressed by the thumb of the assistant with sufficient friction to maintain without slipping any given degree of tension. At the same time, the suture may be instantly released by simply lifting the thumb. The use of the clamp is as follows: A white-silk suture, double armed and 24 inches long, is inserted beneath the skin of the upper lid, 2 mm. from its free edge. Each needle penetrates the skin superficial to the tarsus, about 3 mm. on either side of the mid-line and emerges about 8 mm. away, running parallel to the lid margin. Thus the lid is supported by four strands, evenly
958
NOTES, CASES, INSTRUMENTS
spaced (fig. 2). These sutures are then clamped by the jaws of the instrument so that they equally support the arch like contour of the upper lid. Lax strands are tightened and taut ones re laxed until equal tension is obtained. One white suture, that is, two strands, is sufficient to retract the low er lid. These are caught by a mosquito hemostat and either clamped to the drapes or allowed to hang by its weight. The tendon of the superior-rectus muscle is grasped by Elschnig or other forceps and secured by a long (18 in.) black-silk suture which is brought up through the ring of the hook and back across the face of the thumb plate. It is advantageous to knot the free ends of this suture. The instrument is now lifted into position, so that the lid sutures are at right angles to its blades and the lid sufficiently and evenly raised (fig. 2). The superior-rectus suture is pulled upon, to force the eye downward and expose the upper limbus. This degree of tension is easily maintained by pressure of the thumb against the corrugated plate. Since two thumb plates are pro vided, the instrument may be used from either the right or left side. Should the eye require sudden clos
ure, the thumb is removed from the plate to release tension on the superior rectus and the lid drawn down by a lifting and depressing motion of the clamp. At the close of the operation the superior-rectus suture is first cut, followed by sutures number 1 and 4, which are cut close to the lid. Sutures 2 and 3 serve to keep the lid closed while the dressings are being applied, after which they are readily pulled out by further traction. W e employ routinely an oval, al mond-shaped inner patch of cut gauze, 5 layers thick, which is moistened with saline, squeezed flat, and molded to the closed lids. This is followed by the usual eye patch. The inner patch soon dries and seems to prevent opening of the eye beneath the dressings. I am indebted to my associates in practice, Doctors Frederick Cordes and David Harrington for their criticisms of the design of the instrument and to Mr. Carl Monkhouse and Mr. V. Muel ler for their technical aid in making the necessary experimental models. The clamp may be obtained from Carl Monkhouse, 516 Market Street, San Francisco, or V. Mueller and Company, Chicago. 384 Post Street.
end results compare favorably from a statistical standpoint with those ob tained by other methods. A SPECIAL CLAMP FOR H O L D ING LID SUTURES IN CATARACT OPERATIONS* WARREN D. HORNER, SAN FRANCISCO
957
fulfills these requirements (fig. 1). I t consists of a modified hemostat with closely fitting jaws which will hold silk threads without slipping, throughout its entire grasping surface.
M.D.
The control of the lids by sutures in cataract operations offers certain defi nite advantages. These have been dis cussed by the author in a previous pub lication 1 . An ordinary hemostat was first em ployed to hold the sutures. A hemostat, however, is not designed to grasp threads transversely, hence equal ten sion on the four strands supporting the lid was frequently not maintained, par ticularly when they were properly spaced along the jaws of the clamp. If one converges the four sutures to a common point, an undesirable tendency to "tent" the lid is introduced. The design of a clamp was therefore sought which would overcome this dif ficulty, which would be more easily held than a hemostat, and which would provide a simple means of utilizing a suture in the superior-rectus muscle.
Fig. 1 (Horner). Clamp for holding lid sutures. Inability to look down is so common, particularly following retrobulbar in jection, that a superior-rectus suture is an important aid in cataract extrac tions. The instrument illustrated amply * From the Dept. of Ophthalmology, Uni versity of California Medical School. 1 Horner, W. D. Sutures for lid control in cataract operations. Amer. Jour. Ophth., 1935, v. 18, Jan., p. 33.
Fig. 2 (Homer). Clamp in position. The handle is streamlined and may be comfortably held with either hand. It allows a variety of grips, depending upon the hand of the assistant. The upper blade of the clamp, at its middle, bears a small hook open toward the point of the instrument. This acts as a pulley for the superior-rectus su ture which changes its direction from a vertical pull to the horizontal. A cor rugated plate offers a stop against which the suture is pressed by the thumb of the assistant with sufficient friction to maintain without slipping any given degree of tension. At the same time, the suture may be instantly released by simply lifting the thumb. The use of the clamp is as follows: A white-silk suture, double armed and 24 inches long, is inserted beneath the skin of the upper lid, 2 mm. from its free edge. Each needle penetrates the skin superficial to the tarsus, about 3 mm. on either side of the mid-line and emerges about 8 mm. away, running parallel to the lid margin. Thus the lid is supported by four strands, evenly
958
NOTES, CASES, INSTRUMENTS
spaced (fig. 2). These sutures are then clamped by the jaws of the instrument so that they equally support the arch like contour of the upper lid. Lax strands are tightened and taut ones re laxed until equal tension is obtained. One white suture, that is, two strands, is sufficient to retract the low er lid. These are caught by a mosquito hemostat and either clamped to the drapes or allowed to hang by its weight. The tendon of the superior-rectus muscle is grasped by Elschnig or other forceps and secured by a long (18 in.) black-silk suture which is brought up through the ring of the hook and back across the face of the thumb plate. It is advantageous to knot the free ends of this suture. The instrument is now lifted into position, so that the lid sutures are at right angles to its blades and the lid sufficiently and evenly raised (fig. 2). The superior-rectus suture is pulled upon, to force the eye downward and expose the upper limbus. This degree of tension is easily maintained by pressure of the thumb against the corrugated plate. Since two thumb plates are pro vided, the instrument may be used from either the right or left side. Should the eye require sudden clos
ure, the thumb is removed from the plate to release tension on the superior rectus and the lid drawn down by a lifting and depressing motion of the clamp. At the close of the operation the superior-rectus suture is first cut, followed by sutures number 1 and 4, which are cut close to the lid. Sutures 2 and 3 serve to keep the lid closed while the dressings are being applied, after which they are readily pulled out by further traction. W e employ routinely an oval, al mond-shaped inner patch of cut gauze, 5 layers thick, which is moistened with saline, squeezed flat, and molded to the closed lids. This is followed by the usual eye patch. The inner patch soon dries and seems to prevent opening of the eye beneath the dressings. I am indebted to my associates in practice, Doctors Frederick Cordes and David Harrington for their criticisms of the design of the instrument and to Mr. Carl Monkhouse and Mr. V. Muel ler for their technical aid in making the necessary experimental models. The clamp may be obtained from Carl Monkhouse, 516 Market Street, San Francisco, or V. Mueller and Company, Chicago. 384 Post Street.