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Hydrostatic Anterior Chamber Needle*
RETINAL VASCULATURE
641
Sidman, R. L. : Histogenesis of mouse retina studied with thymidine-H3. In Smelser, G. K. (editor) : The Structure of the Eye. New York, Acad. Press, 1961. Tepperman, J., Bodansky, 0., and Jandorf, B. J. : The effect of para-aminopropiophenone-induced methemoglobinemia on oxygénation of working muscle in human subjects. Am. J. Physiol., 146 :702-709 (Aug.) 1946. Vandenbelt, J. M., Pfeiffer, C, Kaiser, M., and Siebert, M. : Methemoglobinemia after administration of p-amino-acetophenone and p-aminopropiophenone. J. Pharmacol. & Exp. Then, 80:31-38 (Jan.) 1944.
HYDROSTATIC ANTERIOR CHAMBER J.
G.
F.
WORST,
NEEDLE*
M.D.
Groningen, Holland This is an instrument for operating in the anterior chamber without aqueous loss, for discission and for removal of lens material by irrigation. THE
INSTRUMENT
The instrument (fig. 1) consists of: 1. A hollow shaft, hexagonal in cross section ( A ) with a cannula attachment ( B ) and a coupling for attachment of an anterior chamber needle ( C ) . 2. A n exchangable needle ( D ) with washer ( E ) and specially sharpened tip (fig. 2, inset). This needle is stored and sterilized in a special container ( F ) . 3. A special slotted slip-over nut ( G ) for fastening the needle to the shaft. 4. A silicone-rubber cannula ( H ) , with a needle cone ( I ) , for attachment to a syringe or to a venous infusion system. 5. A n air injection needle, with stop ( J ) . T h e actual anterior chamber needle (fig. 2) has a specially sharpened, two-bevelled dagger-shaped tip (inset fig. 2 ) , which greatly facilitates perforation of the corneoscleral junction. T h e incision made by this tip is slightly smaller than the diameter of the needle itself. I n this way a perfectly watertight fit is obtained. STERILIZATION
T h e shaft, the needle and the cannula should be sterilized separately. Metal parts ♦From the University Eye Clinic (Head: Prof. H. M. Dekking).
can be sterilized by any conventional method. If boiling or steam is used, the instrument should be filled in advance with water. T h e needle in its plastic protective container and the silicone-rubber cannula should also be filled with fluid in advance and sterilized by boiling. Heat sterilization may cause the plastics to melt. ASSEMBLY
T h e needle is removed from the container and is inserted in the hexagonal shaft. T h e slotted nut is passed over the body of the needle, thus avoiding damage by contact with its delicate tip. T h e nut is tightened. The silicone-rubber cannula is slipped over the rear end of the shaft. T h e needle cone of the cannula can now be connected to either an intravenous drip system or, preferably, to a syringe. T h e system is now thoroughly washed with saline to expel air bubbles (hold tip of needle u p w a r d ) . T h e cannula should now be clamped with artery forceps or a similar instrument; the hydrostatic needle is ready for use (fig. 3 ) . SURGICAL
APPLICATION
T h e maintenance of the anterior chamber has its particular uses in goniotomy, for which the needle was designed in the first place ( W o r s t , 1963). A special U - s u t u r e is recommended, in conjunction with the hydrostatic anterior chamber needle. This suture serves for steadying the eye, for countertraction when
J. G. F. W O R S T
642
Fig. 1 ( W o r s t ) . Hydrostatic anterior chamber needle. See text for explanation.
