OPERATIONS PERFORMED IN THE EYE DEPARTMENT OF THE MEDICO- CHIRURGICAL HOSPITAL. -BY-. L. WEBSTER FOX, M. D., Professor of Ophthalmology in the Medico-Chirurgical College. Etc. PHILADELPHIA, PA. Reprint /rowi The Ophthalmic Record, Vol. V.. No. 12. OPERATIONS PERFORMED IN THE EYE DEPARTMENT OF THE MEDICO-CHIRURGICAL HOSPITAL. L. WEBSTER FOX. M.D. Professor of Ophthalmology in the Medico-Chirurgical College, etc., Philadelphia, Pa. During the year ending 1895, 2,666 patients received treat- ment in the ophthalmic department of the hospital.* Three hundred and three operations were performed, and in this arti- cle I shall briefly describe the methods, technique and treat- ment followed in these cases. No fixed method was adopted, as each case was a law unto itself, so I tried to adapt such lines of procedure as in my judgment was deemed best for each individual patient. 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 were commensurate to the great care and attention bestowed upon these patients. CATARACT OPERATIONS. Twenty-seven operations were performed, including in this number three needle operations on infants. PRELIMINARY TREATMENT ESSENTIAL IN CATARACT OPERATIONS. I deem it of the greatest importance to interrogate all cat- aract patients presenting themselves for an operation, as to their general habits and family history, and to make a care- ful examination of the urine, restricting meat diet and in- 'See appendix for classification of operations. Operations Performed on the Eye. creasing a vegetable one; also placing the patient, one week before the operation, on mixed treatment, and paying partic- ular attention to bathing both eyes with a boracic solution containing sulpho-carbolate of zinc, examining the eyelashes and particularly the nasal cavities. If any catarrhal affec- tions are found in these cavities it is of paramount import- ance that they receive the proper treatment before the oper- ation is performed. The day before the operation the patient is given a warm bath, a saline purgative, kept in bed, and his face washed with castile soap and water, then washing the skin around the eye to be operated upon with ether, fol- lowing this again with a 1-5000 solution of corrosive subli- mate, after a German method (Schweigger). These precau- tions are repeated in all cases where the cornea of eyeball is incised, and just before the incision additional precaution is taken by dropping on the cornea one or two drops of 1-5000 corrosive sublimate solution. The instruments are sterilized, and all fluids, such as atropia, etc., are boiled in a Llewellyn flask. METHOD OF OPERATION. In childhood or adults up to thirty years of age the needle operation was performed. The cornea being divided into quadrants, the lower and outer quadrant being again sub- divided and a Bowman stop-needle inserted midway between the centre of the cornea and scleral margin, the lens capsule torn by an upward and downward, as w7ell as horizontal, move- ment of the point of the needle, the central anterior portion of L. Webster Fox, M.D. 3 the lens broken up, being careful, however, not to disturb too much of the lens substance. This avoids too rapid swell- ing of the lens, and secondary results, such as cyclitis or even iritis, developing. The eye is carefully prepared for the op- eration similar to that followed in senile cases. The after treatment is also the same. In adults I follow, as near as possible, the Moorfields' incision. The eye is held by a grasp of conjunctiva, in the fixation forceps, at the scleral mar- gin of the cornea down and opposite the point of puncture, which last is to be one or two mm. from the upper and outer quadrant and three mm. below the horizontal line, passing through the corneo-scleral puncture. The blade (Critchett's knife) is directed toward the tip of the patient's nose, and enters parallel with the iris. In this direction it is pushed forward till the point of the knife has reached the centre or a point but little past the centre of the anterior chamber, when the hand is dropped and the blade pointed towards the place of counter puncture, directly opposite and similarly located to the point of puncture. The blade is pushed on through the tissues till the end of the cutting edge towards the handle is at the lips of the puncture. The edge of the knife is now turned a little forward, so that it shall come out in the cor- nea at its upper margin; this is brought about by an easy and moderately rapid