OPHTHALMIC SURGERY 
MELLER OPHTHALMIC SURGERY 
A Handbook of the Surgical Operations on the Eyeball 
and Its Appendages as Practised at the I. Eye 
Clinic, University of Vienna 
BY 
DR. JOSEF MELLER 
«#> 
CLINICAL PROFESSOR OF OPHTHALMOLOGY, I. EYE CLINIC, UNIVERSITY OF VIENNA 
EDITED BY 
DR. WILLIAM M. SWEET 
CLINICAL PROFESSOR OF OPHTHALMOLOGY, JEFFERSON MEDICAL COLLEGE; ATTENDING OPHTHAL- 
MOLOGIST, JEFFERSON HOSPITAL; CONSULTING SURGEON, WILLS’ EYE HOSPITAL, PHILADELPHIA 
THIRD EDITION 
TRANSLATED FROM THE SECOND EDITION, 
“AUGENARZTLICHE EINGRIFFE” (JOSEF SAFAR, VIENNA) 
WITH 219 ORIGINAL ILLUSTRATIONS 
PHILADELPHIA 
P. BLAKISTON’S SON & CO. 
1012 WALNUT STREET Copyright, 1923, by P. Blakiston’s Son & Co 
PRINTED IN U. S. A. 
BY THE MAPLE PRESS YORK PA DEDICATED 
TO THE 
ROCKEFELLER FOUNDATION 
With Feelings of the Deepest Gratitude for 
the Magnificent and Noble Support Which, 
in the Years of Distress, it Granted the Med- 
ical Faculties of the Austrian Universities. PREFACE 
Old writers enumerated a list of qualities which they considered 
requisite in order to become a good surgeon. Some of these qualities 
appear necessary as a matter of course, others indifferent or superflu- 
ous, and but few indispensable. Rarely, however, is information 
given as to how surgery is to be learned. In Keil’s surgical manual 
of 1751 three points are brought before our notice: (1) From loyal 
and sincere teachers, (2) by the assiduous reading of books, and (3) 
through experience and practice. Directions as to teaching, how- 
ever, are entirely wanting. Beer, likewise, lays down a number of 
personal qualities as indispensable, and goes so far as to demand that 
the surgeon should have all the necessary medical and surgical knowl- 
edge, but without going into any particulars as to how that knowledge 
is to be acquired. In general, no special value seems to be attached 
to systematic instruction, but experience and practice are regarded 
as the chief agents in completing the education; and, provided the 
pupil has the suitable qualities of body and mind, experience and 
practice will, with lapse of time, furnish him with the necessary 
knowledge. Fuchs, too, in the preface of the first edition of his man- 
ual says: “Operating can be learned only by watching many opera- 
tions and individual practice.” 
It may therefore not be superfluous to indicate in a few words the 
important part that instruction plays in ophthalmic surgery. Tcach- 
ing has more influence on the development of the pupil than many 
of the general qualities which were at one time supposed to form the 
foundation. Operating is an art, just as any other, for the acquisi- 
tion of which systematic instruction is the chief condition. That 
which the individual can only find out laboriously by himself, what 
he only attains after many failures, is often made clear by a word 
from the master, and with this help all difficulties suddenly dis- 
appear. Even one who is exceptionally talented for any art cannot 
attain the highest degree of proficiency and become master of that art 
if the teacher is wanting. As a condition for becoming proficient 
in ophthalmic surgery, a thorough general preparatory training 
VII VIII 
PREFACE 
in the whole science of ophthalmology is requisite, in the diagnosis 
of the diseases of the eye as well as in the treatment of the patient. 
Operating must therefore form the keystone of ophthalmic study, 
and is an essential part of the instruction of the student. The 
beginner in ophthalmology, on the contrary, is filled with the desire 
to be allowed to operate as soon as possible, but such beginnings can 
only be attended by failure, if the operator is not intimately 
acquainted with all phases of disease of the eye. To be indirectly 
engaged with operations, as assistant, helps materially in becoming 
sufficiently acquainted with the eye as far as surgery is concerned. 
The more highly qualified a man is, the more rapid his education 
in ophthalmic surgery. 
If in such a way general education in ophthalmology and efficient 
instruction act together, the first few operations are almost always 
decisive as to whether the student will become a useful surgeon or not. 
It is a mistake to believe that, in order to become proficient, some 
must perform a few dozen operations, and others, less skillful/ 
perhaps many more. He who, after the first few cases, fails to carry 
out his work well, may withdraw his hand from this branch forever. 
The instruction, as in any other art, consists of two parts, both 
of which are of equal importance. The first is the correct demonstra- 
tion of the proper method of operation, accompanied by correspond- 
ing explanation. For this purpose the clinical patient is unsuitable in 
most cases, especially to the younger student, since operations must 
be performed within a few seconds which require explanations last- 
ing as many hours, an example of which is the incision for cataract. 
There is thus seen the necessity of lectures and demonstrations on 
the cadaver or the eyes of animals. Only he who has been properly 
instructed will then profit by watching the operations of the master 
on a patient, and will grasp and put to use the many details of his 
work, and so gain advantage for himself by observation. He who 
has received no instruction will, even with keen powers of perception, 
gain but little by observation, and that little only in the slow course 
of time; usually he will fail to gain any advantage at all, and, accord- 
ing to his state of mind, will either consider the matter so simple, as 
it appears to be by the sure hand of the master, or he will regard it as 
unattainable. In the latter case he will from the first approach the 
operation waveringly, feeling prepared for failures; in the former, the 
more insignificant he had regarded the work of his master, the more 
disappointed will he be with his own results. PREFACE 
IX 
The second, equally important part of the instruction, is the 
analysis of the mistakes. This has naturally been partly incorporated 
in the lecture on the correct method of performing the operation. 
There are two kinds of mistakes: The one originates in the struc- 
ture of the eye and returns with unfailing regularity with every begin- 
ner; the other is more of a personal character and, from comprehen- 
sible reasons, is also met with by the majority of beginners (slow 
and awkward hand- and finger-movements; directing the whole atten- 
tion to a single detail of the operation, whereby other details, which 
must be followed at the same time, are neglected, etc.). Few of the 
mistakes are of purely personal origin, exceptional mistakes, so to say. 
How these mistakes arise has to be explained by the teacher, who 
must point out the cause, discuss the consequences, and prove in 
detail, by word and demonstration, how they are to be avoided. 
The eye of a patient on the operating-table is unsuitable for such 
demonstrations, as a mistake once made can seldom be corrected. 
We again see the necessity of demonstrating on the eye of a cadaver 
or animal. To carry out this second part of the instruction, and 
to discover the individual mistakes apart from those occurring regu- 
larly and to which all are subject, it is necessary for each pupil to 
practice under the eye of a critical teacher and in the presence of other 
scholars. No clinical teacher would use for this purpose the eye of a 
patient seeking help, even were there thousands at his disposal. 