Fig. 2 (Worst). Detail of needle. perforating the corneoscleral junction and for closing the puncture site after the operation. It, therefore, forms an essential step in the operation (fig. 5). (Note: the surgeon should be seated at the temporal side of the patient.) Method of making U-suture. With proper fixation of the lateral muscle tendon, a corneoscleral stitch is made, entering the conjunctival border and emerging in the scierai limbal area. The stitch is continued by entering the sciera, close to the first stitch, and
Fig. 3 ( W o r s t ) . Syringe, clamp and needle.
emerging at the conjunctival border. The result will be a U-suture with the free ends emerging from the cornea and the puncture sites forming a small square. Entering the anterior chamber. Exerting traction on the U-suture, and with counterfixation on the medial rectus tendon, the tip is passed through the center of the square formed by the U-suture. The needle should be pulled rather than pushed into the anterior chamber. The needle should be introduced with its orifice down (this will prevent intralamellar insertion). When visible in the anterior chamber, the needle is rotated 180 degrees around its axis. This will bring the orifice up (it will keep the sharp tip away from the lens). If a goniotomy is to be performed,* the fixation can be done with the goniotomy lens. One should approach the chamber angle without crossing the pupillary area. When it reaches the chamber angle, the tip of the needle should be turned down again. As the needle, with its cannula clamped, safely and securely preserves the anterior chamber, any cutting or dissecting can now be performed with its special tip. The clamp should only be taken off to deepen the anterior chamber (to prevent capillary bleeding in goniotomy) or to use the needle as an irrigating instrument. * Worst, J. G. F. : Goniotomy. Am. J. Ophth., 57:185-200, 1964.
HYDROSTATIC ANTERIOR CHAMBER NEEDLE Discission cataract.
and removal
of soft
congenital
1. T h e tip of the needle is passed through the anterior lens capsule at least twice, and preferably more times (fig. 7 ) . Performing sideway movements with the shaft of the needle, the anterior capsule is thoroughly destroyed. At the same time, lens material is scooped up with the tip of the needle (fig. 8) which, for this purpose, should be held in the 90-degree position. Care should be taken not to injure the posterior capsule; an operating microscope is a great help in this part of the operation. 2. W h e n stirring of the lens interior has filled the anterior chamber with lens fibers,
643
a counterincision is made with a cataract knife (fig. 9 ) . T h e incision should be made in the cornea, going lamellarly, forming a trap-door incision. 3. T h e clamp is now removed from the silicone-rubber cannula. If an injection is now made into the anterior chamber, one will only notice its deepening, as no aqueous can escape from the trap-door incision. 4. A n iris spatula is now held in the trapdoor incision (fig. 10) and, by slightly rotating the spatula, the orifice is opened. Note that the trap-door incision must be sufficiently large to allow easy insertion of the spatula, otherwise it will keep the orifice closed. By washing the anterior chamber
Figs. 4-12 (Worst). Congenital cataract, right eye. (4) Lateral rectus suture. (5) Limbal U-suture loose ends emerging from cornea. (6) Tip of needle placed in center of U-suture. U-suture is kept taut. Counterfixation with forceps at medial rectus. (7) Needle passed through anterior capsule. (8) Disruption of anterior capsule by lateral movements of needle tip and stirring-up of lens interior. (9) Making of counterincision (trap-door type) with cataract knife. (10) Keeping the counterpuncture open with a spatula and washing out lens material. (11) Air injection in anterior chamber and closure of puncture site with U-suture. (12) Removal of U-suture. Some posterior capsule opacities remain. Large air bubbles fill space left after lens material is removed.
