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Synthetic Plastic Material for Implantation into Orbit Following Enucleation*
NOTES, CASES, I N S T R U M E N T S SYNTHETIC PLASTIC MATERIAL FOR IMPLANTATION INTO ORBIT F O L L O W I N G ENUCLEATION* CONRAD BERENS, M.D. AND SIDNEY ROTH BARD,
M.D.
New York Although the implantation of gold balls into the orbit following enucleation is more satisfactory than that of fat, glass, paraffin, or other substances, the move-
commercially known as "Lucite" was useful for testicular prothesis. Thiel (1939) also reported favorable results with a synthetic plastic known as "Polyviol" in orbital implantation into Tenon's capsule after enucleation. Because of the importance of the prob lem in ophthalmology, experiments with various shapes and sizes of synthetic plastic compounds such as "Lucite" and "Plexiglas" have been performed. The physical, chemical, thermal, and optical
m
P^y
sa
/ti
Fig, 1 (Berens and Rothbard). A, Lucite. B, Plexiglas. Specimens removed after 246 days of subcutaneous implantation. C, Plexiglas, specimen removed after 86 days of intraperitoneal im plantation in a rabbit.
ments of the prothesis have been limited. Moreover, gold balls are heavy and ex pensive. McCrea (1938) was confronted with this problem in the field of urology and found that a new plastic material ♦From the Department of Research, New York Eye and Ear Infirmary, and the Depart ment of Pathology, Cornell University Medical College. Aided by a grant from the John and Mary R, Markle and Ophthalmological Founda tions. Presented before the Section on Oph thalmology, New York Academy of Medicine, April IS, 1940.
properties of these substances have al ready been worked out by the manufac turers. Experimental. To be certain that the material would not be absorbed by nor irritating to the tissues, a study of the effect of these compounds on the animal body was carried out in a small group of rabbits. Under aseptic conditions the plastic materials were placed in the sub cutaneous tissues, pleural and peritoneal cavities, and in the anterior chamber of 550
NOTES, CASES, INSTRUMENTS the eye, and the animals were permitted to survive from 40 to 246 days. There was no evidence of an inflammatory reac tion at any of these sites during the period of observation. The animals gained weight, appeared alert, and were active at all times. When the specimens were removed, the size, shape, and contour were the same as
551
Clinical. The implants are obtainable in 12-mm., 14-mm., 15-mm., 16-mm., and 18-mm. sizes. The form selected as the most desirable is quadrilateral and py ramidal in shape, rounded at one extrem ity, and tapered to a blunt point at the other (fig. 2). Implants may also be ob tained in the form of spheres and cones (fig. 3).
Fig. 2 (Berens and Rothbard). A, implant of plastic material for enucleation. B, implant in place in Tenon's capsule.
on insertion (fig. 1). A thick, white layer of fibrous connective tissue surrounded each specimen, and there was also a rich vascular supply about it. The peritoneal and pleural surfaces were smooth except for a few fibrous adhesions, and the vis cera were normal. The autopsy findings on the organs and tissues were essentially negative. The heart, lungs, liver, spleen, kidneys, and eyes were examined microscopically, and no abnormality which could be attributed to absorption of any constituents of the plastic substances was observed. These findings are not surprising in view of the lack of local irritation produced by the "Lucite" and "Plexiglas."
Sterilization is easily carried out by boiling or by placing the material in solu tions such as alcohol or other antiseptics. Immersion for 10 minutes in one of the following solutions is recommended for sterilization: Merthiolate 1:1,000, Hexylresorcinol (S.T. 37) 1:1,000, Metaphen 1:500, or bichloride of mercury 1:400. The method employed for implantation was that described by Berens in 1937. After enucleation of the eyeball, the im plants, which are flattened on the sides to conform to the recti muscles, are placed in Tenon's capsule with the apex directed toward the apex of the orbit. A running, double-armed suture of no.-5 twisted, paraffinized, black silk is passed first
552
NOTES, CASES, INSTRUMENTS
through Tenon's capsule at the level of the muscular attachments and then through the conjunctiva 3 mm. above the internal canthal ligament. Each muscle is held with artery forceps; the suture is passed in and out of Tenon's capsule in cluding the four ends of the cut recti
of the plastics has been noted, either in histological examination of animal tissues or gross observations of human material. This may be due to the fact that the plastics used have a specific gravity much lower than that of glass or gold and very close to that of the body tissues.
