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Wound Rupture after Cataract Extraction*
W O U N D RUPTURE AFTER CATARACT EXTRACTION* HARRY
S.
CRADLE,
M.D.,
AND CAPT. H. SAUL SUGAR, M.D., Chicago and Vancouver, Washington
The frequent occurrence of rupture of the corneoscleral wound after cataract extraction is a most disturbing problem to the ophthalmic surgeon. There are three definite degrees of such ruptures: (1) a mere gaping of the wound, with edema of the conjunctival flap; (2) a definite rup ture of the wound with forcible tearing of the newly formed capillaries at the wound surface and resultant hyphema ; (3) rup ture of the wound with prolapse of the iris into the incision. The first and second of these are unpleasant but not likely to be serious ; the third form always reduces the number of satisfactory end results. The frequency of wound rupture varies greatly and does not appear to be de pendent upon the skill of the operator nor upon the type of operation employed. In 200 consecutive private cases seen by one of us (H.S.G.), wound rupture without hyphema occurred in 3.5 percent; wound rupture with hyphema took place in 15.5 percent ; and wound rupture with iris pro lapse was seen in 2.5 percent. Of the 31 instances of hyphema, 35.5 percent oc curred on the second day, 22.5 percent on the third day, 9.5 percent on the fourth, 6.5 percent each on the fifth and sixth days, 13.5 percent on the seventh day, 9.5 percent on the eighth day, and 3.5 percent on the eleventh day. Vail1 found, in the literature, an average incidence of 7.9 percent of hyphema following cataract extraction, and in his own statistics 6.2 percent. Philps2 found an incidence of 13.13 percent hyphema in 374 consecutive cataract extractions. It is obvious that, unless external force * Read before the American Ophthalmological Society at Hot Springs, Virginia, May 2931, 1941.
M.C. (by invitation)
has been applied, wound rupture can result only from an increase of pressure from within ; in other words, from an increase in intraocular pressure. Such an increase is not related to the factors that cause glaucomatous hypertension. Duke-Elder 3 has shown that forcible contraction of the orbicularis palpebrarum will cause an in crease in intraocular pressure up to 90 mm. Hg measured manometrically. We repeated his experiment and corroborated his results. A manometer needle was in troduced into the vitreous of a soft eye that was about to be enucleated, and the pressure was found to be 50 mm. of water. The exophthalmometer reading was 14.5 mm. A forcible contraction of the orbicularis by the patient caused the manometer reading to rise to 153 mm. of water. Five cubic centimeters of novocaine solution was then injected retrobulbarly. Subsequent forcible contraction of the orbicularis caused the manometer reading to rise to 252 mm. of water. At this time the exophthalmometer reading was 20 mm. Obviously, the increased proptosis permitted more effective orbi cularis pressure on the globe. Besides the effect of the orbicularis pal pebrarum in raising the intraocular pres sure, two other factors must be con sidered ; namely, the contraction of the recti and oblique muscles, and the com pressibility of the orbital tissues by both the orbicularis and the intraorbital muscles. Clinically, only two of the three factors could be studied. No practical method of paralyzing the recti and oblique muscles postoperatively, except tempo rarily, is available. In order to study the factor of orbital compressibility, an instrument, termed by
426
WOUND RUPTURE AFTER CATARACT EXTRACTION
427
us a compressometer, was devised. This consists of a rigid metal frame held firmly against the lateral orbital margins by a headband, and a movable housing contain ing a stylet. One end of the stylet ter minates in a flat metal ring that fits be tween the eyelids and rests on the sciera, just outside the limbus. T h e other end of the stylet rests against a spiral spring that
Fig. 2 (Gradle and S u g a r ) . Sideview of compressometer when applied to eyeball.