644
J. G. F. WORST
from the infusion bottle or by injection from the syringe, lens material is slowly and gradually removed. 5. When the washing produces no more lens material and the anterior chamber is again clear, there will usually be a considerable amount of lens material left. Stirring up this material is repeated and followed again by washing it out, until virtually all lens material has been removed. Maximal mydriasis is obtained with 15% phenylephrine and 1% Cyclogyl combined with subconjunctival injection of adrenaline 1:1,000 and retrobulbar anesthesia with novocaine-adrenaline. The washing out of the lens material should be checked with a fluorescent light (ultraviolet) or by ophthalmoscopy. Only when there is a red reflex from the fundus has sufficient lens material been removed. The best way to protect the posterior capsule and to check subtotal lens removal is with an operating microscope. 6. The cone of the cannula is now fitted with an air-filled syringe and, while holding the spatula in the counterincision to allow escape of fluid, the anterior chamber is filled with air (fig. 11). 7. The U-suture is tightened around the needle and the needle is retracted (fig. 11). At the moment the tip of the needle passes the U-suture, the suture is pulled tight. This maneuver effectively prevents loss of air from the anterior chamber. The suture may be removed after some minutes, as the puncture site will have been closed by compression and local tissue swelling (fig. 12). Discission of secondary cataract membranes. a. Thin membranes. As the system operates without loss of the anterior chamber, intraocular pressure relations remain optimal, and the chance of vitreous prolapse is limited. Therefore, the system can be used with advantage to incise thin, fragile secondary cataract membranes. This method produces clean central openings in the mem-
brane. The needle is simply introduced into the anterior chamber with the precautions already mentioned and the membrane is dissected, preferably under microscopic control. b. Thick membranes. Scarlike secondarycataract membranes are virtually impossible to break up by incision with a discission knife, or by forming an orifice in them. However, they can be torn apart with the hydrostatic needle without dangerous traction on the surrounding structures, in particular the ciliary processes and the ora serrata region. It is possible to perform this type of dissection with two anterior chamber needles of the hydrostatic type : 1. Two U-sutures are inserted, one at the upper and one at the lower temporal limbal region. 2. A hydrostatic anterior chamber needle is introduced into the anterior chamber as already described and the shaft is temporarily passed to the assistant. 3. A second needle is passed into the anterior chamber and the surgeon now performs the dissection with the two needles under microscopic control. By perforating and supporting the membrane with one needle, the second may effectively dissect it, without undue traction on its supporting structures. If parts of the membrane are torn loose they may be washed out in the manner already described. SUMMARY
A specially beveled needle* for operating in the anterior chamber without aqueous loss has been described. It can be used for discission, followed by subtotal removal of lens material in congenital and traumatic cataract, and for goniotomy. The surgical technique has been described. University Eye Clinic. * The instrument is manufactured by Medical Workshop, Kraneweg 94-96, Groningen, Holland; in the United States by Titmus Optical Company, Petersburg, Virginia.
641
Sidman, R. L. : Histogenesis of mouse retina studied with thymidine-H3. In Smelser, G. K. (editor) : The Structure of the Eye. New York, Acad. Press, 1961. Tepperman, J., Bodansky, 0., and Jandorf, B. J. : The effect of para-aminopropiophenone-induced methemoglobinemia on oxygénation of working muscle in human subjects. Am. J. Physiol., 146 :702-709 (Aug.) 1946. Vandenbelt, J. M., Pfeiffer, C, Kaiser, M., and Siebert, M. : Methemoglobinemia after administration of p-amino-acetophenone and p-aminopropiophenone. J. Pharmacol. & Exp. Then, 80:31-38 (Jan.) 1944.
HYDROSTATIC ANTERIOR CHAMBER J.
G.
F.
WORST,
NEEDLE*
M.D.
Groningen, Holland This is an instrument for operating in the anterior chamber without aqueous loss, for discission and for removal of lens material by irrigation. THE
INSTRUMENT
The instrument (fig. 1) consists of: 1. A hollow shaft, hexagonal in cross section ( A ) with a cannula attachment ( B ) and a coupling for attachment of an anterior chamber needle ( C ) . 2. A n exchangable needle ( D ) with washer ( E ) and specially sharpened tip (fig. 2, inset). This needle is stored and sterilized in a special container ( F ) . 3. A special slotted slip-over nut ( G ) for fastening the needle to the shaft. 4. A silicone-rubber cannula ( H ) , with a needle cone ( I ) , for attachment to a syringe or to a venous infusion system. 5. A n air injection needle, with stop ( J ) . T h e actual anterior chamber needle (fig. 2) has a specially sharpened, two-bevelled dagger-shaped tip (inset fig. 2 ) , which greatly facilitates perforation of the corneoscleral junction. T h e incision made by this tip is slightly smaller than the diameter of the needle itself. I n this way a perfectly watertight fit is obtained. STERILIZATION
T h e shaft, the needle and the cannula should be sterilized separately. Metal parts ♦From the University Eye Clinic (Head: Prof. H. M. Dekking).
