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Surgical Approach to Foreign Bodies
CORRESPONDENCE Fund under the auspices of the same com mittee. The family of Dr. Friedenwald also contributed most generously to the fund. At no time has there been a public request for contributions. This fund has now been turned over the the trustees of the Associa tion for Research in Ophthalmology as a permanent endowment fund for the Frieden wald Lectureship. Further contributions to the fund are necessary if it is adequately to carry out this function. All those interested in perpetuating the memory of a great oph thalmologist whose contributions are so im portant to all ophthalmologists are invited and urged to send contributions. They may be sent to the secretary of the Association for Research in Ophthalmology, Dr. Lorand V. Johnson, 10515 Carnegie Avenue, Cleve land 6, Ohio. Suggestions for possible candidates for the awards would be welcomed by the trus tees. These may also be sent to Dr. Johnson. T. E. Sanders. WILLIAM ZENTMAYER It is with sorrow that T H E JOURNAL learns of the death on March 18th at his home in Merion Station, Pennsylvania, of William Zentmayer, one of the deans of American ophthalmology. A review of his life will appear in an early issue of T H E JOURNAL.
CORRESPONDENCE T H A N K YOU
Editor, American Journal of Ophthalmology: May I have the privilege of the hospitality of T H E JOURNAL for a personal message to many of my friends and colleagues. On my 60th birthday I received a Birth day Book which is so extraordinary that it is quite out of this world, containing mes sages from ophthalmological and medical bodies from practically every country in the world, as well as delightful messages from
945
many individuals. To thank the latter indi vidually is a pleasure; to thank the official bodies is easy and an equal pleasure; but to thank everyone from the individual societies who have done me the great personal honour of signing the pages of the book, is an im possible task, for they are numbered in thou sands, many of them from America. Words are a very imperfect medium for expressing the thoughts which I feel, and I hope that those who showed me so much kindness will accept my thanks through this letter. Stewart Duke-Elder. SURGICAL APPROACH TO FOREIGN BODIES
Editor, American Journal of Ophthalmology: In the December, 1957, AMERICAN JOUR
(page 745) is an article, "Surgical approach to foreign bodies," which is so misleading and poten tially dangerous that certain statements therein should be challenged as to their authoritativeness. The authors refer to "pinpoint localization and precise mm. surgery." Precise surgery is impossible under the procedure described in this article. The "pinpoint localization" apparently consists of "two Sweet localiza tions." Operators experienced in the removal of intraocular foreign bodies know that Xray localizations cannot approach the accu racy of the Berman foreign body locator, which really pinpoints the location of a for eign body within a mm. The authors recommend an incision eight mm. from the limbus. Apparently they as sume that all foreign bodies are free in the vitreous. If they were, an exact X-ray locali zation would be quite unnecessary. Actually, foreign bodies which have enough velocity to perforate the sclera usually pass through the vitreous until they meet some more resistant tissue, such as the sclera, choroid, or retina, in which they are commonly imbedded, so that they are seldom free in the vitreous. If the operator attempts to move such a forNAL OF OPHTHALMOLOGY
SH6
CORRESPONDENCE
eign body from the position in which it has lodged to an incision eight mm. from the limbus, he is very likely to draw the foreign body sideways through the retina and cause unnecessary damage. An incision located directly over the posi tion where the foreign body has lodged, as determined by use of the Berman locator, causes minimum amount of damage to the retina and confines the damage to a point where the area can be easily and accurately treated to discourage detachment of the ret ina. If the foreign body is really free in the vitreous, an incision eight mm. from the limbus in the lower, temporal portion of the eye is, of course, most conveniently located, and is no more traumatizing than if located anywhere else. The manner of making the incision as de scribed in this article is open to criticism. It is described as "concentric to the limbus." The incision which was being used by my father, Dr. Elbert S. Sherman, 30 years ago, and which was not necessarily original with him, is easier and less traumatizing. This consists of the placing of a doublearmed 4-0 suture in a radial direction, so that the bites of the needles, about two mm. apart, straddle the intended incision. A scratch incision is then made down to the choroid, the length of the incision depending upon the size of the foreign body, which is usually known. The lips of the wound are separated by traction on the ends of the suture, which has been left loose. Im mediately after withdrawal of the foreign body, usually with the hand magnet, the area is cauterized in whatever manner the opera tor chooses, the suture is drawn up and tied. In this way no suturing of the sclera is per formed while vitreous is escaping or pro truding. (Even though the vitreous has not been entered with the tip of the magnet, and I have never entered the vitreous with the tip of a magnet, vitreous may still es cape.) (Signed) A. Russell Sherman, Newark, New Jersey.
N
REPLY TO DR. SHERMAN
Editor, American Journal of Ophthalmology: Dr. Sherman, in his comments on our article, has inadvertently overlooked several details. In December, 1957, AMERICAN JOURNAL OF OPHTHALMOLOGY, we stated:
Many foreign bodies in the vitreous may be re moved through a pars plana approach closest to the particle, using a section six-mm. long, concentric with and eight-mm. behind the limbus. Struble and Croll, in "Technical refine ments in the removal of magnetic foreign bodies from posterior segment of the eye," (AMERICAN JOURNAL OF OPHTHALMOLOGY,-
29: 151-161. [Feb.] 1946) came*to the fol lowing conclusions regarding magnetic for eign bodies free in the vitreous. Steel Fragment 0.25 mm. 0.50 mm. 1.00 mm. Critical Zone II Distance in mm. 3.0 to 7.0 6.0 to 10.0 11.0 to 16.0
Certain Zone I Distance in mm. 3.0 6.0 11.0 Failure Zone III Distance in mm. Greater than 7.0 Greater than 10.0 Greater than 16.0
By noting in advance the size of the particle from the X-ray film and referring to the table above, one can determine with some degree of accuracy whether an ap proach over the pars plana will be successful or whether it will be necessary to approach the particle more posteriorly over the cho roid. We stressed that the nonpenetrating technique should be followed. We are at present working with Mr. R. Essling, an engineer, to increase the strength of the hand-magnet so that any intraocular foreign bodies free in the vitreous could readily be extracted by the pars plana ap proach. Also intraocular foreign bodies em bedded in the retina and choroid can be re moved more readily with the new experi mental hand-magnet through a sclerotomy opening directly over the intraocular foreign body.