sweep, combined with a slight eleva- tion and circular movement in withdrawing the hand. If too much tension be not given the muscles of the hand, the cut is finished by this procedure. If the hand suddenly grows rigid it will be impossible to finish the cut, and a sawing mo- tion must be made. To the novice this will frequently hap- pen, but should be corrected as soon as possible, as the ser- rated edge of a wound which always follows this see-sawing makes an entrance for pathogenic germs and the wound does not close up as rapidly or as firmly as by the one sweep. The iridectomy forceps are now entered, closed, and advanced till 4 Operations Performed on the Eye. their points are opposite the pupillary edge of the iris, when the forceps are allowed to open and grasp the iris. This is drawn out of the lips of the wound and slightly advanced till it is rendered taut; the lower blade of a DeWecker scis- sors are now gently slipped under the projecting iris and held horizontally and firmly in place, w'hile the upper blade is made to descend and sever the iris with one cut. Tn this w ay the ideal key-hole iridectomy is obtained. To the rupturing of the capsule with Jager's cystotome I wish to call especial attention. These delicate hooks are at right angles to the handle; they are made to conform to the anterior portion of the lens. The point is inserted into the anterior chamber, posterior to the iris and hooked into the capsule, by a gentle upward movement of the hand, the lens is rotated about its antero-posterior axis and thus torn from its zonular attachment, the capsule will only rupture after the insertion of the hook is brought to the surface of the wound and the instrument is drawn horizontally along the edges of the primal incision. By this rotary movement of the cataract the posterior capsule is torn or the lens is de- livered with the capsule, doing away with the secondary op- eration. When I find that the posterior capsule remains in- tact and is visible I rupture it at once with the cystotome. When the capsule is somewhat thickened I find that Jager s hook will not rupture the capsule as easily as the straight cystotome of Daviel. It will rotate the lens as I have de- scribed above, and the advantage claimed for it is that wre have fewer secondary operations to perform. Tf the capsule is thin it tears very easily, and by making a rectangular in- cision we can tear off almost the whole of the anterior cap- sule. The lens is then easily delivered with a Daviel's spoon. Especial care must be noted that no cortical matter remains behind, and that the edges of the iris are freed from the lips of the corneal wound. L. Webster Fo.c, M.D. 5 Figure 1. The after-dressing in cataract operations is a very import- ant factor towards its successful termination, nearly every ophthalmic surgeon having his own peculiar way of applying a dressing to an eyeball, some following the "rational meth- od," devised by Michel and Chisolm, or the Von Graefe or modifications of the same or both. The preparation of the dressings always takes considerable time, and their adjust- ment is not always satisfactory. *The eye-pads now used in the hospital are of two kinds, black and white, and are made as follows: First, a lining of antiseptic gauze, then a layer of absorbent cotton, next the black linen sheet, and lastly the white gauze for the external covering. The smaller pads, Fig. 1, fit closely over the eyeballs (lids closed), the material being identical with that of the larger ones. The size of the larger pads, Fig. 2, is six and a half by three and a half inches. Both large and small pads are shaped and cut by a steel die, so as to assure a uniformity of size and thickness. They fit comfortably and evenly to the face, being held in place by adhesive strips. There are still a few ophthalmic surgeons who think it quite unnecessary to take all these precautions, but happily the number is growing less year by year, and the percentage of successful operations growing higher and higher. The results of thus carrying out the details of the technique was very satis- Made by Seabury & Johnson. 