Fig. 1 (Gradle and Sugar). Compressometer as seen from above without headband and re taining framework. is put into action by finger pressure. T h e movement of the stylet and the force exerted on the spring are determined from a calibrated scale (figs. 1, 2, and 3 ) . By making uniform pressure upon the spring, the total degree of compressibility of the orbit is measured. By using three units of pressure on the spring, the rela tive amount of orbital compressibility is determinable. Such measurements were made upon a series of 137 eyes just prior to cataract extraction by the various operators at the Illinois Eye and E a r Infirmary. There Fig. 3 (Gradle and Sugar). Compressometer applied to eyeball as seen from in front.
428
HARRY S. GRADLE AND H. SAUL SUGAR
was no significant difference in either the total or relative compressibility of the eyeballs within the orbits. An interesting sidelight as to the value of the corn-
Fig. 4 (Gradle and Sugar). Surface dissection of lids.
pressometer is its usefulness in making the differential diagnosis of cases of exophthalmos. In one instance in the series studied, decreased orbital compressibility was due to hyperthyroidism. An instru ment called a piezometer, built on the principle of a tonometer, was used by Gutman4 in making a differential diagno sis between orbital tumors and exophthalmos, but was not utilized in the same manner as we have done. In the same series of 137 cases the effect of orbicularis contraction on wound rupture was studied by using the Hertel exophthalmometer. As can be seen in the illustration of the surface dissection of
Fig. S (Gradle and Sugar). Surface dis section of lids showing orbicularis fibers,
the orbicularis (figs. 4, 5, and 6 from Sabotta-McMurrich), the fixed points of insertion of that muscle are at the inner and outer bony margins of the orbit. The degree of protrusion of the apex of the cornea beyond the plane passing through these fixed points could, therefore, easily be determined with the exophthalmometer. The average exophthalmometer reading of the 137 eyes was 17.3 mm. Table 1 shows the variations in these measurements as well as the relationship between the bulbar proptosis and the orbital compressibility. The results of the first 85 cataract op erations in this series were tabulated in order to determine the number having hyphema and iris prolapse. Three in stances of the latter occurred, two of
Fig. 6 (Gradle and Sugar). Semidiagrammatic view of dissection of lids showing inser tion of orbicularis fibers. The black lines at the outer canthus demonstrate the direction of the scissor cuts in tenotomizing the orbicularis.
these with hyphema. Hyphema alone was present in a total of 13 eyes (15.3 per cent). In these cases no relationship was found between the bulbar position and the incidence of postoperative hyphema. The hyphema cases are tabulated in table 2. Corneoscleral sutures had been used in four of the eyes with wound rupture and hyphema. Two of these sutures were of the McLean type, one was a Verhoeff, and one a modified Liégard suture. No conclu sions can be drawn from these cases, since
WOUND RUPTURE AFTER CATARACT EXTRACTION
429
TABLE 1 T H E RELATIONSHIP BETWEEN BULBAR PROPTOSIS AND ORBITAL COMPRESSIBILITY
Exophthalmometer Readings 7 10 13 16 19 22
to to to to to to
9.5 12.5 15.5 18.5 21.5 25
Average Units
Number of Eyes
Applied
3.0 3.3 3.2 3.3 3.3 3.3
5.0 6.3 6.4 6.4 6.4 6.5
1 11 33 45 35 12
mm. mm. mm. mm. mm. mm.
it has been shown by Leech and Sugar 5 and McLean6 that the use of corneoscleral sutures seems to decrease the incidence of wound rupture. At the time that the series of post operative cataract cases were being studied, it was believed that if wound rup ture followed violent contracture of the orbicularis muscle, elimination of the action of this muscle for a period of about seven days should prevent further rup ture. Such suspension of the function of the orbicularis power could be accom plished only by performing tenotomy of the muscle. This was done in 40 consecu tive private cases by one of us (H.S.G.). A wide canthotomy was made, followed by upward and downward incisions be neath the skin, cutting through the orbicu laris fibers at a point before their inser
Average Orbital Compressibility mm. mm. mm. mm. mm. mm.