If the fresh eye of a cadaver can be obtained, an injection through the 
sclerotic into the vitreous chamber will make the eye sufficiently 
tense for operation, but, as they are to be had only in small numbers, 
even in large hospitals, they have to be reserved for the last stages of 
instruction. In spite of the great anatomical difference between the 
eyes of animals and those of man, the eyes of swine are not only 
perfectly adapted for preparatory instruction, but are exceedingly 
suitable for the operative details which must be minutely studied 
and perfectly executed. All the important steps of the operation for 
cataract (holding and guiding the knife, carrying it through the anter- 
ior chamber, making the counterpuncture, the position of the incis- 
ion, the simultaneous firm hold upon the eye without pressure), 
so difficult for the beginner to follow, may be practiced on and learned 
from animal eyes with great success. He who has learned to per- 
form the operation on these eyes with skill, will do so equally well on 
the human eye, and, on account of its smaller size, will find his task 
decidedly easier. X 
PREFACE 
Other details, however, which for anatomical reasons cannot be 
carried out so well on the eyes of animals as on the living human eye 
(such as the iridectomy, which on account of the rigidity of this 
membrane in animals can never be performed with complete success) 
require no specially detailed practice. Any one who is only fairly 
skillful can, after suitable preparation, execute them even the first 
time without a mistake. 
After thorough practice on animals’ eyes it is instructive for pupils 
to watch operations performed on patients by a surgeon not yet a 
complete expert. I might even say that they learn more in this way 
than by watching an expert himself. They became critics who follow 
the smallest detail with tense curiosity, recognizing the errors in 
their birth, even before they have become accomplished facts, and 
therefore immediately perceive any procedure that would be likely 
to lead to failure. After the completion of the operation, a detailed 
discussion of its course, and especially of any incidents that may have 
arisen, completes the instruction. Trained in such a way, even a 
beginner may, with a clear conscience venture to perform the opera- 
tion on a patient, convinced that it will be a success and the eye suffer 
no injury. It is also of the greatest advantage to have the assistance 
of his teacher, as the tested guidance of the latter inspires him with 
steady confidence. I consider it a mistake to set the student to work 
on a blind eye for his first attempt because there is no fear of injuring 
the sight. It is well known that operations on such eyes are more 
difficult, and frequently cannot be carried out in the regular manner. 
Take, for instance, the iridectomy in an eye blinded through glau- 
coma. Particularly such operations are nearly always connected 
with incidents of a serious character. On the conscientious beginner, 
such complications make a bad impression and often have an unfav- 
orable influence on him for further operations. 
After the amount of training that I considered necessary for my 
pupils, I have first always entrusted them with an eye, on the opera- 
tion of which no extraordinary incidents might be expected to arise, 
and have had the satisfaction of seeing that in no case did the opera- 
tion fail or the patient suffer injury. It depends entirely upon the 
skill of the individual operator whether he is first entrusted with 
simple operations only, such as puncture of the anterior chamber, 
etc., or permitted to perform the extraction of cataract. It is impor- 
tant that such patients be chosen, as by their composure and obedience 
will prevent all superfluous difficulties from arising. PREFACE 
XI 
Although fundamental importance is to be attached to the 
instruction, it must not be overlooked how greatly the teaching is 
furthered by the talent of the pupil and by the possibility of extensive 
surgical practice. With a small group of pupils all teaching is in 
vain; they are wanting in all manual skill and talent. In such cases 
the straightforward sincere teacher will unhesitatingly express his 
candid opinion and so spare the pupil useless trouble and unavoid- 
able disappointment. 
The great majority may be trained to become quite useful 
surgeons; but perfect mastership is attained by the few. 
This book may be judged from the theories propounded therein. 
Its chief object is the instruction in our art. “Non eruditis, sed 
erudiendis, non docentibus, sed discentibus.” 
It takes for granted that by a longer stay in a surgical and an 
ophthalmic clinic the reader has obtained a fair grounding in surgery 
in general and in ophthalmic surgery in particular. Therefore, I 
have omitted a paragraph on general principles, such as is usually 
contained in similar works. The fundamental idea of instruction in 
writing this book also decided me further to abandon a description 
of all different methods of operation. Such a collection may be found 
in all the well-known great works which need only be read by those 
who are at last able to operate. 
It is for purposes of teaching that some operations are treated with 
more detail than others, and the procedure itself, that is, the technical 
details, has been dealt with more minutely than the indications, the 
different varieties of methods, or even theoretical details; all the latter 
have been entirely omitted. 
Dr. Sweet has, in most self-sacrificing manner, consented to 
undertake the laborious task of thoroughly revising the translation. 
To his suggestions I am indebted for many valuable corrections, and 
I herewith beg to proffer my most hearty and sincere thanks to him 
for his faithful cooperation. 
J. Meller. 
Vienna. CONTENTS 
Page 
CHAPTER I 
The Lachrymal Apparatus i 
Excision of the lachrymal sac, i. 
CHAPTER II 
The Lachrymal Apparatus (continued) 23 
Excision of the palpebral lachrymal gland, 23; lachrymal probing, 26; Toti’s 
Dacryocysto-rhinostomia, 34; West’s operation, 37. 
CHAPTER III 
Spasmodic and Senile Ectropion 38 
Spasmodic ectropion, 38; Snellen suture, 38; senile ectropion, 39; Kuhnt- 
Szymanowski operation, 40; paralytic ectropion, 48. 
CHAPTER IV 
Cicatricial Ectropion 49 
Recent injuries, 49; V-Y operation, 51; non-pedicled skin-flaps, 51; epidermal 
inlays, 55; pedicled skin-flaps, 56; Fricke operation, 63; Dieffenbach operation, 
64; Biidinger operation, 65; Kuhnt-automargino plastic operation, 73; symble- 
pharon, 76; Rogman’s operation, 78. 
CHAPTER V 
Entropion and Trichiasis 82 
Spastic entropion, 83; Gaillard’s suture, 85; Graefe’s operation, 85; Hotz- 
Anagnostakis operation, 86; tarsoplasty, 92; Snellen operation, 92; Panas 
operation, 92; tarsal enucleation, 95; trichiasis, 95; method of Flarer, 95; 
method of Jaesche-Arlt, 96; method of Spencer Watson, 96; mucous 
membrane flaps, 97; electrolytic epilation, 98. 
CHAPTER VI 
Canthotomy—Canthoplasty—Tarsorrhaphy 100 
Canthotomy, 100; canthoplasty, 101; Kuhnt operation, 102; tarsorrhaphy, 
104; external tarsorrhaphy, 105; Elschnig operation, 107; internal tarsor- 
rhaphy, 109; Arlt operation, no. 