can be sterilized by any conventional method. If boiling or steam is used, the instrument should be filled in advance with water. T h e needle in its plastic protective container and the silicone-rubber cannula should also be filled with fluid in advance and sterilized by boiling. Heat sterilization may cause the plastics to melt. ASSEMBLY
T h e needle is removed from the container and is inserted in the hexagonal shaft. T h e slotted nut is passed over the body of the needle, thus avoiding damage by contact with its delicate tip. T h e nut is tightened. The silicone-rubber cannula is slipped over the rear end of the shaft. T h e needle cone of the cannula can now be connected to either an intravenous drip system or, preferably, to a syringe. T h e system is now thoroughly washed with saline to expel air bubbles (hold tip of needle u p w a r d ) . T h e cannula should now be clamped with artery forceps or a similar instrument; the hydrostatic needle is ready for use (fig. 3 ) . SURGICAL
APPLICATION
T h e maintenance of the anterior chamber has its particular uses in goniotomy, for which the needle was designed in the first place ( W o r s t , 1963). A special U - s u t u r e is recommended, in conjunction with the hydrostatic anterior chamber needle. This suture serves for steadying the eye, for countertraction when
J. G. F. W O R S T
642
Fig. 1 ( W o r s t ) . Hydrostatic anterior chamber needle. See text for explanation.
Fig. 2 (Worst). Detail of needle. perforating the corneoscleral junction and for closing the puncture site after the operation. It, therefore, forms an essential step in the operation (fig. 5). (Note: the surgeon should be seated at the temporal side of the patient.) Method of making U-suture. With proper fixation of the lateral muscle tendon, a corneoscleral stitch is made, entering the conjunctival border and emerging in the scierai limbal area. The stitch is continued by entering the sciera, close to the first stitch, and
Fig. 3 ( W o r s t ) . Syringe, clamp and needle.
emerging at the conjunctival border. The result will be a U-suture with the free ends emerging from the cornea and the puncture sites forming a small square. Entering the anterior chamber. Exerting traction on the U-suture, and with counterfixation on the medial rectus tendon, the tip is passed through the center of the square formed by the U-suture. The needle should be pulled rather than pushed into the anterior chamber. The needle should be introduced with its orifice down (this will prevent intralamellar insertion). When visible in the anterior chamber, the needle is rotated 180 degrees around its axis. This will bring the orifice up (it will keep the sharp tip away from the lens). If a goniotomy is to be performed,* the fixation can be done with the goniotomy lens. One should approach the chamber angle without crossing the pupillary area. When it reaches the chamber angle, the tip of the needle should be turned down again. As the needle, with its cannula clamped, safely and securely preserves the anterior chamber, any cutting or dissecting can now be performed with its special tip. The clamp should only be taken off to deepen the anterior chamber (to prevent capillary bleeding in goniotomy) or to use the needle as an irrigating instrument. * Worst, J. G. F. : Goniotomy. Am. J. Ophth., 57:185-200, 1964.
HYDROSTATIC ANTERIOR CHAMBER NEEDLE Discission cataract.