4LM. Fig. 3 (Berens and Rothbard). A, spherical implant. B, ovoid implant. C, cone-shaped implant. D, quadrilateral, pyramidal-shaped implant.
muscles in the bite. One needle is passed through Tenon's capsule and the con junctiva above the point of introduction of the first needle, thus crossing the su tures. The needles are passed through a small piece of rubber tubing, 3 mm. apart, so that the suture may be easily removed. After the plastic implant is introduced, and after making sure that there is a firm closing of Tenon's capsule, the su tures are tied. The conjunctival incision is closed with a running 0000 plain catgut suture. A pressure dressing, which is held by adhesive, and a bandage are applied (fig. 4 ) . Up to the present time eight plastic implants have been inserted in the orbital cavities of patients, and no untoward effects have been observed. Although the plastic compounds have proved to be nonirritating to both animals and human beings, they have been under observation for not more than nine months and, therefore, it is possibly too early to draw final conclusions concern ing their ultimate value. To date, how ever, no irritating qualities nor absorption
It is also too early to state whether or not a quadrilateral, pyramidal shape may have certain disadvantages, but in the
Fig. 4 (Berens and Rothbard), Pursestring suture placed in Tenon's capsule and recti muscles. Conjunctival wound is not closed.
eight human orbits in which the implants* have been retained, good motility of the ♦The implants are made by V. Mueller and Company, Chicago, Illinois.
NOTES, CASES, INSTRUMENTS prothesis has resulted. It would seem that the pyramidal shape should tend to stretch the muscles more than the spheri cal shape, and that pivoting on the point of the implant should result in better average motility. Certainly, for many patients the fact that the material cannot be broken is an added advantage, and further studies of its possibilities seem justified. CONCLUSIONS
1. Synthetic plastic compounds, such as "Lucite" and "Plexiglas" cause no
SS3
irritation to human or animal tissues nor are they absorbed or changed in any man ner. 2. Good motility of the prothesis has resulted after implantation of the quadri lateral, pyramidal shaped forms. 35 East Seventieth Street. 1300 York Avenue. Acknowledgment is made to Rohm and Haas, Philadelphia, for supplying us with "Plexiglas" for use in the experiments, and to E. I. DuPont de Nemours, Arlington, New Jersey, for "Lucite."
REFERENCES
Berens, C. Enucleation with implantation of foreign substances into Tenon's capsule. Amer. Jour. Ophth., 1937, v. 20, March, p. 293. McCrea, L. E. Lucite: A new synthetic material suitable for testicular prosthesis. Urol. & Cutan. Rev., 1938, v. 42, p. 723. Thiel, R. Polyviol inserts for plastic formation of the stump after enucleation of the eye. Klin. M. f. Augenh., 1939, v. 103, p. 530.
THE POSTERIOR APPROACH FOR THE REMOVAL OF MAGNETIC INTRAOCULAR FOREIGN BODIES* F L E M I N G A. BARBOUR, M.D.,f A N D F. BRUCE FRALICK,
M.D.
Ann Arbor, Michigan
Most intraocular injuries are incurred in industry, and it is highly important, from the patient's standpoint, that every effort be made to preserve the injured eye so that he may continue to pass industrial visual-requirement tests and maintain his employability. A detailed method of removing magnetic foreign bodies from the vitreous chamber is pre sented. It has been used by us for the last several years and we believe that it offers several distinct advantages. * From the Department of Ophthalmology, University of Michigan. t John E. Weeks Scholar in Ophthalmology.
Before surgery can be considered, sev eral questions about the injured eye must be answered. The cornea and sclera should be very carefully studied by means of loupe and slitlamp for evidence of scarring from foreign-body penetration. Since tiny missiles may enter the eye and leave a minute scar that is almost in visible, a roentgenogram of the posterioranterior and lateral projections of the orbit should be taken in every case in which there is a suggestive history. Oc casionally the subsequent value of X-ray evidence in the court room cannot be overestimated. If evidence of a foreign body is seen on the test films, then one of the several methods of exact localiza tion, such as the Sweet procedure, should be carried out. Fortunately, most metallic foreign bodies are magnetizable. Of the alloys, magnesium steel has very slight magnetic properties. Chromium and tungsten alloys are not markedly different from ordinary
M.D.