CHAPTER VII 
Ptosis 112 
Eversbusch operation, 113; Hess operation, 118; Pagenstecher’s operation, 
123; Motais operation, 124. 
XIII XIV 
CONTENTS 
CHAPTER VIII 
PAGE 
Operations on the Ocular Muscles 129 
Tenotomy, 129; advancement, 132; convergent strabismus, 138; divergent 
strabismus, 145. 
CHAPTER IX 
Enucleation of the Eyeball. Operations on the Orbit 148 
Enucleation, 148; abscission, 160; evisceration, 160; evisceration with insertion 
of a globe in the sclera, 160; enucleation with implantation of a globe 
in Tenon’s capsule, 161; of fat, 161; of cartilage, 161; optico-ciliary neurotomy; 
162; exenteration of the orbital cavity, 164; operations on the orbit, 165; 
Kronlein operation, 166; Muller operation, 173. 
CHAPTER X 
Extraction of Senile Cataract 175 
Extraction with iridectomy, 180; extraction with round pupil, 197. 
CHAPTER XI 
Cataract (continued) 226 
Discission, 226; discission for high myopia, 229; discission of secondary 
cataract, 231; iridotomy, 233; discission through the sclera, 235; linear 
extraction, 237. 
CHAPTER XII 
Operations for Glaucoma 242 
Primary glaucoma, 242; iridectomy, 242; anterior sclerotomy, 253; irido- 
encleisis, 257; excision of the sclera, 258; Lagrange operation, 258; sclero- 
corneal trephining, 262; posterior sclerotomy, 267; cyclodialysis, 269; de 
Vincentiis operation, 274; secondary glaucoma, 275; tonometry, 279. 
CHAPTER XIII 
Optical Iridectomy—Conjunctivoplasty—Operations for Iris Prolapse 
and Anterior Synechia 283 
Optical iridectomy, 283; prolapse of the iris, 287; conjunctivoplasty, 290; 
operations for anterior synechia, 294. 
CHAPTER XIV 
Operations on the Cornea—Operations for Retinal Detachment and 
Vitreous Opacities 298 
Cauterization and paracentesis, 298; Saemisch section, 299; tattooing the 
cornea, 300; conical cornea, 301; corneal staphyloma, 302; corneal transplanta- 
tion, 303; detachment of the retina, 306. 
CHAPTER XV 
Extraction of Foreign Bodies from the Interior of the Eye 318 
Magnetic foreign bodies, 322; non-magnetic foreign bodies, 328. CONTENTS 
XV 
page 
Minor Ophthalmic Operations 321 
Chalazion, 332; subconjunctival injections, 333; operative treatment of ptery- 
gium, 334; operative treatment of trachoma, 337; the ophthalmic assistant, 
340; anesthesia, 346. 
Index 351 
CHAPTER XVI OPHTHALMIC SURGERY 
CHAPTER I 
THE LACHRYMAL APPARATUS 
EXCISION OF THE LACHRYMAL SAC 
Anatomy.—The operator should study in each individual case 
the relation of the internal palpebral ligament and the anterior lachry- 
mal crest. 
The Internal Palpebral Ligament.—If the finger is placed against 
the outer canthus, and both lids stretched toward the temple horizon- 
tally, the ligament is seen between the inner canthus and the nose as 
a well-outlined and prominent cord immediately beneath the skin. 
This ligament, also known as the tarsal ligament, arises from the 
lachrymal process of the superior maxillary bone, and divides into 
two branches, each of which is continuous with the upper and 
lower tarsus, respectively, thus fastening them to the bone. The 
upper extremity of the lachrymal sac lies immediately behind the 
horizontal part of the tendon, the remainder of the sac extending 
downward for its entire length. 
The Anterior Lachrymal Crest (Fig. i cr.a.).-—This is the most 
important landmark throughout the operation. It is part of the 
frontal process of the maxillary bone, runs in an arch inward and 
upward, continuing the lower orbital margin, and forms the anterior 
boundary of the lachrymal sac fossa. In its lower half the crest is 
prominent, usually in the form of a sharp edge, and the fossa is corre- 
spondingly deep in this portion, but further upward it becomes 
flatter and disappears gradually toward the nasal process of the 
frontal bone. The upper portion of the crest has a nearly perpen- 
dicular direction. The surface of the frontal process of the maxillary 
bone is directed forward and forms a cavity which is sometimes a 
rather deep fossa immediately inward from the crest. This cavity 
may be mistaken for the saccal fossa. In thin individuals the crest 2 
THE LACHRYMAL APPARATUS 
at times is seen through the skin, but in all persons it may be easily 
found by gliding the finger along the lower orbital margin in a 
direction upward and inward. There are variations in its distinct- 
ness due to the anatomical development and to different thicknesses 
of the covering tissues. Sometimes it is easily felt as a sharp ridge, 
while in other instances, where it is flatter and more rounded, it is 
Fig. i.-—Region of the lachrymal apparatus. 
readily found by passing a pair of closed forceps from the side of the 
bridge of the nose toward the inner orbital wall. According to the 
degree of inclination which the plane of the ascending frontal process 
of the maxilla and the nasal bone forms with the sagittal plane, and 
in proportion to the height of the nasal bridge, the crest is situated 
either relatively superficial, and then can be reached easily, or it is 
deep, and access to the tear-sac is more difficult. 
Posteriorly the saccal fossa is bounded by the posterior lachrymal 
crest, which is part of the lachrymal bone, a thin bony plate, with a 
prominent sharp edge. This posterior crest is of no importance as a 
landmark, and is not exposed in the ordinary course of the operation. 
Indications for Excision of the Lachrymal Sac.— Operation is 
indicated in all cases of chronic blennorrhea of the lachrymal sac, 
(i) which lead to marked thickening of its walls and eventually to 
its dilatation, to total obstruction of the naso-lachrymal duct, or to 
the formation of a fistula ; (2) when an operation (iridectomy, extrac- 
tion of a cataract, etc.) is to be performed on the eye of the corre- EXCISION OF THE LACHRYMAL SAC 
3 
sponding side; (3) when a purulent infiltration of the cornea has taken 
place (infected erosion, ulcus serpens, etc.), as cauterization would 
not prevent the discharge from the diseased sac flowing over the 
denuded area and by its microorganisms producing new infections; 
and (4) in all dispensary patients who have not the time for a long 
course of treatment with sounds, a method that usually promises 
but indifferent results. Particularly is resection recommended if the 
treatment with probes has previously been carried out without 
substantial improvement. 