and removal
of soft
congenital
1. T h e tip of the needle is passed through the anterior lens capsule at least twice, and preferably more times (fig. 7 ) . Performing sideway movements with the shaft of the needle, the anterior capsule is thoroughly destroyed. At the same time, lens material is scooped up with the tip of the needle (fig. 8) which, for this purpose, should be held in the 90-degree position. Care should be taken not to injure the posterior capsule; an operating microscope is a great help in this part of the operation. 2. W h e n stirring of the lens interior has filled the anterior chamber with lens fibers,
643
a counterincision is made with a cataract knife (fig. 9 ) . T h e incision should be made in the cornea, going lamellarly, forming a trap-door incision. 3. T h e clamp is now removed from the silicone-rubber cannula. If an injection is now made into the anterior chamber, one will only notice its deepening, as no aqueous can escape from the trap-door incision. 4. A n iris spatula is now held in the trapdoor incision (fig. 10) and, by slightly rotating the spatula, the orifice is opened. Note that the trap-door incision must be sufficiently large to allow easy insertion of the spatula, otherwise it will keep the orifice closed. By washing the anterior chamber
Figs. 4-12 (Worst). Congenital cataract, right eye. (4) Lateral rectus suture. (5) Limbal U-suture loose ends emerging from cornea. (6) Tip of needle placed in center of U-suture. U-suture is kept taut. Counterfixation with forceps at medial rectus. (7) Needle passed through anterior capsule. (8) Disruption of anterior capsule by lateral movements of needle tip and stirring-up of lens interior. (9) Making of counterincision (trap-door type) with cataract knife. (10) Keeping the counterpuncture open with a spatula and washing out lens material. (11) Air injection in anterior chamber and closure of puncture site with U-suture. (12) Removal of U-suture. Some posterior capsule opacities remain. Large air bubbles fill space left after lens material is removed.
644
J. G. F. WORST
from the infusion bottle or by injection from the syringe, lens material is slowly and gradually removed. 5. When the washing produces no more lens material and the anterior chamber is again clear, there will usually be a considerable amount of lens material left. Stirring up this material is repeated and followed again by washing it out, until virtually all lens material has been removed. Maximal mydriasis is obtained with 15% phenylephrine and 1% Cyclogyl combined with subconjunctival injection of adrenaline 1:1,000 and retrobulbar anesthesia with novocaine-adrenaline. The washing out of the lens material should be checked with a fluorescent light (ultraviolet) or by ophthalmoscopy. Only when there is a red reflex from the fundus has sufficient lens material been removed. The best way to protect the posterior capsule and to check subtotal lens removal is with an operating microscope. 6. The cone of the cannula is now fitted with an air-filled syringe and, while holding the spatula in the counterincision to allow escape of fluid, the anterior chamber is filled with air (fig. 11). 7. The U-suture is tightened around the needle and the needle is retracted (fig. 11). At the moment the tip of the needle passes the U-suture, the suture is pulled tight. This maneuver effectively prevents loss of air from the anterior chamber. The suture may be removed after some minutes, as the puncture site will have been closed by compression and local tissue swelling (fig. 12). Discission of secondary cataract membranes. a. Thin membranes. As the system operates without loss of the anterior chamber, intraocular pressure relations remain optimal, and the chance of vitreous prolapse is limited. Therefore, the system can be used with advantage to incise thin, fragile secondary cataract membranes. This method produces clean central openings in the mem-
brane. The needle is simply introduced into the anterior chamber with the precautions already mentioned and the membrane is dissected, preferably under microscopic control. b. Thick membranes. Scarlike secondarycataract membranes are virtually impossible to break up by incision with a discission knife, or by forming an orifice in them. However, they can be torn apart with the hydrostatic needle without dangerous traction on the surrounding structures, in particular the ciliary processes and the ora serrata region. It is possible to perform this type of dissection with two anterior chamber needles of the hydrostatic type : 1. Two U-sutures are inserted, one at the upper and one at the lower temporal limbal region. 2. A hydrostatic anterior chamber needle is introduced into the anterior chamber as already described and the shaft is temporarily passed to the assistant. 3. A second needle is passed into the anterior chamber and the surgeon now performs the dissection with the two needles under microscopic control. By perforating and supporting the membrane with one needle, the second may effectively dissect it, without undue traction on its supporting structures. If parts of the membrane are torn loose they may be washed out in the manner already described. SUMMARY
A specially beveled needle* for operating in the anterior chamber without aqueous loss has been described. It can be used for discission, followed by subtotal removal of lens material in congenital and traumatic cataract, and for goniotomy. The surgical technique has been described. University Eye Clinic. * The instrument is manufactured by Medical Workshop, Kraneweg 94-96, Groningen, Holland; in the United States by Titmus Optical Company, Petersburg, Virginia.