Operations

OPERATIONS. J O H N A. M C C A W , M. D. DENVER.

This section of the Digest reviews the literature of 1918. Only general operative procedures are reviewed. All particular operations will be found under the headings of the portions of the eye on which they are practiced; or in connection with the diseases which render them necessary. BIBLIOGRAPHY.

Axenfeld, T. Optlcoclliary Neurectomy. Kiln. Monatsbl. t. Augenh., v. 60, p. 29. Bamberger. Substitute for a Pipette. Deut. med. Woch., 1917, p. 1423. Abst. Klin. M. f. Augenh., v. 60, p. 404. Crosiley, E. R. Device to Immobilize Head and Eyelids in Operations on Eyeball. (2 ill.) Jour. Amer. Med. Assn., v. 69, p. 2103. Amer. Jour. Ophth., v. 1, p. 66. Duverger. Local Anesthesia of Eye and Orbit. Presse Med., v. 26, p. 408. Macphall, J. N. Importance of Some Minor Operations. Indian Med. Gaz., v. 53, p. 205. Maddox, E. E. Close vs. Distant Illumination for Operation. Brit. Jour. Ophth., v. 2, p. 84. Amer. Jour. Ophth., v. 1, p. 626.

8antos Fernandez, J. Absence of Dressings in Eye Operations. Arch, de Oftal. Hisp.Amer., Sept., 1917. Abst. Amer. Jour. Ophth., v. 1, p. 274. Toussant. Portable Case Containing Ophthalmic Instruments for Army Surgeon. Arch. M6d. Beiges, Feb., 1918. Pagenstecher, A. H. Optlcoclliary Neurectomy; Resection of Optic Nerve, etc. Arch. 1 Augenh., v. 79, 1915. Arch, of Ophth., v. 47, p. 409. Wood, H. Technlc in Surgery of Eye, Ear, Nose and Throat. South. Pract., v. 39, p. 295. Zarzyckl. Ocular Osteoplasty. Paris Chlrurg., 1917, v. 9, p. 690. Abst. Jour. Surg. Gynec. and Obstet., v. 27, p. 440.

DIGEST OF T H E L I T E R A T U R E . LOCAL

ANESTHESIA.—Duverger

de-

scribes his methods of local anesthesia in orbito-ocular surgery. A 5 percent solution of cocain is used for instillation, and two solutions of novocain (procain). One is Novocain 02 Adrenalin (1/1000) 2 drops Aqua distillata 2.00 The other contains 4 times as much novocain (procain). The latter is used for orbital conditions where an edema is not desirable. A 2 cc. syringe and two needles, one 3 cm. and the other 4^2 cm. long, are employed. The needle is inserted in the skin 1 cm. beyond the external canthus. The point is pushed between the skin and conjunctiva toward the base of the lid as far as the inner extremity of the lid, using the syringe full. If the other lid is to be injected, the process is repeated below. The only contraindication is phlegmon of the orbit. At lyi cm. below the external canthus, the 3 cm. needle is plunged with a quick thrust to the bone, then directed upward, backward, and inward, toward the upper inner angle of the orbit. It passes between the bone and

fornix, the internal and inferior recti along the sclera and crosses the optic nerve. A few drops of the solution may be injected during its passage, but most of the 2 cm. is injected in different directions at the posterior pole. For deep anesthesia of the body of the muscle, puncture the lower lid at the orbital margin at its inner or external third. The needle is directed backward and upward in the direction of the muscle to 3 cm. and 1 cc. of the solution is injected. Anesthesia of the conjunctiva and tendon is secured by subconjunctival injection in the region of its insertion. The 4]/2 cm. needle is inserted at the orbital margin just below the pulley of the superior oblique, and is passed backward along the bone. When fully inserted, 2 cc. of a 4 percent solution is injected. Then the \l/i cm, needle is inserted along the bone immediately above the external palpebral ligament and is pushed backward and inward in a horizontal plane along the bone to the depth of the length of the needle. The needle is inserted in the region of the infraorbital groove, and by moving the needle, the groove is found. One

DIGEST OF THE LITERATURE

c c is injected. Infraorbital and external nasal anesthesia are the same, except that in the external nasal the 3 cm. needle is used. Anesthesia of the acnmal gland is obtained by a single injection along the fronto-lacrimal nerve. INSTRUMENTS

AND

APPARATUS. —

j-rossley has a device to immobilize the a d e elic!s th u y during operations on ne eyeball. The apparatus consists of Wo parts, the base and superstructure carrying the lid hooks. The base conhv lo- a r e c t a n &ular wooden block, 12 °y U inches, lengthwise thru which is a long screw on which are mounted two ^ o n g metal uprights, one of which is sta wnary and the other movable. Attached to these are large pads which grasp the sides of the head as the one approaches the other. The superstructure is a metal frame which is attached 10 t n e "Pnghts. On the cross-bars of the superstructure are mounted two sliding ?cks for fixing the lid hooks after the j'as have been retracted. Between the "yo uprights is placed a circular pad serves as a comfortable headrest. % means of clamps the apparatus i s nxed firmly to the table on which th< the Patient lies. As a substitute for a pipette Bamberger cuts a large piece from a drainage tube about 8 or 10 cm. long and closes the upper end with a round piece of wood, or, what is still better, a small conical piece of cork. ILLUMINATION.—Maddox,

for illumi-

nation during discission of after-cataract, and for emergency night operations, attaches with wire a tiny electric lamp to one limb of the forceps, half an inch from the gripping end. An ordinary flash lamp furnishes the current. The bulb is so placed that it illuminates the iris brilliantly when the forceps are gripping the hmbal conjunctiva, and the grip of the forceps insures a perfectly steady light and maintains its distance from the cornea. The forceps are out of use during Part of the operation. During this interval Maddox secures the advantages °t close illumination in one of three Wa y s : (1) An assistant holds the lamp on the sa me forceps. (2) The lamp is