Rendering the Operative Area Anesthetic and Anemic.—Most 
descriptions of the operation call attention to the probability of pro- 
Fig. 2.—Pravaz’s syringe. Capacity i c.c. Piston pulled out. The division lines 
represent tenths. 
fuse hemorrhage and the difficulties that this accident entails. Co- 
cain injected subcutaneously neither produces complete anesthesia 
nor anemia of the parts. The addition of adrenalin solution to the 
cocain accomplishes the desired result, and renders possible an almost 
bloodless and painless operation. General anesthesia has many 
disadvantages and is seldom indicated. 
After the conjunctival sac has been rendered anesthetic by a few 
drops of 3 per cent, solution of cocain, the lower canaliculus is 
dilated with a conical probe and a i per cent, solution of cocain 
injected into the sac by means of a lachrymal syringe. To prevent 
the fluid from flowing into the nose and eventually into the mouth, 
the patient should be placed in a sitting position with the head bent 
slightly forward. In most instances the fluid will escape through the 
canaliculi, particularly the upper, the naso-lachrymal duct being 
closed. This preliminary procedure not only anesthetizes but 
cleanses the sac, which is of decided advantage, for, although the 
sac itself is not injured during the operation, the canaliculi and naso- 
lachrymal ducts are cut through, and the contained secretion may 
escape and contaminate the wound. But, in my experience, infec- 4 
THE LACHRYMAL APPARATUS 
tion of the wound is of rare occurrence, and, should it occur, is never 
serious. 
The injection into the deeper tissues is made with a syringe of 
i c. c. capacity (Pravaz’s preferred, Fig. 2), which is filled with a solu- 
tion composed of eight to nine parts of 1 per cent, solution of cocain 
and one to two parts of adrenalin or suprarenal solution (1-1000). 
One-third of the contents of the syringe is injected beneath the skin, 
the needle entering slightly below the tarsal ligament. This pro- 
duces a slight bulging forward of the lachrymal-sac region, but mas- 
sage causes the immediate disappearance of this swelling. The point 
of the needle is now inserted above the tarsal ligament and pushed 
vertically down to the bone. The syringe is then twisted forward 90° 
so that the needle is turned in the direction of the orbit. Holding it 
in this position the point is pushed forward closely along the perios- 
teum and the second third of the solution injected, so that the tissue 
around the top of the lachrymal sac and the branches of the naso- 
ciliary nerve, which pass here to the tear-sac and its fossa, are 
infiltrated. With the remainder of the solution the region imme- 
diately about the entrance into the naso-lachrymal duct is anes- 
thetized. The needle is now inserted below the tarsal ligament 
ill a direction vertical to the lachrymal crest, the syringe turned so 
that the needle lies parallel to the bone, when it is pushed slightly 
backward. Should the point of the needle enter the lachrymal sac 
itself, recognized by the escape of fluid from the puncta, it must be 
pulled out somewhat and turned in a slightly different direction. 
The stated quantity of adrenalin Q?{0 to %o c.c.) suffices fully for 
the production of anemia. In my experience it has never been fol- 
lowed by bad after-results, either local, such as marked secondary 
hemorrhage or necrosis of the tissues, or constitutional. Occa- 
sionally a patient may complain of sudden distress, such as a sensa- 
tion of oppression and palpitation of the heart, but these symptoms 
disappear shortly. In elderly patients with advanced arteriosclero- 
sis, not more than }{0 c.c. of the adrenalin should be injected, and this 
amount will be sufficient. Dropping the adrenalin into the wound is 
unsatisfactory. After the sac has been peeled out, and before the 
probe is inserted into the nose, cocain should be dropped into the 
wound. The cocain will diffuse itself into the duct along the probe, 
and make the curetment almost painless. EXCISION OF THE LACHRYMAL SAC 
5 
Immediately after completing the injections, the operation may 
be commenced. In the majority of cases layer after layer of tissue 
may be removed without hemorrhage, as in the dissection on the 
cadaver. I have irequently resected lachrymal sacs in a few minutes 
without assistance. The incision through the skin may bleed more 
than expected, as occasionally the skin contains abnoimally large 
veins. The deeper parts are always absolutely anemic. 
This method of local anesthesia gives such periect results in 
causing anemia of the operative area, and consequently dearness of 
Fig. 3.—With the thumb of the left hand (1. th.) the skin is fixed, but not pulled or 
stretched. The cutting edge of the knife is directed vertically against the bone. The 
incision is downward, slightly outward and somewhat curved, 3 to 4 mm. distant from 
internal canthus. 
the tissues, that there is no necessity of employing deep injections 
into the orbit to interrupt the conductivity of the naso-ciliarv nerve. 
The entire operation is therefore performed outside the orbit. 
The method recommended for the extirpation of the sac has 
proved eminently satisfactory. It requires an accurate knowledge 
of the topographic anatomy of this region, which will be discussed as 
the various stages of the operation are described. 
The Skin Incision.-—The incision through the skin begins at a 
point 3 mm. above the ligament of the internal canthus and 3 mm. to 
the inner side of the canthus. The direction of this incision is down- 
ward, the upper half perpendicular or nearly so, and the lower half 6 
THE LACHRYMAL APPARATUS 
curved slightly outward (Fig. 3). If, for instance, the upper half of 
the cut is not straight, but curved toward the upper lid, an ugly fold 
of skin is frequently produced at the upper angle of the incision during 
the healing process. While making the incision, which, by the way, 
corresponds to the direction of the crest but is situated several milli- 
meters internally from it, the lids must not be pulled outwaid with 
the idea of making the skin tense. This prevents the incision from 
being made in the desired line. It is sufficient to press the upper 
inner part of the skin backward against the bone with the thumb. 
If we use a sharp knife, slight pressure of the blade against the skin 
will indicate the direction of the incision, and then to deepen it the 
skin may again be stretched. 
The length of the incision is not of much importance. The 
beginner should make a long incision (about 1 % cm.), as this facilitates 
the dissection of the sac. The expert operator usually prefers a short 
incision. The length of the cut may vary, therefore, from 1 cm. to 
cm. If the incision is more than 3 mm. from the internal canthus 
the difficulties of dissection are greatly increased, because the distance 
from the sac is proportionately greater. 
Introduction of the Tear-sac Speculum.—After the cut is com- 
pleted the lateral edge of the incision is lifted up and dissected from 
the underlying tissue with the scalpel turned toward the canthus, and 
the tear-sac speculum (Muller’s) is introduced. The internal margin 
of the wound is not to be dissected, otherwise there is danger of 
injury to the larger blood-vessels, with consequent hemorrhage, and 
because the tear-sac is situated laterally from the incision. The 
internal wound-margin is so loosely adherent to the underlying tis- 
sues that the hooks of the speculum can be securely introduced with- 
out further preparation. The speculum is of great value, as it takes 
the place of an assistant and, by compressing the surrounding tissues, 
aids materially in hemostasis. The speculum is introduced closed, 
with its handle turned downward and slightly outward. The edges 
of the wound are first gently lifted with forceps, and the hooks 
fastened securely into the wound-edges, so that no injury of the cor- 
nea be produced by any sudden jerk. An erosion is dangerous 
because of the great liability of infection. The patient must keep his 
eyelids closed throughout the entire operation. 
