ONE THOUSAND OPHTHALMIC

OPERATIONS.1

BY L. WEBSTER FOX, A.M., M.D., Professor of Ophthalmology, Medico-Chirurgical College, Philadelphia, Pa.

In my lectures I lay special importance on the interrogation of all cataract-patients presenting themselves for an operation as to their general habits and family history, to a careful examination of the urine, restricting a meat-diet and increasing a vegetable one, also placing the patient, one week before the operation, on mixed treat

THESE operations were performed as they presented themselves from time to time in the out-patient department of the Medico-Chirurgical Hospital. The great-ment, and paying particular attention to

est care was given in the selection of such cases as our judgment dictated would prove beneficial to the patient. The patients were placed upon preliminary treatment, and attention given to the hygiene of the body, careful sterilization of instruments and bandages, and especial attention to the after-treatment. In such operations as cataract, iridectomy for chronic and acute glaucoma, chronic iritis, iridectomies for artificial pupils, and capsulotomies, especial attention was given to preliminary treatment, as small doses of hydrargyrum and salicylate of strontium,

as well as attention to the facial and

gen

bathing both eyes with a boric solution containing sulphocarbolate of zinc, examining the eyelashes and particularly the nasal cavities. If any catarrhal affections are found in those cavities, it is of paramount. importance that they receive the proper treatment before the operation is performed. The day before the operation the patient is given a warm bath, saline purgatives, kept in bed, and his face washed with Castile soap and water; then washing the skin around the eye to be operated on with ether; following this again a 1 to 2000 These solution of corrosive sublimate. precautions are repeated in all cases where the cornea of the eyeball is incised, and just before the incision additional precaution is taken by dropping on the cornea 1 or 2 drops of 1 to 2000 corrosive-subli

A

eral bathing. I consider these particulars as essential to the success of the operations designated. To such operations as skingrafting, strabismus, and lacrymal operations the above care is not quite so impor-mate solution. The instruments and bandtant. The success of these operations ages are always sterilized. nevertheless depends upon operative skill and carrying out of the technique of each operation with judgment. No fixed method was adopted; each case was a law unto itself. The greatest care was exercised in carrying out the after-treatment from day to day; the hygienic surroundings were the best that an up-to-date hospital could afford, and the results obtained commensurate to the great care and attention bestowed upon these patients.

Testing for Good Light-projection. satisfactory test can be made with a lighted. candle in a dark room. The patient is asked to fix the eye, the candle is moved about in different quadrants of the visual field, and, if the patient locates it promptly, we may assume that the retina is in good condition, and that, if no inflammatory reaction follows the operation, a favorable result may be anticipated.

Another test which may be applied is to see whether the irides respond promptly to light. This is done as follows: Both eyes are covered by the hands (this places both eyes in a darkened chamber); the pupils dilate; one hand is suddenly removed from the cataractous eye, and the iris, which is dilated, suddenly contracts

if the retina appreciates light. In such sary to remove part of the soft lens by cases a favorable result may be anticipated. | Teale's method: that is, to make an in

METHOD OF OPERATION.

In childhood or adults up to thirty years of age the needle operation is performed. Discission (Needle).—A puncture is made with a Bowman stop-needle in the lower and outer quadrant of the cornea, midway between the center of the pupil and the corneo-scleral margin. Two sweeps of the point of the needle are made in the vertical and two in the horizontal directions, to lacerate the capsule of the lens. This causes rapid breaking down of the cataract and allows its particles, which become separated, to pass into the anterior chamber and later to become absorbed.

One thing I must repeat, and that is: be careful not to do too much in the stirring up of the lens. Absorption takes place in from three to nine weeks. Sometimes a secondary operation must be performed.

We are indebted to the late Dr. J. C. Saunders, the founder of Moorfields Eye Hospital (1804), London, for having suggested the operation. He also invented the delicate needle with which he so successfully operated. Sir William Bowman, many years afterward, modified the shape of this needle by having a shoulder placed on it. Nearly all ophthalmic surgeons use it, and it is now known as Bowman's stop-needle. When the posterior capsule remains intact and obscures central vision a secondary operation must be performed,capsulotomy. I prefer making an incision in the cornea with a broad needle through the capsule in the vertical direction, then passing De-Wecker scissors through the corneal opening, allowing the blades to separate, one blade to pass behind the capsule, the second to the front horizontally, and with one snip cut the capsule in two. This operation is most successful.

cision into the anterior chamber and suck out part of the lens-substance with a specially-devised instrument.

