Resection of the Optic 
Nerve. 
By L. WEBSTER FOX, M. D., 
PHILADELPHIA. 
FROM THE 
Medical and Surgical Reporter, 
February 7, 1891. [From the Medical and Surgical Reporter, 
February 7, 1891.] 
RESECTION OF THE OPTIC NERVE. 
BY L. WEBSTER FOX, M. D., 
PHILADELPHIA. 
The loss of an eye under any circumstances 
or conditions is a very serious affliction. 
The vacant stare and dull look of an arti- 
ficial eye can never compensate, for one 
which may be disfigured by a leucoma or 
partial atrophy, for even such eyes are pre- 
ferable to wearing glass ones, be they ever 
so well matched. No matter how smooth 
an artificial eye is polished, sooner or later 
the secretions corrode its surface and those 
irregular projections cause more irritation, 
and the result is more offensive secretions, 
which become dry and harden upon the sur- 
face of the eye, usually appearing as a hori- 
zontal band over the cornea. To morbid 
individuals, especially women, these results 
are, to say the least, disagreeable, and to the 
observer equally so. 
The question has often arisen, How can 
we best overcome the necessity for an enu- 
cleation. Eyeballs are removed, as a rule, 
fonthree indications: 
i. If wounded or cut in the ciliary region 
(the danger zone), to prevent sympathetic 
ophthalmia. 
2. If atrophied, to make room for an arti- 
ficial eye. 
3. For new growths (tumors). 4 
The first indication is the most important. 
If we can prevent sympathetic ophthalmia 
we also may save an eyeball; but by sav- 
ing the eyeball we do not necessarily pre- 
vent sympathetic ophthalmia. In the sec- 
ond case an atrophied eyeball is disfiguring 
and is removed for cosmetic purposes, and 
because it may be a hiding place for new 
bone development, which may remotely pro- 
duce sympathetic irritation. I have fre- 
quently removed a stump and found bone 
shells with edges as sharp as a splinter of 
glass. With such a foreign body irritating 
it, an optic nerve might readily be the focus 
of migratory ophthalmia. 
Where a tumor exists we have but one re- 
course-enucleation. 
At the October meeting of the Societe 
D' Ophtalmologie? of Paris, the question of 
resection or laceration of the optic nerve 
was discussed, especially by Drs. De Wecker, 
Chauvel, Gillet de Grandmont and others. 
Dr. De Wecker, who has had exceptional 
facilities for putting into practice the text 
of his teachings, made the following re- 
marks. 
" I propose to continue the campaign I 
have undertaken against the abuse of enu- 
cleation, and I firmly believe that by mak- 
ing more popular the simple resection of the 
optic nerve in cases where we have danger 
of migratory ophthalmia, no more eyes»will 
be taken out, except when they are the seat 
of a neoplasm (tumors). 
"If the transmission of migratory oph- 
thalmia by the optic nerve is confirmed (and 
1 Recueil D' Ophtalmologie, October, 1890. 5 
I am convinced of it), the simple resection 
of the nerve will afford a sure means of pre- 
venting it. Boucheron and Schoeler's 
method, which includes cutting the ciliary 
nerves, does not, however, answer the pur- 
pose. The only way to prove conclusively 
that resection of the optic nerve can take 
the place of enucleation is that a large num- 
ber of resections shall be made and the re- 
sults noted. The operation must also be 
made as simple as the operation for enucle- 
ation. If we were to follow the complicated 
operations as described by Schweigger or 
Pagenstecher it would certainly never be- 
come popular. 
" Being aware of the difficulties which be- 
set one, and fearing that in the midst of 
operation, by an unlucky cut of the scissors, 
a hemorrhage should follow, it occurred to 
me to forego the section of the nerve, which 
is the most difficult part of the operation, 
and simply to tear off the nerve near its op- 
tic entrance. This idea was suggested to 
me by the cases recorded, in which the eyes 
were torn out with the optic nerve attached, 
and also the savage custom of the Tyrolese 
wrestlers, who put eyes out by introducing 
their thumbs into the orbits on the temple 
side. I suppose that such displacement of 
the globe could only be effected after tear- 
ing off the nerve at its optic attachment. 
On a .recent visit to the Tyrol, a wrestler 
presented himself with his eyeball hanging 
on his cheek and asked whether the eye 
could be replaced and be useful to him. 
Being answered in the negative, he seized 
the eyeball, tore it off and flung it to the 
ground. My experiments upon the cadaver 6 
were made with a view to ascertain whether 
or not a nerve could be torn. With my 
double hook I have never been able to tear 
off the nerve at its entrance into the orbit, 
even when pulling with all my strength. All 
I could do was to sever the nerve by pull- 
ing with the hook; in other words, the hook 
cut its way through the nerve. On several 
occasions I succeeded in tearing the eyeball 
from the nerve, the vitreous humor escaping 
through the opening made by the head of 
the nerve disappearing. I also tried to tear 
the nerve off as it entered the orbital fora- 
men; but I signally failed in this also. We 
have a well-known case, in which a drunken 
man fell against a door, the key of which 
was projecting, and the eye thrust itself 
through the ring of the key, the nerve being 
completely severed. In another case, a horn 
of a cow drove the eye into the maxillary 
sinus. Here also the nerve was severed. 