6 Operations Performed on the Eye. factory, no losses from panophthalmitis and but one case of Figure 2. iritis followed. This was a patient of hemorrhagic diathesis. There was considerable bleeding from the incised iris, the anterior chamber filled with blood and kept oozing for two days. At the end of the third day the anterior chamber com- menced to clear up, but subsequent iritis closed the pupil. An iridotomy later gave the patient useful vision. The visual corrections varied from 20-100 to 20-20. In those cases which had the lowered visual acuity, it was found that we had to deal with intra ocular disturbances, such as vitreous opacities, retino-choroiditis, etc. GLAUCOMA. Four acute and twenty chronic cases. In the whole domain of ophthalmic surgery I have found this the most difficult operation to perform and gain a permanent benefit. In acute cases we do get immediate relief, but in chronic cases it is not so successful. The operation which I follow is that taught by the late Prof. Mauthner. The incision well into the sclerotic with a broad keratome, three to four mm. from the corneo scleral margin and removing, at least, one-sixth of the circumference of the iris. Instead of cutting the iris with one snip of the DeWecker's, three cuts are made-this gives a broad iridec- L. Webster Fox, M.D. 7 tomy and the edges of the iris do not become incarcerated in the lips of the wound. The same precautions are taken with the cleanliness of the eye and instruments as in cataract opera- tions, and dressings are also the same. ARTIFICIAL PUPILS. Ten cases. The leucomas of the cornea which necessitated these operations were the sequelae of ulcers of the cornea and traumatism. IRIDOTOMY. Eight cases. These closed pupils followed cataract opera- tions or injuries. The method followed was with a broad needle cut the cornea two or three mm. from its scleral margin, temporal side, in the vertical direction, and drive the needle through the iris into the vitreous chamber. In withdrawing the needle (which is a spear-shaped instrument, two mm. wide at its greatest width), we make a slight upward incision in the cornea, forming an opening four to five mm. long, large enough to admit the closed blades of a DeWecker's scissor's into the anterior chamber, and as soon as the points of this instrument have entered they are allowed to open, so that the second blade enters the opening in the iris and is allowed to pass behind it, while the other blade passes in front of the iris in the anterior chamber; by making one cut a well-defined opening is made. In some cases where the fibers of the iris have lost their resil- iency it may become necessary to make an upward or downward cut as indicated. This same operation is also performed where the thickened capsule remains after a cataract operation. The capsule is easily removed with a Tyrrel's hook or by an iris forceps, if necessary. I infinitely prefer it to the old-fashioned way of needling the capsule. ENUCLEATION AND MULES OPERATION EVISCERATION. The enucleations were after the Vienna method, that is, completely denuding the sclerotic of all conjunctival and mus- 8 Operations Performed on the Eye. cular attachments, and after taking out the eyeball the eyelids are pressed into the orbital cavity with a ball of sterilized lint, and held in place by a pressure bandage for twenty-four hours. The method above described gives an excellent orbit for an artificial eye. In this operation the edges of the conjunctiva are never stitched with sutures. Evisceration (Mules) was performed in twelve cases, as they have been described elsewhere.* I shall simply refer to this method to say that it is the ideal operation for the proper adjustment of an artificial eye, and now I do not remove an eye- ball except under extraordinary circumstances. The details of the evisceration operation are carried out under ether, as follows: The eye is thoroughly irrigated with a lotion, which I shall call formula No. 1, to designate it from almost the same formula for sterilizing instruments. FORMULA No. 1.-Irrigating Fluid. Hydrarg. bichlor 1-50 grains. Zinci sulphocarbolatis 30 grains. Aq. menth pip 2 drachms. Aq. camph., aq. destil., (aa.) 2 ounces. M. ft. Sol. Used hot. The same formula is used for instruments without the hydrargyrum. The eyelids are separated with the ophthalmostat. The conjunctiva is dissected from its corneo scleral attachment, back to about the equator of the eyeball, no attention being- paid to the cutting of the muscles, and they are separated from the eyeball in every instance, uniting again in the process of healing. Then the cornea is excised, this being best done with a large Beer's knife, as in performing a Hap operation for cata- ract; the lower half of the cornea is then removed with curved scissors, and the contents of the globe are taken