The after-treatment is the constant application of iced pledgets of cotton saturated in 1 to 2000 corrosive-sublimate solution changed frequently-every halfhour-and the iris well dilated with atropia solution, 1 grain to fōiij, three times daily.

To

Corneal Incision for Senile Cataract (118 Cases).-To-day an incision is made in the cornea; part of the iris removed or not, according to the will of the operator; and the cataract pressed out through the corneal wound. There are many different methods, all more or less similar, and all having the same object in view. Daviel, who in 1745 made the first corneal incision, are we indebted for the operation upon which all subsequent methods are based. I follow, in part, a method suggested by Professor Snellen,-that is, to make a semiflap incision in the cornea, inclining the cutting edge of the knife backward as I approach the apex of the cornea, and make a large incision in the conjunctiva, which gives me a conjunctival flap. An iridectomy is also performed. rupturing the capsule of the lens I use Jaeger's cystotome, it being less dangerous than the ordinary straight cystotome commonly used.

In

The delivery of the cataract brought about by slight pressure upon the lower half of the cornea, tilting the lens forward, accentuating the pressure with the Daviel spoon as the lens makes its appearance in the wound. Great care must be taken to see that all cortical matter is cleaned out of the anterior chamber and that the iris does not become incarcerated in the lips of the wound. The conjunctival flap is then The only complication which may arise stroked into its place and the eye bandis the too rapid swelling of the lens. This aged. The after-dressing in cataract operpressure on the ciliary bodies may cause ations is a very important factor in its cyclitis. When it does, it may be neces-successful termination. Every ophthalmic

The leucoma of the cornea which necessitate such operations are the sequelæ of ulcers of the cornea and traumatism. The incision is made in the corneo-scleral | tection. margin opposite the clear cornea with a broad keratome well into the anterior

OPERATION.

The eyelids are separated with the ophthalmostat. The conjunctiva is dis

sected off from its corneo-scleral attachment back to about the equator of the eyeball, the muscles also being separated; then the cornea is excised. This is best done with a large Beer knife, as if performing a flap-operation for cataract. The lower half of the cornea is removed with curved scissors, and the contents of the globe are taken out with a small scoop devised for the purpose.

Great care is necessary to remove the ciliary bodies, choroid, and the head of the optic nerve, leaving a clean, white sclera.

I pack the scleral cavity with sterilized gauze. After waiting a few minutes this. is removed, and the contents of the scleral cavity are again thoroughly irrigated with antiseptic fluid and again packed. A sterilized glass or gold globe, of whatever size is best suited to the case, is then inserted with a specially-devised instrument. The sclera is split vertically so that the edges may be drawn together and held by stitches of No. 4 black silk, using large needles, completely hiding the ball. The orbit is again thoroughly irrigated with the 1 to 1000 hydrargyrum-corrosive solution and the socket packed with bismuth-formiciodide powder. The bandages are not disturbed for three days. During this time the patient may complain of considerable pain. It is better to control the pain with an opiate than to disturb the bandages. This constant pressure keeps down the conjunctival swelling which I formerly experienced, and was a factor, I believe, in causing the silk threads to cut their way out and ultimately to allow the glass or gold ball to escape.

As a rule, the conjunctival sutures are removed in four or five days. It is important that both eyes are kept bandaged for at least six days. By allowing the liberty of one, too much rotation of the eye is permitted and, as a consequence, the antago

nistic muscles of the operated eye pull apart, and there is great pressure brought against the sutures, which are liable to be

torn out.

From the large number of operations now under observation, and no unfavorable ones reported, it may be considered a very safe one, and if we have in evisceration a method equally as safe as in enucleation, why not give the patient the advantage of the new method (Mules)?

IMPLANTATION OF A GLASS OR GOLD BALL
IN THE ORBIT FOR THE BETTER SUPPORT
OF AN ARTIFICIAL EYE IMMEDIATELY
AFTER ENUCLEATION (90 CASES).