The Superficial Fascia.—In the wound stretched by the speculum 
is exposed a delicate, thin, white membrane, the superficial fascia. EXCISION OF THE LACHRYMAL SAC 
7 
The fascia may be considerably thickened toward the palpebral 
fissure by layers of connective-tissue fibers, some of which are joined 
with the ligamentum canthi, and radiate from it. They must not be 
confounded with the true ligament of the canthus, which belongs to 
a deeper stratum. 
The scalpel with which the incision was made is put aside, and, 
until the completion of the operation, a pair of small slightly curved 
scissors is used, the blades of which have sharp points. With tooth- 
Fig. 4.—The separation and pulling to either side of the muscle-fibers (m.) exposes 
the deep fascia (f. p.) in the wound; behind this the sac must be looked for. In the 
upper angle of the wound are the transverse fibers of the ligament of the internal canthus 
(1. c.). Through the fascia the anterior lachrymal crest;](cr. a.) can always be felt and 
can occasionally be seen. 
forceps a fold of the superficial fascia is picked up, transfixed with one 
blade of the scissors, and slit throughout the entire length of the 
wound, pushing it back toward both margins. 
The Orbicularis Muscle.-—In this way there is exposed a layer of 
red fibers, the orbicularis muscle (palpebral portion), the fibers of 
which, as is known, arise from the internal palpebral ligament and 8 
THE LACHRYMAL APPARATUS 
form the superficial part of this muscle. As the resistance of the 
wound-margins is diminished by splitting the superficial fascia, the 
speculum pulls the two margins apart, and the line-shaped incision 
becomes a rather large rhomboidal opening. Only a small portion of 
this wound-surface, the lateral part, corresponds to the position of 
the sac. After locating the position of the anterior crest, the muscle 
overlying it is slit up, and the fibers pushed back toward both sides 
with the closed scissors. 
The Deep Fascia.—This brings to view in the floor of the opera- 
tive wound a dense white membrane, the deep fascia, covering the 
lachrymal sac (Fig. 4) and extending from the anterior to the posterior 
lachrymal crest. Above, below, and at the inner side the fascia 
becomes continuous with the periosteum of the neighboring bones, 
but at the posterior lachrymal crest it fuses with the orbital septum, 
thus completing the membrane which separates the lachrymal fossa 
from the orbit. The specially thickened upper portions of this fascia 
form a prominent dense cord which has already been referred to as 
the internal canthal ligament. 
The fibers visible at this point may be referred to as the anterior branch of the 
ligament. From it radiate bundles of fibers into the tarsus of the upper and lower lid. 
In contradistinction to this, the portion of the fascia attached to the posterior lachrymal 
crest is spoken of as the posterior branch of the ligament. This arrangement, useful 
also because of the differences in insertion of the muscle-fibers, is understood without 
difficulty when a horizontal section of the skull made through the region of the canthal 
ligament is viewed. By pulling the lids outward an angular folding of the deep fascia is 
produced, which bounds a triangular space with the lachrymal fossa. Its floor is 
formed by the fossa itself, its branches (anterior and posterior) by the corresponding 
portions of the internal canthal ligament. In this triangle is to be found the cross- 
section of the lachrymal sac. 
At this stage of the dissection the operator sees neither the crest, 
unless it is abnormally prominent, nor the lachrymal groove. To 
note their exact positions, he must feel around with the forceps, 
gliding from the side of the nose toward the orbit. The anterior 
lachrymal crest must serve as a landmark during the entire operation. 
By not dissecting too near the median line he will, on the one hand, 
escape the mistake of incising the periosteum of the dorsum of the 
nose, instead of freeing the lachrymal sac; and on the other hand avoid 
going in the wrong direction from the sac toward the orbit. 
Exposing the Sac.—The deep fascia is now split with the scissors, 
inserted to the outer side of the anterior lachrymal crest, and 3 2 mm. 
behind it. This is not easy, even on the cadaver, if we wish to escape EXCISION OF THE LACHRYMAL SAC 
9 
injuring the sac. The fascia is tense, and it is difficult to pick up a 
fold of the tissue for transfixion by the scissors. We are, therefore, 
forced to perforate it with one of the points of the scissors held almost 
parallel to the plane of the fascia. It is our custom to make the cut 
through the fascia Y mm. behind the crest, and not, as done by others, 
directly on the crest. This makes dissection of the lateral wall easier. 
Fig. 5.—The deep fascia is incised throughout the entire length of the wound mm. 
behind (i.e., to the side of) the crest (cr. a.). This lays bare the bluish-red lachrymal sac 
(sa.). The ligament of the internal canthus, which the figure shows to have been pre- 
served, is cut through at the same time. 
As the sac lies immediately below the fascia, its anterior wall may 
be injured by cutting too brusquely. This is particularly true when 
the sac is not diseased, as on the cadaver, and the walls are thin and 
friable through beginning decomposition. For purposes of demon- 
stration (it may also be done most successfully on the living sub- 
ject), it is as well to slit the fascia along its entire length with a narrow, 
pointed knife (the Graefe linear knife), holding it obliquely with the 
cutting surface forward. I prefer to use the scissors for this cut. 
The danger of injuring the tear-sac may be diminished by drawing 10 
THE LACHRYMAL APPARATUS 
away the fascia, grasping the ligament with the forceps, and pulling 
it outward and forward. Moreover, since the diseased sac is thick- 
ened, the danger of injuring it is reduced to a minimum. However, 
the operator should begin with a very short cut through the fascia 
Fig. 6.—The lateral margin of the fascial wound (f. 1.) is grasped with the forceps, 
and the closed scissors made to separate the loose areolar tissue between sac (sa.) and 
fascia, as far back as the bone. 
so that, even in case the sac is perforated, the wound need not 
be extensive. This cut should extend through the whole length of 
the membrane, and sever the ligament of the canthus at the same 
time. In the slit-like opening thus produced may be seen the lachry- 
mal sac, readily distinguished because of its bluish color (Fig. 5). 
In operating on living patients, it is not uncommon to have the 
anterior wall of the sac bulge through the opened fascia in the form 
of a hernia. EXCISION OF THE LACHRYMAL SAC 
11 
Removing the Sac.—The remainder of the operation consists in 
peeling the sac out of its bed. From now on, the operator must con- 
stantly keep close to the wall of the sac, and not injure the fascia or 
cut it away at the same time. There are no large blood-vessels in 
the loose tissue connecting the sac with its fascial capsule, and, there- 
fore, during the dissecting there will be no annoying hemorrhage. 
Fig. 7.—The lower half of the lateral wall of the sac is dissected from the deep fascia. 