15

attached to a thin metal disc, fixed by adhesive plaster just above the patient's other eyebrow. (3) A lamp is fastened to a nose-piece clipped on the patient's nose. Maddox finds the advantages of close illumination to be greater economy, greater portability, greater kindliness to the patient's eye, since a close light is diffused widely over his retina with no possibility of the image of the filament being thereon, and increase of the surgeon's visual acuteness. OPTICOCILIARY NEURECTOMY.—Axen-

feld's case was a young woman who had in her right eye a specific retinal choroidal process with vitreous hemorrhages and lowered tension, a high grade atrophy of the iris, and at the edge of the lens a white glistening cataract growing in extent, and with dilated pupil, quite noticeable. The eye was blind. Axenfeld concluded that it would be easier to leave the greatly reduced eyeball in the socket and place over it a shell prothesis, than to enucleate or eviscerate. As the cornea was normal with a normal reflex, he felt that an operative diminution of the contact sense was indicated. He performed a neurectomy, following the method of Miiller of Wiesbaden. His result from a cosmetic and psychologic viewpoint was excellent. Regarding the complication of a rctrobulhar hemorrhage, he thinks that primarily it does not come from the central artery, but rather from the ciliary arteries and also the retrobulbar veins. His method to prevent hemorrhage is to inj'ect several drops of novocain-adrenalin into the apex of the orbit and thus secure a deep anesthesia. With a fine long canula he bores down and out close to the orbital margin, thru the iodized lid tissue, slowly past the bulbus, 3 to 4 cm. deep. By observing the canula, lie convinces himself that there is no hemorrhage, then injects a small amount of novocain-adrenalin, }/?, c c , which is quickly absorbed. A large injection should be avoided, as it causes exophthahnos. Anesthesia is produced in 10 to 15 minutes, being helped by a drop of cocain in the conjunctival sac. \

16

OPERATIONS

When the optic nerve is severed, one can quickly compress, and then turn, the eyeball and carry the operation quietly to completion. To be more sure after resection, a small orbital plate with l/2% perhydral may be inserted and pressed against the wounded orbital tissues for several seconds. A further bettering of the technic upon which Axenfeld lays stress is the galvanic cauterization of the ciliary nerves in the sclera near the entrance of the optic nerve. There is naturally a regeneration of the ciliary nerves •from the central stump, and in the course of time many a neurectomied eye becomes more or less irritable. Pagenstecher also writes upon opticociliary neurectomy, and resection of the optic nerve. This operation is indicated in two groups of cases. The first group includes cases of absolute glaucoma with great pain. The second, those of total staphyloma where the staphylomatoUs formation has not advanced to the point of causing a great deformity. There is a third group of cases, where the danger of sympathetic inflammation could not be excluded, but enucleation is refused. In these cases a large piece of the optic nerve is resected. Pagenstecher's method of operation is as follows: The conjunctiva is divided between the inferior and internal recti muscles about 1 cm. distant from the corneal limbus. The scissors then proceed into the deeper parts along the sclera. With a double hook introduced in the scleral tissue posterior to the equator in a meridian, which connects the corneal diameter with the optic nerve entrance, the eye is drawn upwards and outwards, keeping traction exactly in this meridian. This puts the optic nerve on a stretch, and with strong scissors curved on the flat, the optic nerve is divided well back of its insertion into the eyeball. Keeping up the traction with the hook, the optic nerve remaining attached to the eyeball is then brought forward on the flat of the scissors, until it appears in the wound. The optic nerve is then

seized with a toothed forceps and the nerve divided close to the sclera. All of the ciliary nerves about the optic nerve entrance are then divided. The eyeball is allowed to return to its normal position and it is very important at this time to exercise, strong pressure upon the eyeball to prevent a retrobulbar hemorrhage. The conjunctival wound is closed with one or two sutures and a firm pressure bandage applied. The after treatment is in duration abdut the same as in simple enucleation. OCULAR OSTEOPLASTY.—Zarzycki following enucleation transplants an osteoperiosteal graft into the orbit in order to supply the artificial eye with a stump that moves synchronously with the other eye. The operation is done in three stages. The first stage consists of enucleation and tamponing of the cavity until ready to receive the graft. The second stage consists in the removal of the osteoperiosteal graft from the upper third of the inner surface of the tibia and trimming it to the proper size and thickness, about 1 to 2 mm. In the third stage the graft is sutured with fine catgut to the conjunctiva, not including the periosteal surface. No drainage is made. Zarzycki thinks that results as regard mobility are much better if musculo-conjunctival suture of the rectus muscle is done in the first stage. The artificial eye may be fixed after the fifteenth day. DRESSINGS.—Santos Fernandez thinks since he has known of unruly patients who removed the dressing on the day of the operation, and at the same time were cured, that dressings in eye operations are not necessary after the second day. General papers on operative procedures have been written by Wood on technic of eye, ear, nose, and throat surgery; and Macphail on the importance of some minor operations. Toussant describes a portable instrument case for the army surgeon.