tion into the orbital periosteum. One un pleasant feature of this method was the frequency with which hemorrhage from the external angular artery occurred, which often had to be clamped off. In none of these cases did wound rupture, even of the first degree, occur. The same procedure was followed in a series of 52 consecutive cases at the Illinois Eye and Ear Infirmary, carried out by the same operators and under the same conditions as in the previous series of 85 cases with out canthotomy or orbicularis tenotomy. In that series hyphema occurred in nine cases (17.3 percent). Iris prolapse oc curred in one other case. In these cases no relationship was found between the bulbar position and the incidence of post operative hyphema. The hyphema cases are shown in table 3. In three of these
TABLE 2 INSTANCES OF WOUND RUPTURE WITH HYPHEMA
Postoperative Day When Hyphema Was Noted Fourth First Seventh Second Second (prol.) First Ninth Third First Second First Second (prol.) First Range 1 to 9 days p-op. Average 2.7 days
Exophthalmometer Reading
Compressometer Units of Pressure Applied
18.5 mm. 10 mm. 18 mm. 17 mm. 15 mm. 15.5 mm. 19.5 mm. 17 mm. 19 mm. 14 mm. 17 mm. 17 mm. 17 mm. 10 to 19.5 mm. 16.5 mm.
7 6 6 6 6 6 6 7 6 '6 7 6 7 6 to 7 6.3
Orbital Compressibility 4 3 3 3.5 3 3 3 4 3.5 3 4 3 4 3 to 4 3.3
mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm.
430
HARRY S. GRADLE AND H. SAUL SUGAR TABLE 3 WOUND RUPTURE WITH HYPHEMA IN CASES WITH ORBICULARIS TENOTOMY
Postoperative Day When Hyphema Was Noted Sixth Second Third Sixth Sixth Eighth Fourth Sixth Sixth Range 2 to 8 days Average 5 .2 days
Exophthalmometer Reading
Compressometer Units of Pressure Applied
20 mm. 14 mm. 20.5 mm. 17 mm. 11 mm. 15 mm. 23.5 mm. 18 mm. 13 mm. 11 to 23.5 mm. 16.9 mm.
6 6 6 6 7 6.5 7 7 6 6 to 7 6.4
cases corneoscleral sutures had been used (two Verhoeff and one modified Liégard sutures). T h e only difference ob served between the two series of cases was the later appearance of the hyphema in the cases with orbicularis tenotomy. CONCLUSIONS
W e believe that rupture of the wound after operation for senile cataract is due to increased intraocular pressure brought about by forcible contracture of the orbi cularis a n d / o r the recti and oblique muscles. Compressibility of the eyeball within the orbit is approximately the same in all normal eyes, and hence is not to be regarded as a factor in wound rupture.
Vail, Derrick. Trans. Amer. Ophth. Soc, 1933, v. 32, p. 496. - Philps, S. A. Brit. Jour. Ophth., 1940, v. 24, p. 122. Duke-Elder, W. S. Jour. Physiol., 1931, v. 71, p. 1. 1 Gutman, A. Zeit. f. Augenh., 1927, v. 63, p. 136. 5 Leech, V. M., and Sugar, H. S. Arch, of Ophth., 1939, v. 21, 966. ' McLean, J. M. Arch, of Ophth., 1940, v. 23, p. 554. 3
3 3 3 3.5 4 3.5 3 3 3 3 to 4 3.2
mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm.
In the series of cases studied, the degree of bulbar proptosis made little difference in the end results, although it is probable that in instances of definite exophthalmos it would be an important factor in caus ing wound rupture. Tenotomy of the orbicularis as a means of preventing orbicularis action during the postoperative danger period gave ex cellent results in a series of 40 private cases, whereas in 52 clinic patients the results were approximately the same as in a series of nontenotomized cases. A further study in a larger series of cases will be made. 58 East Washington Street. Barnes General Hospital.