The canaliculi (c.) are visible as a bluish cord above, f. 1., lateral margin of the fascial 
incision; sa., sac. 
For the purpose of explanation it is best to distinguish only two 
walls of the lachrymal sac, the lateral (orbital), which is turned 
toward the fascia, and the inner or median (nasal), which lies adjacent 
to the bone of the fossa. The designation anterior and posterior 
wall are altogether avoided in the description. 
It is my custom first to separate the lateral wall of the sac from the 
fascia. For this purpose I pick up the lateral margin of the fascial 
wound with tooth-forceps and separate with closed scissors the deli- 
cate connective-tissue fibers which connect the sac with the lateral 12 
THE LACHRYMAL APPARATUS 
wall of the fascia, beginning in the lower half of the wound 
(Fig. 6). With a few strokes the lateral wall is separated back to the 
bone. 
It is only when the upper part is reached that a disturbing factor 
is met. At this point a bluish cord is seen going to the lid, the can- 
Fig. 8.—Cutting the canaliculi. One blade of the scissors, which must be applied 
parallel and close to the lateral fascia, is introduced far up behind the canaliculi (c.), 
the other is in front of them. One cut severs the canaliculi; sa., sac. 
aliculi (Fig. 7), which must be cut as close to the fascia as possible 
(Fig. 8)—and not dissected by the closed scissors—or a piece of the 
mucous membrane will be left hanging to the fascia. 
The median wall of the sac is next loosened. Should the portion 
of the fascia left behind at the anterior crest be too broad to free 
the crest easily, it should be incised (i in Fig. 10). Gliding along the 
upper flat half of the crest with the point of the closed scissors, 
the wall of the sac may be readily separated from the bone as far as the 
posterior lachrymal crest (Fig. 9). Although the periosteum of the EXCISION OF THE LACHRYMAL SAC 
13 
lachrymal fossa could be spared with proper precautions we usually 
remove it together with the sac. The denuding of the bone is not 
significant of future disease. 
When the upper half of the median portion of the sac has been 
freed, its lower half is peeled out from behind the prominently pro- 
jecting crest without injuring the sac; but if the excision has been 
era. 
sa. 
Fig. 9.—A short transverse cut (easily seen in Fig. 10 (i.), while in this drawing it is 
pulled to one side by the forceps) into the median margin of the fascial wound exposes 
the anterior crest (cr. a.); this makes it easy to push the closed scissors between the bone 
and sac (sa.) at the upper part of the crest and to loosen the sac. The point of the 
scissors is directed toward the bone. 
begun at the lower steep portion of the crest, the sac will usually be 
injured. This is a mistake frequently committed by beginners. 
The sac has now been cleared from all sides, but the upper extrem- 
ity is still fastened to the surrounding structures, and the lower is con- 
tinuous with the mucous membrane of the duct. For the first time 
since the operation began we can now grasp the entire sac with the 
forceps without risk of tearing it, and dissect it out of the fascia, with 14 
THE LACHRYMAL APPARATUS 
which its top is intimately united, by making small nicks with the 
scissors as near as possible to the wall of the sac (Fig. io). 
In freeing the top care is taken not to cut much tissue because of 
the danger of injury to large blood-vessels. In spite of the greatest 
caution, we sometimes have profuse hemorrhage. Because of this, I 
Fig. io.—The sac, having been freed on both sides, is now for the first time grasped 
with forceps near its apex (t.) and separated from the surrounding structures with sharp 
cuts of the scissors as near the sac wall as possible. The upper margin of the wound is 
lifted up with a double tenaculum, i., transverse cut into fascia. 
have recommended that the dissection of the upper extremity shall be 
postponed until the entire sac has been completely shelled out. Even 
should a considerable bleeding then occur, it need not cause much 
annoyance, as the entire sac is safely held in the forceps. 
As soon as the upper portion has been freed, the entire sac maybe 
pulled forward. Should the posterior surface still be attached to the EXCISION OF THE LACHRYMAL SAC 
15 
bone by several connective-tissue fibers, a few strokes with the closed 
scissors will suffice to separate it. 
The sac is next dissected downward as far as possible. For this 
purpose I grasp the sac with the forceps at its lowest portion (Fig. 11). 
and, with the scissors from above downward near the wall of the sac, 
make several cuts in front and to both sides, freeing the path to the 
Fig. ii.—The sac, having been freed from the surrounding structures at all points 
except at its lowest portion, is grasped with the forceps low down; the vertically held 
scissors are made to cut away all the tissue attached to its lateral wall as close to it as 
possible until the naso-lachrymal duct is reached. 
beginning of the naso-lachrymal duct. Finally, the vertically held 
scissors are pushed down into the bony portion of the duct from the 
anterior or lateral surface, and the sac is cut through. While the 
assistant tampons the wound, I put the sac over a Bowman probe 
to convince myself by the intactness of the wall, that it has been 
removed as a whole. If the stricture is complete, the sac will have 
the appearance of a closed cyst, and the mucous lining is brought to 
view only after the sac has been cut open. If we now examine the 16 
THE LACHRYMAL APPARATUS 
wound cavity (Fig. 12), and this should never be omitted, we will see 
as the median boundary the lachrymal crest and the bony lachrymal 
fossa, deprived of its periosteum; and as the lateral wall the dense, 
white, smooth, glistening deep fascia (the posterior branch of the 
internal ligament of the canthus), which completely separates 
the wound from the orbit. The sac does not properly lie within 
the orbital cavity, but rather outside it. 
Cureting the Naso-lachrymal Duct.—The final procedure is to 
find the opening of the naso-lachrymal duct. The probe is placed 
Fig. 12.—Operative field after completed excision.—-The small portion of the deep 
fascia, which has been left behind, is seen hanging to the anterior lachrymal crest; on it 
the transverse incision (i.) is still visible. The saccal fossa (f. s.) is quite empty. The 
outer border is formed by the deep fascia (f. p.) which is firmly attached to the posterior 
lachrymal crest; it is of a white color and has a distinct luster. Behind the anterior 
crest is the probe, which passes through the duct into the nose. 
vertically close to the bone immediately behind the anterior lachry- 
mal crest and pushed downward. Should the passage be closed, the 
probe must be forced through the cicatricial tissue. In every instance 
this passage must be enlarged with a sharp curet, and all the mucous 
membrane found in the duct scraped away. Curet ment of the 
cavity which contained the sac is not only unnecessary, if the sac has 
been excised properly, but superfluous. The naso-lachrymal duct 
is probed in every case and made patulous by curetment, both to 
prevent possible secretion from the mucous membrane, and to 
provide drainage. Before closing the wound with sutures, it must EXCISION OF THE LACHRYMAL SAC 
17 
be washed out with a weak corrosive sublimate solution, care being 
taken that the fluid will not enter the opened naso-lachrymal duct 
and through it reach the mouth of the patient. 