out with a small scoop (Fig. 3) devised for the purpose. See "Codex Medicos" and '-.Medical News." L. Webster Fox, M.D. 9 Figure 3. Great care is necessary to remove the ciliary bodies, choroid and the head of the optic nerve, leaving a clean white sclera. Mr. Carter has devised a rubber bulb, w hich is inserted into the scleral cavity and inflated with air to produce pressure on the central artery, preventing hemorrhage. As this application has not been a success with me 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. Figure 4. A sterilized glass globe (Fig. 5), which is best suited to the case, is then inserted with a specially devised instrument (Fig. 4). The sclera is split so that the edges may be drawn together and held by stitches of No. 4 black silk, using large needles, thus completely hiding the glass ball. The orbit is again thoroughly irrigated with the hot solution, the palpebral space packed with sterilized cotton, saturated with lotion No. 2. and this dressing is kept wet day and night for twenty-four hours, when the cavity is again bathed with hot water and fresh dressings applied, continuously saturated with the lotion, over which is bound a sterilized bandage. Figure 5. 10 Operations Performed on the Eye FORMULA NO 2. Zinci chlor 10 graine. Liq. plumbi subacetatis 2 drachms. Tinct. opii Tinct. belladon, (aa). . . . Iss drachms. Aq. camph. Aq. des til, (aa) q.s. ad 4 ounces. M. ft. Sol. Apply cold or iced. At the end of twenty-four hours the upper eyelid is some- what swollen, puffy and oedematous, but the tumefaction gradually disappears. As a rule the conjunctival sutures are not removed under six to ten 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. As a sequence, the antagonistic muscles of the operated eye pull apart and there is great pressure against the sutures, which are liable to be torn out. Up to the present writing I have performed thirty opera- tions and have had but three mishaps, the glass ball coming out on account of faulty stitching of the sclerotic coat. In the first case the catgut gave way and in two others the silk was too fine and broke before the cicatrical adhesions were formed. Both Mules and Bickerton have had cases where the glass balls came out. THE SURGICAL TREATMENT OF GRANULAL LIDS. The modified grattage operation was followed. When in Paris in 1891 I saw it put to a practical test by Dr. Darier, and I also had the opportunity of examining a number of patients upon whom the operation had been performed with gratifying results. Figure 6. L. Webster Fox, M.D. 11 Two instruments have been specially devised for the opera- tion. Fig. 6. A catch dressings forceps having on the male blade three pins, which, when the instrument is closed, pass through the corresponding openings in the opposing or female blade; these points pierce the eyelid, thus preventing slipping when complete eversion of the upper lid is made. Fig. 7. The second instrument is a tri-bladed scarificator Figure 7. or scalpel; the outside blades are jointed so that they may be easily turned when being cleaned. They are securely held in place in a platinum handle, and make parallel incisions. The details of the operation are as follows: The upper eyelid is grasped by the forceps, along its margin, then turning the edge upon itself the lid is rolled up until the retrotarsal fold is brought out. The exposed part is now thoroughly scari- fied with the three-blade scapel, not only horizontally, but vertically. The granular tissue is then scrubbed with a tooth brush, the brush having been steeped in a corrosive sublimate solution 1 to 500 just before using. Immediately after the grattage, the part is washed with the 1 to 500 solution. Another part of the lid is unrolled and the scarifying, scrubbing and washing repeated, and in like manner the whole of the eyelid. The lower lid is then similarly treated, and if necessary, the operation is extended to the other eye. If extensive pannus of the cornea exists, peritomy may be per- formed. In 1883, I hastened the cure by eversion of the upper lid and excising the granulations with the curved scissors and scraping the parts with a scoop and followed this operation by cutting through the cartilage from the inner to the outer canthus; in other words, I followed the scraping operation by a 12 Operations Performed on the Etje. Burow incision.