New York Although the implantation of gold balls into the orbit following enucleation is more satisfactory than that of fat, glass, paraffin, or other substances, the move-
commercially known as "Lucite" was useful for testicular prothesis. Thiel (1939) also reported favorable results with a synthetic plastic known as "Polyviol" in orbital implantation into Tenon's capsule after enucleation. Because of the importance of the prob lem in ophthalmology, experiments with various shapes and sizes of synthetic plastic compounds such as "Lucite" and "Plexiglas" have been performed. The physical, chemical, thermal, and optical
m
P^y
sa
/ti
Fig, 1 (Berens and Rothbard). A, Lucite. B, Plexiglas. Specimens removed after 246 days of subcutaneous implantation. C, Plexiglas, specimen removed after 86 days of intraperitoneal im plantation in a rabbit.
ments of the prothesis have been limited. Moreover, gold balls are heavy and ex pensive. McCrea (1938) was confronted with this problem in the field of urology and found that a new plastic material ♦From the Department of Research, New York Eye and Ear Infirmary, and the Depart ment of Pathology, Cornell University Medical College. Aided by a grant from the John and Mary R, Markle and Ophthalmological Founda tions. Presented before the Section on Oph thalmology, New York Academy of Medicine, April IS, 1940.
properties of these substances have al ready been worked out by the manufac turers. Experimental. To be certain that the material would not be absorbed by nor irritating to the tissues, a study of the effect of these compounds on the animal body was carried out in a small group of rabbits. Under aseptic conditions the plastic materials were placed in the sub cutaneous tissues, pleural and peritoneal cavities, and in the anterior chamber of 550
NOTES, CASES, INSTRUMENTS the eye, and the animals were permitted to survive from 40 to 246 days. There was no evidence of an inflammatory reac tion at any of these sites during the period of observation. The animals gained weight, appeared alert, and were active at all times. When the specimens were removed, the size, shape, and contour were the same as
551
Clinical. The implants are obtainable in 12-mm., 14-mm., 15-mm., 16-mm., and 18-mm. sizes. The form selected as the most desirable is quadrilateral and py ramidal in shape, rounded at one extrem ity, and tapered to a blunt point at the other (fig. 2). Implants may also be ob tained in the form of spheres and cones (fig. 3).
Fig. 2 (Berens and Rothbard). A, implant of plastic material for enucleation. B, implant in place in Tenon's capsule.
on insertion (fig. 1). A thick, white layer of fibrous connective tissue surrounded each specimen, and there was also a rich vascular supply about it. The peritoneal and pleural surfaces were smooth except for a few fibrous adhesions, and the vis cera were normal. The autopsy findings on the organs and tissues were essentially negative. The heart, lungs, liver, spleen, kidneys, and eyes were examined microscopically, and no abnormality which could be attributed to absorption of any constituents of the plastic substances was observed. These findings are not surprising in view of the lack of local irritation produced by the "Lucite" and "Plexiglas."
Sterilization is easily carried out by boiling or by placing the material in solu tions such as alcohol or other antiseptics. Immersion for 10 minutes in one of the following solutions is recommended for sterilization: Merthiolate 1:1,000, Hexylresorcinol (S.T. 37) 1:1,000, Metaphen 1:500, or bichloride of mercury 1:400. The method employed for implantation was that described by Berens in 1937. After enucleation of the eyeball, the im plants, which are flattened on the sides to conform to the recti muscles, are placed in Tenon's capsule with the apex directed toward the apex of the orbit. A running, double-armed suture of no.-5 twisted, paraffinized, black silk is passed first
552
NOTES, CASES, INSTRUMENTS
through Tenon's capsule at the level of the muscular attachments and then through the conjunctiva 3 mm. above the internal canthal ligament. Each muscle is held with artery forceps; the suture is passed in and out of Tenon's capsule in cluding the four ends of the cut recti
of the plastics has been noted, either in histological examination of animal tissues or gross observations of human material. This may be due to the fact that the plastics used have a specific gravity much lower than that of glass or gold and very close to that of the body tissues.