The Sutures.—The skin of the neighborhood is thin, often easily 
torn, and usually curled up at the margins of the wound, and, if the 
edges are not perfectly apposed, primary union is impossible, and the 
relatively large wound must fill in by granulation. This retards heal- 
ing and produces a broad and conspicuous scar, while the delicate scar 
following well applied sutures and primary healing is often hardly 
visible. 
Three sutures suffice, if the wound is to 2 cm. in length; if 
shorter, perhaps only two. Thin silk is the best material for the pur- 
pose. Small hooks, sharp and somewhat bent, are inserted into both 
the upper and lower wound-angle, and the wound somewhat stretched. 
The thin, sharply curved needles containing the thread are then 
pushed through near the margins of the wound. The assistant must 
well adapt both margins with two pairs of forceps.- He then turns the 
forceps to one side, so that the operator, who holds the looped threads 
parallel to the wound, can apply the knot readily at the side. The 
knots should only be drawn tight enough to maintain perfect adapta- 
tion, as the silk readily cuts through the easily lacerated skin. The 
threads must then be cut short. In order to prevent the possibility 
of secretion of the epithelium of the canaliculi, it is advisable to 
destroy the membrane by introducing the pointed end of a galvano- 
cautery. 
The Dressings.—Before applying the dressing, the intactness of 
the corneal surface must be investigated. I have already called 
attention to the danger of an accidentally produced corneal erosion. 
The closed eyelids are first covered with a small pad of gauze to pre- 
vent erosion of the cornea by threads from any part of the dressing. 
A tightly rolled pad of iodoform gauze is pressed slowly and with 
gradually increasing force against the wound, thus obliterating the 
sac cavity. A second small pad made of the sterile gauze is placed on 
top of the iodoform gauze to ensure permanent compression. The 
eye is then covered with a few layers of gauze, and the entire dressing 
secured with a strip of adhesive plaster, which should be drawn 
tightly. Lastly the bandage is applied. The other eye remains open. 
After-treatment.—On the following day the layers of gauze 
covering the eye are removed for the purpose of inspecting the 18 
THE LACHRYMAL APPARATUS 
cornea. The compression-pad, however, is not removed from the 
wound, the outer angle of the palpebral fissure being opened only 
slightly with the fingers. If the case progresses satisfactorily, the 
first complete change in dressings is made on the third day. On 
the fifth day the dressing is taken off, the stitches removed, and the 
wound is found healed. Should the suture-openings bleed, it will 
suffice to dust them with xeroform or to close them for a day with 
adhesive plaster. 
If, however, blood has collected in the wound-cavity, the progress 
of the healing is retarded. The cause of the accumulation of blood 
is nearly always incomplete compression of the wound. In this com- 
plication the patient complains of pain within a day or two after the 
operation, and upon removal of the dressings the wound is found to 
be bulging, and the skin dusky red and tender to the touch. It then 
becomes necessary to remove the sutures, and forcibly open the 
wound with a sharp sound or probe, in order to afford free drainage 
for the accumulated fluid. A small drain of iodoform gauze should be 
inserted and a moist antiseptic dressing applied. 
Although this complication is annoying, it is usually found that 
in the course of a few days the wound fills with granulations and 
cicatrizes in a short time. 
It is an entirely different matter, however, if the inflammation and 
accumulation are due to retained particles of mucous membrane of 
the sac—in other words, if the excision has been incomplete. This 
may happen occasionally to the most experienced operator; in the 
case of beginners it is not a rare occurrence. 
Accidents and Complications of Excision.—The proper excis- 
ion of the lachrymal sac is one of the most difficult of operations, and 
many of the accidents that arise are due to faulty technic. 
Locating the Sac.—The beginner experiences considerable diffi- 
culty in finding the sac, except in cases in which it has become so dis- 
tended as to be visible as a tumor through the skin. Error is often 
made in severing the fibers of the orbicularis muscle. The speculum 
broadens the wound, and the surgeon must first be clear as to the 
location of the crest. This usually lies close to the lateral branch of 
the speculum. If the muscle is severed too far nasally, the surgeon 
will strike the periosteum to the inner side of the crest, where he will 
look in vain for the sac. The anterior lachrymal crest must serve as 
a landmark throughout the operation; and the operator should always EXCISION OF THE LACHRYMAL SAC 
19 
keep as close as possible to the bone. He will then not be misled into 
looking for the sac too near the nose in the periosteum of the bone, 
and will also avoid penetrating the orbital tissue with which he should 
never even come in contact. 
Opening into the Orbit.—If the surgeon loses his bearings and 
dissects toward the orbit, the connective-tissue septum is usually 
injured and considerable disturbance is produced by the entrance of 
orbital fat into the wound. The fat prevents a good view of the 
operative field, retards the operation considerably by the hemorrhage 
following its excision, and may lead to infection of the orbit and 
orbital abscess. Infection, however, does not necessarily follow, and 
the chief disadvantage is delay in the operation by the protrusion of 
the fat and the hemorrhage. The beginner enters the orbit not from 
injury to the fascia but because he fails to work toward the crest. 
Injury to the Sac.—Should the sac be injured, the accident is of no 
importance provided the operator remedies the mistake at once and 
returns to dissect at the proper point. It may happen that during 
the opening of the deep fascia (especially if done quickly) not only the 
fascia but also the anterior wall of the sac, which lies immediately 
beneath it, are slit open. If the operator is not aware of the accident, 
he may dissect off only the lateral half of the wall, thinking that he 
has the entire sac before him. If he is sufficiently careful, however, 
and notes the injury, he can retrace his steps and without much 
difficulty find the right spot for continuance of the dissection on the 
outer side of the sac wall. The cleaner the dissection of the sac, i.e., 
the closer to the wall of the sac the operator keeps by constantly dis- 
secting between it and the covering fascia, the more satisfactory will 
be the course of the operation. It is remarkable with what perfect 
freedom from hemorrhage and pain the operation may be performed. 
The operator who lacks sufficient knowledge concerning the exact 
position and surroundings of the sac, and resects it together with all 
the attached tissues so as to be certain to have the sac in the excised 
portion, will be greatly annoyed by hemorrhage, and his patient will 
suffer much pain. 
Retained Portions of the Sac.—If small particles of the mucous 
membrane are allowed to remain, there is a continuation of the dis- 
charge, and, still more unpleasant for the patient, the formation of a 
fistula. Experienced operators may fail in extirpating the entire sac, 
and to obtain a perfect cure must resort to future operations. The 20 
THE LACHRYMAL APPARATUS 
failure to remove every particle of the sac may be due to an exception- 
ally profuse hemorrhage preventing accurate dissection, tearing of 
the sac during operation, or, finally, partial destruction of the anterior 
wall of the sac from rupture of the abscess into the surrounding 
tissue without having gone so far as perforation of the skin. The 
beginner finds greater difficulty in the resection of the lateral than of 
the median wall, because the bony landmarks are less prominent. 