* This relieves the friction of the lid upon the globe by allowing the tissues of the lid to elongate. There is very little reaction in this apparent harsh treat- ment. The patient is put to bed and a lotion (formula No. 2), applied. The eye pads are kept saturated for two or three days, and the results obtained, when the operation is carried out properly, are exceedingly gratifying. It is rarely that the operation must be performed more than once. The French method is to turn the eyelid after twenty-four hours and apply to the conjunctival surface again the 1 to 500 solution of sublimate. In my experience it is very painful and is not necessary. The constant application of the antiphlogistic lotion does better. EPIPHORA. LACHRYMAL ABSCESS. Thirteen cases. Treatment: Local applications are only palliative measures. When epiphora exists, due to a narrow- ing of the puncta, relief may be obtained by dilating, with a fine-pointed probe; when, however, one is dealing with a stric- ture or an abscess of the canal, more radical measures must be applied. Slit up the canal with a Weber's knife and follow this by passing a good-sized probe through the canal, and then insert a silver style. The slitting of the canal and passing the knife downward is apparently a simple operation, but still one not free from danger-false passages are easily made, or the knife may break by wedging it within the bony canal. In cases where there is pronounced swelling and edema of the lids, it is better to use the antiphlogistic lotion for sev- eral days before opening the canal with the knife. If the ab- scess has "pointed," Petit's method of opening should be fol- lowed, i. e., incising the abscess and passing the knife into the canal below the lachrymal sac. "See Fox and Gould Diseases of the Eye. Second Edition, page 85. L. Webster Fox, M D. 13 STRABISMUS. SQUINTS. Convergent strabismus. Eighty-six operations were per- formed. The method followed was. first, to place the patient under a mydriatic, and correct the ametropia, making an allow- ance for the full or partial correction according to the degree. The rotation of the eyeballs being noted, etc., then a complete or partial tenotomy is performed, as indicated. Under cocaine a vertical incision is made over the insertion of the tendon of the internal rectus. The conjunctiva is drawn away and with the points of the scissors snipping Tenon's capsule thus expos- ing the muscle. A hook is inserted under the muscle, which is gently raised and as it is drawn away from the eyeball one blade of the scissors inserted underneath, the second blade to the outside of the tendon, and with one or two cuts the muscle is separated from the eyeball. Only one eye is operated upon at one sitting. It may be necessary also to perform a partial tenotomy of the superior rectus when the squint is more than four lines. I do not operate on children under ten years of age. Divergent squint Nineteen operations. This was a very disappointing operation to the older surgeons and a very tedi- ous one to the present day surgeon. Since its introduction by Prof. Guerin it has undergone various modifications at the hands of Von Graefe, Critchett, Bowman, Knapp and others. For a moderate degree of divergence I prefer snipping the external rectus and advancing conjunctiva and Tenon's capsule This is best done by taking out an oval piece of conjunctiva and tenons capsule (DeWecker's operation) with a T-shaped forceps and then uniting the edges of those tissues together. Tn the pronounced cases I now follow the operation sug- gested by Richard Williams, of Liverpool. "An incision is made in the conjunctiva and subconjunctival tissue over the tendon of the internal rectus, extending from near the margin of the cornea for about half an inch towards the inner canthus. The edges of this incision being separated and an aperture having been made in the capsule, the strabismus hook is in- 14 Operations Performed on the Eye. serted under the tendon in the usual way, and then confided to an assistant; a curved needle, armed with a suitable silk thread, is then inserted in the conjunctiva near the margin of the cornea and carried between the sclerotic and conjunc- tiva towards the muscle behind the hook. It is then passed through the tendon from edge to edge at right angles to the course of its fibre, and brought out at the opposite side of the conjunctival wound. The edge of the conjunctiva at this side of the incision is now raised with a pair of forceps, the needle is insinuated between it and the sclerotic, and brought out near the margin of the cornea at the