This must not be confused with the

Mules operation (evisceration). In the last one hundred cases where I might have performed a Mules or enucleation I followed out the simple implantation: that is, inserting a gold or glass ball into the cavity made by the removal of the eyeball.

I am following up this series of cases most carefully: First, to compare it with the advantages claimed for the Mules operation. Second, to establish a substitute which will overcome the prejudice to the Mules method.

There is an element of doubt existing to-day in the minds of many ophthalmic surgeons that in the evisceration (Mules) operation, owing to the sclerotic coat with the post-ciliary and optic nerves being still joined to the fellow-eye, there remains great danger from sympathetic ophthalmia. I hope to prove that in this operation (simple implantation) we are secure from this probability and at the same time have a substitute which gives all the advantages of the Mules operation and none of its dangers.

Mr. Adams Frost, of London, in 1886 devised the insertion of a glass ball immediately after enucleation of the eyeball. His method was as follows: After incising the conjunctiva all around the cornea each rectus was raised on a hook, seized with

forceps, severed from its attachments, and | to wear an artificial eye. The success of secured by a ligature; the eyeball was then this operation is due to the conformer and removed and the glass ball introduced. the location of the incision in the orbital The tendons were next united across the tissues. Failure is now almost unknown ball by means of the sutures previously by this method. passed through them, and, finally, the conjunctiva was brought together.

Out of seven cases Mr. Frost could only claim one successful operation. Mr. William Lang, a short time afterward, followed out a suggestion made to him by Mr. Gray, of Moorfields, to excise the eye and place the artificial globe in Tenon's capsule. Mr. Lang first brought Tenon's capsule together and then sewed up the conjunctiva. Mr. Lang was not successful, and gave up the operation on account of his failures. I have now perfected this operation so that it has become practically successful in every case. My method is as follows: Immediately after the enucleation I insert a glass or gold sphere, bring the edges of the wound together with six or eight silk sutures longitudinally, then I give support with four sutures, two above and two below, opposite each other, so that the swelling of the conjunctiva which follows presses on these sutures and thus the pressure is taken off the primal suture along the edges of the wound; over all is placed a conformer, which is shaped like an artificial eye with a circular opening. This metal conformer keeps the ball in place and prevents it coming forward. An antiseptic powder, bismuth formic iodide (Mulford's), is freely dusted over it, the lids closed, and both eyes bandaged and kept so for forty-eight hours, when the eye is dressed and the conformer taken out. The stitches are removed on the fourth or fifth day. This method now makes this operation successful in almost every case (98 per cent.).

THE RADICAL CURE OF GRANULAR LIDS (50 CASES).

The routine practice was formerly to use caustics, powerful astringents, or the actual cautery, all to the same end: that is to get rid of the granulations and render smooth the inner surface of the eyelids. According to Müttermilch, it takes a case of granular lids ten years to cure itself, and about the same time, according to this distinguished author, if the ordinary everyday treatment is also applied. It was only after Manolescu, of Bucharest, had the courage to inaugurate and give to the world a radical treatment that we are now able to cure granular lids of the worst type in a few weeks. During a recent visit to Paris I saw the operation put to a practical test by Dr. Darrier. I also had the opportunity of examining a number of patients upon whom the operation had been performed months before with the most gratifying results. The technique which I follow today differs in only one procedure from that suggested by Darrier, and that is I add the Burow operation to it.

Two instruments have been especially devised for this operation: First, a catch dressing-forceps, having on the male blade three pins, which, when the instrument is closed, pass through corresponding openings in the opposing, or female, blade; these forceps grasp the eyelid along its margin, and is used in rolling the eyelid upon itself, rolling it up until the retrotarsal fold is exposed; then, with a threebladed scalpel the exposed part is thorI have elsewhere described my latest oughly scarified horizontally and vertically. operation for the implantation of a glass The scarified surface is thoroughly or gold ball in the orbit where the eye has scrubbed with a tooth-brush saturated been previously removed, where the tissues with a solution of hydrargyrum bichloride, of the orbit, as well as the lids, have con- 1 to 500. Another part of the lid is then. tracted, and where it is almost impossible unrolled, and the scarifying, scrubbing,