In these instances the traction did not act 
directly and exclusively on the optic nerve, 
as in my experiments on the dead body. In 
the case of the intoxicated man who thrust 
his eye through the ring of the key, all the 
weight of his body exerted a traction on the 
whole funnel-shaped bundle of muscles of 
the eyeball. The traction pressed on their 
insertions around the passage of the optic 
nerve into the orbit, and tore them off from 
their insertion simultaneously with the 
sheath-to which they are attached. This 
is also the reason why we do not find the 
tearing off of the nerve isolated ; the inter- 
nal rectus being always detached in this sort 
of traumatism. We must therefore give up 
the combined operation of resection and 7 
tearing, in place of the simple resection. 
All that is left for us to do is to try to im- 
prove the operation of simple resection ; to 
make it always feasible and easy so as to 
supplant the repulsive enucleation." 
M. Chauvel who made some experiments 
upon the elongation of the optic nerve stated 
that he was never able to tear the nerve of 
the human eye, although he was able to do 
so in rabbits. 
M. Gillet de Grandmont corroborated Dr. 
De Wecker's statements, especially those re- 
lating to tearing the globe from the nerve, 
and related an instance in which a woman in 
a fit of melancholy, suddenly thrust her in- 
dex finger and thumb into her orbit. Her 
strength was so great that with her left hand 
she took hold of the eyeball, tore it off with 
three centimeters of the optic nerve, and 
threw it on an adjacent bed. This was the 
work of a few seconds. She made a similar 
attempt on the right eye, but the attendant 
seized her right hand, only, however, after the 
patient had succeeded in thrusting her index 
finger under the inferior muscles and had 
torn them from the globe. A severe hemor- 
rhage followed, no other complications arose, 
and in a few days she recovered the sight in 
her right eye. 
We miss very much in the foregoing re- 
marks a description of the exact way in 
which De Wecker, Grandmont and others 
perform resection of the nerve. 
A few years ago Mr. Brudnell Carter and 
Dr. T. Herbert Bickerton performed an op- 
eration for opening the sheath of the optic 
nerve in optic neuritis. Mr. Carter designed 
special instruments for this operation, and 8 
the difficulties were made easy for exposing 
the optic nerve. In performing this opera- 
tion, I found but little difficulty in follow- 
ing Carter's method. The one obstacle 
was, that the orbital fat would constantly get 
in the way. Dr. Shakespeare, who assisted 
at this operation, suggested a speculum shaped 
like Sims's uterine speculum. With this 
instrument the difficulties were overcome in 
a subsequent operation. 
If resection of the optic nerve can be 
performed with complete protection against 
sympathetic ophthalmia, it will be a boon 
to many unfortunates. The wearing of an 
artificial eye is as annoying as it is un- 
sightly. 
The details of the operation for resection 
are essentially as follows. The lids are sep- 
arated with the ordinary ophthalmostat; a 
vertical incision is made through the con- 
junctiva over the insertion of the external 
rectus muscle; the conjunctiva is dissected 
off as far back as the external canthus will 
permit. This exposes completely the mus- 
cle. Two silk threads are then passed 
through the muscle near its tendinous inser- 
tion. These threads will be required in a 
subsequent stage of the operation, to unite 
the detached muscle to the eyeball. The 
muscle is then cut and drawn to the temple 
side. This exposes the globe. With curved 
scissors, all tissue is then separated from the 
eyeball. The optic nerve is found by pass- 
ing a hook-which is nothing more than a 
strabismus hook bent at a right angle. This 
hook brings forward the nerve, and then the 
retractor is passed downwards until it meets 
the nerve, and is then passed down and out, 9 
keeping the adipose tissue out of the way. 
A second bent hook is inserted under the 
optic nerve, and also pressed backward. A 
certain portion of the nerve becomes ex- 
posed, and with a delicate flat forceps the 
nerve is grasped and held firmly. This is to 
prevent hemorrhage from the ophthalmic vein 
and artery (central) after the cut with the 
scissors. The eyeball is rotated forward, so 
that the non-severed nerve becomes exposed 
and a small piece of its bulbar end is cut 
off. By keeping pressure on the orbital end 
of the nerve for a few minutes, all danger 
of hemorrhage is aborted. The eyeball is 
then rotated into place, and the external 
muscle is re-adjusted. Over this the con- 
junctiva is replaced, and it is held in posi- 
tion with black silk, which may be removed 
in three days. Antiphlogistic dressings are 
applied day and night for several days. Very 
little reaction follows, and in a week or ten 
days the eye has assumed its normal appear- 
ance, with no disfigurement, and the action 
of the muscle is complete.