point corresponding to the point of entrance. At this juncture, the external rectus may be divided or not, according to the re- quirements of each individual case. This point having been disposed of, the tendon of the internal rectus is divided at a safe distance from the ligature and the hook is removed. By now tying the two ends of the loop together, the margin of the cornea is brought into opposition with the cut end of the ten- don and the eye brought into a position of more or less squint. Finally, the edges of the conjunctival incision are brought together by means of a fine suture." According to Williams, and I have been able to confirm this, the advantages claimed for the operation are (1) that it is much shorter and simpler than the usual method; (2) that by passing the ligature in the manner described, a very firm hold is obtained, both of the tendon and of the conjunctiva, which is sometimes apt to tear; (3) that no anaesthetic is finally required. PTOSIS. Two cases. Prof. Pauas' method followed and splendid suc- cess obtained. TATTOOING. Six cases. The operations were performed for cosmetic pur- poses and they were successful. I use the four-needle prick suggested by DeWecker. The success of these operations lie in using plenty of India ink. One disappointment which takes L. Webster Fox, M.D. 15 place is that the ink fades away after a certain time. This is not the case if the ink is of the consistency of paste when applied to the leucoma of the cornea and thoroughly driven into the tissues by the needles. PERITOMY. Eleven cases. Operation: A complete circular band of con- junctiva is dissected around the cornea-one centimetre in width. When the pannus is pronounced, I make a circular incision of the corneal blood vessels with a Beer's knife. The results obtained are very satisfactory and only in few cases is it necessary to repeat this latter operation. PTERYGIUM. Five cases. The pterygium is always transplanted. This is done as follows: An incision is made in the conjunctiva above and below the growth, along its borders from the cornea to the caruncle. The conjunctiva slightly dissected above, but very extensively below the growth, making a pocket which ex- tends to the insertion of the inferior rectus muscle. The pterygium is then separated from the eyeball with scissors, leaving, however, the corneal attachment intact, and then raised, and a needle (two needles are threaded on one strand of silk) is passed through the corneal end of the pterygium from the upper side downwards; the second needle is passed in like manner, but brought out upwards, leaving enough tissue between the two threads that will not cut through; with the strabismus hook the pterygium is separated from its corneal attachment (Prince), and is then turned downward into the cul-de-sac, the needles, one at a time, passed through the con- junctiva over the insertion of the inferior rectus muscle, bring- ing the head of the growth almost in contact with the inferior muscle, to which it unites, being held in place by the silk thread, which is tied in a knot. This brings the raw surfaces of the pterygium against the raw surfaces of the eyeball. The edges of the conjunctiva are brought together over the pterygium and while there is some puckering of tissue in the 16 Operations Performed on the Eye. caruncular space, it usually disappears, making a successful operation. I have only attempted in a brief way to give a general idea of my surgical procedures. In many instances I was obliged to apply such methods as the exigencies of the case required, but in the main I have followed the lines as described above. Tn the minor operations the every day practice was adopted. During the last six months I have restricted my operations in certain lines and expanded in others. APPENDIX. Anchyloblepharon 1 Advancement muscle 19 Burows 12 Bowman's with style 3 Cataract27 Curetting ulcer of the cornea 1 Capsulotomy 2 Enucleation Grattage 12 Glaucoma, acute 1 Hordeolum 3 Iridotomy 8 Iridectomy30 Lachrymal obstruction 4 Lachrymal abscess 0 Mules' operation, Evisceration 13 Pterygium 5 PeritomyH Ptosis 2 Paracentesis of cornea 2 Removal of proud flesh after Mules 1 Removal of scar 1 Removal of foreign body from eye 20 Removal of granulation after tenotomy 1 Removel of tumor from lid 1 Sclerotomy 3 Saemisch operation 1 Tarsal cyst 8 Tenotomy86 Tattooing of cornea 6 Stretching of lids 2 Symblepharon 1 Operations performed303 1304 Walnut street. Philadelphia. Pa.