REFERENCES 1
Orbital Compressibility
S.
CRADLE,
M.D.,
AND CAPT. H. SAUL SUGAR, M.D., Chicago and Vancouver, Washington
The frequent occurrence of rupture of the corneoscleral wound after cataract extraction is a most disturbing problem to the ophthalmic surgeon. There are three definite degrees of such ruptures: (1) a mere gaping of the wound, with edema of the conjunctival flap; (2) a definite rup ture of the wound with forcible tearing of the newly formed capillaries at the wound surface and resultant hyphema ; (3) rup ture of the wound with prolapse of the iris into the incision. The first and second of these are unpleasant but not likely to be serious ; the third form always reduces the number of satisfactory end results. The frequency of wound rupture varies greatly and does not appear to be de pendent upon the skill of the operator nor upon the type of operation employed. In 200 consecutive private cases seen by one of us (H.S.G.), wound rupture without hyphema occurred in 3.5 percent; wound rupture with hyphema took place in 15.5 percent ; and wound rupture with iris pro lapse was seen in 2.5 percent. Of the 31 instances of hyphema, 35.5 percent oc curred on the second day, 22.5 percent on the third day, 9.5 percent on the fourth, 6.5 percent each on the fifth and sixth days, 13.5 percent on the seventh day, 9.5 percent on the eighth day, and 3.5 percent on the eleventh day. Vail1 found, in the literature, an average incidence of 7.9 percent of hyphema following cataract extraction, and in his own statistics 6.2 percent. Philps2 found an incidence of 13.13 percent hyphema in 374 consecutive cataract extractions. It is obvious that, unless external force * Read before the American Ophthalmological Society at Hot Springs, Virginia, May 2931, 1941.
M.C. (by invitation)
has been applied, wound rupture can result only from an increase of pressure from within ; in other words, from an increase in intraocular pressure. Such an increase is not related to the factors that cause glaucomatous hypertension. Duke-Elder 3 has shown that forcible contraction of the orbicularis palpebrarum will cause an in crease in intraocular pressure up to 90 mm. Hg measured manometrically. We repeated his experiment and corroborated his results. A manometer needle was in troduced into the vitreous of a soft eye that was about to be enucleated, and the pressure was found to be 50 mm. of water. The exophthalmometer reading was 14.5 mm. A forcible contraction of the orbicularis by the patient caused the manometer reading to rise to 153 mm. of water. Five cubic centimeters of novocaine solution was then injected retrobulbarly. Subsequent forcible contraction of the orbicularis caused the manometer reading to rise to 252 mm. of water. At this time the exophthalmometer reading was 20 mm. Obviously, the increased proptosis permitted more effective orbi cularis pressure on the globe. Besides the effect of the orbicularis pal pebrarum in raising the intraocular pres sure, two other factors must be con sidered ; namely, the contraction of the recti and oblique muscles, and the com pressibility of the orbital tissues by both the orbicularis and the intraorbital muscles. Clinically, only two of the three factors could be studied. No practical method of paralyzing the recti and oblique muscles postoperatively, except tempo rarily, is available. In order to study the factor of orbital compressibility, an instrument, termed by
426
WOUND RUPTURE AFTER CATARACT EXTRACTION
427
us a compressometer, was devised. This consists of a rigid metal frame held firmly against the lateral orbital margins by a headband, and a movable housing contain ing a stylet. One end of the stylet ter minates in a flat metal ring that fits be tween the eyelids and rests on the sciera, just outside the limbus. T h e other end of the stylet rests against a spiral spring that
Fig. 2 (Gradle and S u g a r ) . Sideview of compressometer when applied to eyeball.