4LM. Fig. 3 (Berens and Rothbard). A, spherical implant. B, ovoid implant. C, cone-shaped implant. D, quadrilateral, pyramidal-shaped implant.
muscles in the bite. One needle is passed through Tenon's capsule and the con junctiva above the point of introduction of the first needle, thus crossing the su tures. The needles are passed through a small piece of rubber tubing, 3 mm. apart, so that the suture may be easily removed. After the plastic implant is introduced, and after making sure that there is a firm closing of Tenon's capsule, the su tures are tied. The conjunctival incision is closed with a running 0000 plain catgut suture. A pressure dressing, which is held by adhesive, and a bandage are applied (fig. 4 ) . Up to the present time eight plastic implants have been inserted in the orbital cavities of patients, and no untoward effects have been observed. Although the plastic compounds have proved to be nonirritating to both animals and human beings, they have been under observation for not more than nine months and, therefore, it is possibly too early to draw final conclusions concern ing their ultimate value. To date, how ever, no irritating qualities nor absorption
It is also too early to state whether or not a quadrilateral, pyramidal shape may have certain disadvantages, but in the
Fig. 4 (Berens and Rothbard), Pursestring suture placed in Tenon's capsule and recti muscles. Conjunctival wound is not closed.
eight human orbits in which the implants* have been retained, good motility of the ♦The implants are made by V. Mueller and Company, Chicago, Illinois.
NOTES, CASES, INSTRUMENTS prothesis has resulted. It would seem that the pyramidal shape should tend to stretch the muscles more than the spheri cal shape, and that pivoting on the point of the implant should result in better average motility. Certainly, for many patients the fact that the material cannot be broken is an added advantage, and further studies of its possibilities seem justified. CONCLUSIONS
1. Synthetic plastic compounds, such as "Lucite" and "Plexiglas" cause no
SS3
irritation to human or animal tissues nor are they absorbed or changed in any man ner. 2. Good motility of the prothesis has resulted after implantation of the quadri lateral, pyramidal shaped forms. 35 East Seventieth Street. 1300 York Avenue. Acknowledgment is made to Rohm and Haas, Philadelphia, for supplying us with "Plexiglas" for use in the experiments, and to E. I. DuPont de Nemours, Arlington, New Jersey, for "Lucite."
REFERENCES
Berens, C. Enucleation with implantation of foreign substances into Tenon's capsule. Amer. Jour. Ophth., 1937, v. 20, March, p. 293. McCrea, L. E. Lucite: A new synthetic material suitable for testicular prosthesis. Urol. & Cutan. Rev., 1938, v. 42, p. 723. Thiel, R. Polyviol inserts for plastic formation of the stump after enucleation of the eye. Klin. M. f. Augenh., 1939, v. 103, p. 530.
THE POSTERIOR APPROACH FOR THE REMOVAL OF MAGNETIC INTRAOCULAR FOREIGN BODIES* F L E M I N G A. BARBOUR, M.D.,f A N D F. BRUCE FRALICK,
M.D.
Ann Arbor, Michigan
Most intraocular injuries are incurred in industry, and it is highly important, from the patient's standpoint, that every effort be made to preserve the injured eye so that he may continue to pass industrial visual-requirement tests and maintain his employability. A detailed method of removing magnetic foreign bodies from the vitreous chamber is pre sented. It has been used by us for the last several years and we believe that it offers several distinct advantages. * From the Department of Ophthalmology, University of Michigan. t John E. Weeks Scholar in Ophthalmology.
Before surgery can be considered, sev eral questions about the injured eye must be answered. The cornea and sclera should be very carefully studied by means of loupe and slitlamp for evidence of scarring from foreign-body penetration. Since tiny missiles may enter the eye and leave a minute scar that is almost in visible, a roentgenogram of the posterioranterior and lateral projections of the orbit should be taken in every case in which there is a suggestive history. Oc casionally the subsequent value of X-ray evidence in the court room cannot be overestimated. If evidence of a foreign body is seen on the test films, then one of the several methods of exact localiza tion, such as the Sweet procedure, should be carried out. Fortunately, most metallic foreign bodies are magnetizable. Of the alloys, magnesium steel has very slight magnetic properties. Chromium and tungsten alloys are not markedly different from ordinary