CORRESPONDENCE T H A N K YOU
Editor, American Journal of Ophthalmology: May I have the privilege of the hospitality of T H E JOURNAL for a personal message to many of my friends and colleagues. On my 60th birthday I received a Birth day Book which is so extraordinary that it is quite out of this world, containing mes sages from ophthalmological and medical bodies from practically every country in the world, as well as delightful messages from
945
many individuals. To thank the latter indi vidually is a pleasure; to thank the official bodies is easy and an equal pleasure; but to thank everyone from the individual societies who have done me the great personal honour of signing the pages of the book, is an im possible task, for they are numbered in thou sands, many of them from America. Words are a very imperfect medium for expressing the thoughts which I feel, and I hope that those who showed me so much kindness will accept my thanks through this letter. Stewart Duke-Elder. SURGICAL APPROACH TO FOREIGN BODIES
Editor, American Journal of Ophthalmology: In the December, 1957, AMERICAN JOUR
(page 745) is an article, "Surgical approach to foreign bodies," which is so misleading and poten tially dangerous that certain statements therein should be challenged as to their authoritativeness. The authors refer to "pinpoint localization and precise mm. surgery." Precise surgery is impossible under the procedure described in this article. The "pinpoint localization" apparently consists of "two Sweet localiza tions." Operators experienced in the removal of intraocular foreign bodies know that Xray localizations cannot approach the accu racy of the Berman foreign body locator, which really pinpoints the location of a for eign body within a mm. The authors recommend an incision eight mm. from the limbus. Apparently they as sume that all foreign bodies are free in the vitreous. If they were, an exact X-ray locali zation would be quite unnecessary. Actually, foreign bodies which have enough velocity to perforate the sclera usually pass through the vitreous until they meet some more resistant tissue, such as the sclera, choroid, or retina, in which they are commonly imbedded, so that they are seldom free in the vitreous. If the operator attempts to move such a forNAL OF OPHTHALMOLOGY
SH6
CORRESPONDENCE
eign body from the position in which it has lodged to an incision eight mm. from the limbus, he is very likely to draw the foreign body sideways through the retina and cause unnecessary damage. An incision located directly over the posi tion where the foreign body has lodged, as determined by use of the Berman locator, causes minimum amount of damage to the retina and confines the damage to a point where the area can be easily and accurately treated to discourage detachment of the ret ina. If the foreign body is really free in the vitreous, an incision eight mm. from the limbus in the lower, temporal portion of the eye is, of course, most conveniently located, and is no more traumatizing than if located anywhere else. The manner of making the incision as de scribed in this article is open to criticism. It is described as "concentric to the limbus." The incision which was being used by my father, Dr. Elbert S. Sherman, 30 years ago, and which was not necessarily original with him, is easier and less traumatizing. This consists of the placing of a doublearmed 4-0 suture in a radial direction, so that the bites of the needles, about two mm. apart, straddle the intended incision. A scratch incision is then made down to the choroid, the length of the incision depending upon the size of the foreign body, which is usually known. The lips of the wound are separated by traction on the ends of the suture, which has been left loose. Im mediately after withdrawal of the foreign body, usually with the hand magnet, the area is cauterized in whatever manner the opera tor chooses, the suture is drawn up and tied. In this way no suturing of the sclera is per formed while vitreous is escaping or pro truding. (Even though the vitreous has not been entered with the tip of the magnet, and I have never entered the vitreous with the tip of a magnet, vitreous may still es cape.) (Signed) A. Russell Sherman, Newark, New Jersey.
N
REPLY TO DR. SHERMAN
Editor, American Journal of Ophthalmology: Dr. Sherman, in his comments on our article, has inadvertently overlooked several details. In December, 1957, AMERICAN JOURNAL OF OPHTHALMOLOGY, we stated:
Many foreign bodies in the vitreous may be re moved through a pars plana approach closest to the particle, using a section six-mm. long, concentric with and eight-mm. behind the limbus. Struble and Croll, in "Technical refine ments in the removal of magnetic foreign bodies from posterior segment of the eye," (AMERICAN JOURNAL OF OPHTHALMOLOGY,-
29: 151-161. [Feb.] 1946) came*to the fol lowing conclusions regarding magnetic for eign bodies free in the vitreous. Steel Fragment 0.25 mm. 0.50 mm. 1.00 mm. Critical Zone II Distance in mm. 3.0 to 7.0 6.0 to 10.0 11.0 to 16.0
Certain Zone I Distance in mm. 3.0 6.0 11.0 Failure Zone III Distance in mm. Greater than 7.0 Greater than 10.0 Greater than 16.0
By noting in advance the size of the particle from the X-ray film and referring to the table above, one can determine with some degree of accuracy whether an ap proach over the pars plana will be successful or whether it will be necessary to approach the particle more posteriorly over the cho roid. We stressed that the nonpenetrating technique should be followed. We are at present working with Mr. R. Essling, an engineer, to increase the strength of the hand-magnet so that any intraocular foreign bodies free in the vitreous could readily be extracted by the pars plana ap proach. Also intraocular foreign bodies em bedded in the retina and choroid can be re moved more readily with the new experi mental hand-magnet through a sclerotomy opening directly over the intraocular foreign body.