Fig. 1 (Gradle and Sugar). Compressometer as seen from above without headband and re taining framework. is put into action by finger pressure. T h e movement of the stylet and the force exerted on the spring are determined from a calibrated scale (figs. 1, 2, and 3 ) . By making uniform pressure upon the spring, the total degree of compressibility of the orbit is measured. By using three units of pressure on the spring, the rela tive amount of orbital compressibility is determinable. Such measurements were made upon a series of 137 eyes just prior to cataract extraction by the various operators at the Illinois Eye and E a r Infirmary. There Fig. 3 (Gradle and Sugar). Compressometer applied to eyeball as seen from in front.
428
HARRY S. GRADLE AND H. SAUL SUGAR
was no significant difference in either the total or relative compressibility of the eyeballs within the orbits. An interesting sidelight as to the value of the corn-
Fig. 4 (Gradle and Sugar). Surface dissection of lids.
pressometer is its usefulness in making the differential diagnosis of cases of exophthalmos. In one instance in the series studied, decreased orbital compressibility was due to hyperthyroidism. An instru ment called a piezometer, built on the principle of a tonometer, was used by Gutman4 in making a differential diagno sis between orbital tumors and exophthalmos, but was not utilized in the same manner as we have done. In the same series of 137 cases the effect of orbicularis contraction on wound rupture was studied by using the Hertel exophthalmometer. As can be seen in the illustration of the surface dissection of
Fig. S (Gradle and Sugar). Surface dis section of lids showing orbicularis fibers,
the orbicularis (figs. 4, 5, and 6 from Sabotta-McMurrich), the fixed points of insertion of that muscle are at the inner and outer bony margins of the orbit. The degree of protrusion of the apex of the cornea beyond the plane passing through these fixed points could, therefore, easily be determined with the exophthalmometer. The average exophthalmometer reading of the 137 eyes was 17.3 mm. Table 1 shows the variations in these measurements as well as the relationship between the bulbar proptosis and the orbital compressibility. The results of the first 85 cataract op erations in this series were tabulated in order to determine the number having hyphema and iris prolapse. Three in stances of the latter occurred, two of
Fig. 6 (Gradle and Sugar). Semidiagrammatic view of dissection of lids showing inser tion of orbicularis fibers. The black lines at the outer canthus demonstrate the direction of the scissor cuts in tenotomizing the orbicularis.
these with hyphema. Hyphema alone was present in a total of 13 eyes (15.3 per cent). In these cases no relationship was found between the bulbar position and the incidence of postoperative hyphema. The hyphema cases are tabulated in table 2. Corneoscleral sutures had been used in four of the eyes with wound rupture and hyphema. Two of these sutures were of the McLean type, one was a Verhoeff, and one a modified Liégard suture. No conclu sions can be drawn from these cases, since
WOUND RUPTURE AFTER CATARACT EXTRACTION
429
TABLE 1 T H E RELATIONSHIP BETWEEN BULBAR PROPTOSIS AND ORBITAL COMPRESSIBILITY
Exophthalmometer Readings 7 10 13 16 19 22
to to to to to to
9.5 12.5 15.5 18.5 21.5 25
Average Units
Number of Eyes
Applied
3.0 3.3 3.2 3.3 3.3 3.3
5.0 6.3 6.4 6.4 6.4 6.5
1 11 33 45 35 12
mm. mm. mm. mm. mm. mm.
it has been shown by Leech and Sugar 5 and McLean6 that the use of corneoscleral sutures seems to decrease the incidence of wound rupture. At the time that the series of post operative cataract cases were being studied, it was believed that if wound rup ture followed violent contracture of the orbicularis muscle, elimination of the action of this muscle for a period of about seven days should prevent further rup ture. Such suspension of the function of the orbicularis power could be accom plished only by performing tenotomy of the muscle. This was done in 40 consecu tive private cases by one of us (H.S.G.). A wide canthotomy was made, followed by upward and downward incisions be neath the skin, cutting through the orbicu laris fibers at a point before their inser
Average Orbital Compressibility mm. mm. mm. mm. mm. mm.
tion into the orbital periosteum. One un pleasant feature of this method was the frequency with which hemorrhage from the external angular artery occurred, which often had to be clamped off. In none of these cases did wound rupture, even of the first degree, occur. The same procedure was followed in a series of 52 consecutive cases at the Illinois Eye and Ear Infirmary, carried out by the same operators and under the same conditions as in the previous series of 85 cases with out canthotomy or orbicularis tenotomy. In that series hyphema occurred in nine cases (17.3 percent). Iris prolapse oc curred in one other case. In these cases no relationship was found between the bulbar position and the incidence of post operative hyphema. The hyphema cases are shown in table 3. In three of these
TABLE 2 INSTANCES OF WOUND RUPTURE WITH HYPHEMA
Postoperative Day When Hyphema Was Noted Fourth First Seventh Second Second (prol.) First Ninth Third First Second First Second (prol.) First Range 1 to 9 days p-op. Average 2.7 days
Exophthalmometer Reading
Compressometer Units of Pressure Applied
18.5 mm. 10 mm. 18 mm. 17 mm. 15 mm. 15.5 mm. 19.5 mm. 17 mm. 19 mm. 14 mm. 17 mm. 17 mm. 17 mm. 10 to 19.5 mm. 16.5 mm.
7 6 6 6 6 6 6 7 6 '6 7 6 7 6 to 7 6.3
Orbital Compressibility 4 3 3 3.5 3 3 3 4 3.5 3 4 3 4 3 to 4 3.3
mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm.
430
HARRY S. GRADLE AND H. SAUL SUGAR TABLE 3 WOUND RUPTURE WITH HYPHEMA IN CASES WITH ORBICULARIS TENOTOMY
Postoperative Day When Hyphema Was Noted Sixth Second Third Sixth Sixth Eighth Fourth Sixth Sixth Range 2 to 8 days Average 5 .2 days
Exophthalmometer Reading
Compressometer Units of Pressure Applied
20 mm. 14 mm. 20.5 mm. 17 mm. 11 mm. 15 mm. 23.5 mm. 18 mm. 13 mm. 11 to 23.5 mm. 16.9 mm.
6 6 6 6 7 6.5 7 7 6 6 to 7 6.4
cases corneoscleral sutures had been used (two Verhoeff and one modified Liégard sutures). T h e only difference ob served between the two series of cases was the later appearance of the hyphema in the cases with orbicularis tenotomy. CONCLUSIONS
W e believe that rupture of the wound after operation for senile cataract is due to increased intraocular pressure brought about by forcible contracture of the orbi cularis a n d / o r the recti and oblique muscles. Compressibility of the eyeball within the orbit is approximately the same in all normal eyes, and hence is not to be regarded as a factor in wound rupture.
Vail, Derrick. Trans. Amer. Ophth. Soc, 1933, v. 32, p. 496. - Philps, S. A. Brit. Jour. Ophth., 1940, v. 24, p. 122. Duke-Elder, W. S. Jour. Physiol., 1931, v. 71, p. 1. 1 Gutman, A. Zeit. f. Augenh., 1927, v. 63, p. 136. 5 Leech, V. M., and Sugar, H. S. Arch, of Ophth., 1939, v. 21, 966. ' McLean, J. M. Arch, of Ophth., 1940, v. 23, p. 554. 3
3 3 3 3.5 4 3.5 3 3 3 3 to 4 3.2
mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm.
In the series of cases studied, the degree of bulbar proptosis made little difference in the end results, although it is probable that in instances of definite exophthalmos it would be an important factor in caus ing wound rupture. Tenotomy of the orbicularis as a means of preventing orbicularis action during the postoperative danger period gave ex cellent results in a series of 40 private cases, whereas in 52 clinic patients the results were approximately the same as in a series of nontenotomized cases. A further study in a larger series of cases will be made. 58 East Washington Street. Barnes General Hospital.
REFERENCES 1
Orbital Compressibility