It is also quite a common error to sever the sac some distance below 
the apex, and to leave the apex behind. It must be remembered that 
the apex is closely adherent to the fascia covering it and should, 
therefore, be removed with the sharp edge of the scissors. Cureting 
blindly with a sharp spoon is a crude procedure, and entirely without 
value. Inspection of the wound is important to determine that the 
bony walls are healthy and that no part of the sac has been retained. 
Hemorrhage.—Should profuse hemorrhage occur before every por- 
tion of the sac has been excised, the speculum must be removed and 
the wound well packed with tannin-iodoform gauze until all bleeding 
has been checked. The wound is then held widely open with the 
speculum, and a careful examination made. In most instances the 
retained segments of the wall are seen, and may be separated from 
the underlying fascia and bone. It is only by removing all the 
mucous tissue that a cure and primary healing of the wound can 
be expected. 
Suppuration.—Unless every particle of the sac is removed primary 
union of the wound will not take place. The secretion from retained 
portions of the mucous membrane soon distends the wound, and the 
sutures cut out or must be removed to allow escape of the fluid, other- 
wise persistent suppuration will be the inevitable result. In the 
event of suppuration the wound must be loosely packed with iodo- 
form-gauze and washed with weak bichlorid solution or a 6 per cent, 
solution of hydrogen peroxid. Immediate curetment of the operated 
area is an error, because the granulations in the wound mask the 
tissues, and the mucous membrane of the lateral wall, not having the 
support of bone, always escapes the sharp instrument. Cure will 
follow only after careful dissection of the entire lateral wall and apex 
of the sac. 
Results of Operation.—The final results of excision of the lach- 
rymal sac are eminently satisfactory. In a short time the scar is 
hardly visible, the conjunctival catarrh constantly associated with the VARIETIES OF LACHRYMAL SAC DISEASE 
21 
blennorrhea soon disappears, and also the epiphora, the latter prob- 
ably through a nervous influence. Should the catarrh and epi- 
phora persist, a careful examination should be made of the canaliculi, 
and if any mucopurulent discharge can be squeezed from them, some 
of the mucous membrane has surely been left behind If excessive 
lachrvmation continues for several months the palpebral lachrymal 
gland must be resected. 
Varieties of Sac Disease.—Inflammation of the lachrymal sac is 
met with in several different forms. 
Acute Dacryocystitis.—In this affection no incision through the skin 
should be made unless perforation seems imminent. Applications 
of warm, moist, antiseptic dressings are to be continued until the 
inflammation has completely disappeared. At the end of a few 
weeks extirpation of the sac should be performed to prevent a return 
of the inflammation. Prior to the employment of cocain-adrenalin 
injections, profuse hemorrhage from the dilated blood-vessels was 
to be expected. 
If perforation is unavoidable, an incision must be made down to 
the bone, and a tampon of moist iodoform gauze inserted. 
Chronic Dacryocystitis.—Operation will often be required in 
patients who have been treated without success by repeated curetings, 
and it is then necessary to dissect the entire lateral wall and apex of 
the sac before a cure is effected. The operator should endeavor to 
remove layer after layer, at least as far as possible in the scar-tissue, 
instead of following the usual practice of cutting down in the first 
incision to the anterior lachrymal crest. 
The anemia produced by the cocain-adrenalin infiltration in the 
dense scar-tissue is of decided advantage, as it permits the operator 
to see every step of the operation clearly. The bluish color of the 
mucosa readily differentiates it from the white of the scar-tissue, and 
in most instances the mucous membrane can be peeled off easily. 
This is then followed by a close scrutiny of the wound to determine 
that all the lining has been removed, and then, as in a completely 
performed excision of the lachrymal sac, the wound is closed by 
sutures. 
Fistulous Dacryocystitis.—The most difficult cases are those in 
which a fistula has formed either after an acute dacryocystitis 
or following attempted extirpation. A much longer incision (2 cm.) 
is required to conveniently reach the fossa, and the fistula must be 22 
THE LACHRYMAL APPARATUS 
completely excised. The incision, which at first is only through the 
skin, is at once deepened to the crest after the wound-edges have been 
dissected up and the cut well stretched with the speculum. The 
entire fossa is now cleaned out, thus excising all of the exposed scar- 
tissue. The lateral fascial boundary may often be found, so that 
after completing the operation there is presented the usual picture 
of the wound, i.e.: the median border formed by the bone with its 
prominent crest and the lateral border by the fascia. It is not advis- 
able to use the curet, but prove by close inspection of the wound that 
none of the mucous membrane has been forgotten. Suturing the 
wound is unfortunately often impossible, as the skin, particularly 
if several attacks of dacryocystitis have preceded the operation, is 
easily torn. By packing the wound loosely, the rapid development 
of granulations is favored, and the cavity will soon fill up. Even 
after such an operation the scar may be remarkably insignificant. 
It is not uncommon for the repeated mistreatment of the tissues to 
result in an ectropion through shrinking of the scar. Success in 
elevating the lid and retaining it permanently in its proper position 
may be achieved by sutures going obliquely through the wound- 
edges from without inward and from below upward. 
Dilated Sac.—If there is great dilatation of the lachrymal sac, 
which acts like a tumor and pushes the skin forward, the operation 
cannot be performed by the rules laid down. The tissues covering 
the sac may be so atrophic that immediately after cutting through 
the skin the wall of the sac may be exposed. In other respects, 
however, the removal of the sac does not differ in the slightest from 
that of other tumors in this region. 
Tuberculosis of the Sac.—Tuberculous infiltration, which is seen 
especially in children, results frequently in destruction of the wall of 
the sac and necrosis of the bone, so that a radical operation is difficult. 
The diseased tissue must then be cut away, the necrosed bone 
removed, and the wound packed with iodoform gauze and permitted 
to heal by granulation. Recurrence is common in this type of 
disease, and is usually accompanied by formation of fistulae, which 
then make secondary operations necessary. CHAPTER II 
THE LACHRYMAL APPARATUS (continued) 
EXCISION OF THE PALPEBRAL LACHRYMAL GLAND 
The palpebral portion of the lachrymal gland is the lobule of 
gland-substance which surrounds the excretory ducts of the orbital 
lachrymal gland at the point where they pass toward and through the 
superior conjunctival fornix. Toward the nasal side the excretory 
ducts do not extend beyond the temporal quarter. The lowest excre- 
tory duct lies at a level of the ligamentum canthi externum, or a little 
beneath it. This so-called inferior lachrymal gland may be seen at 
the outer part of the lid in many individuals by lifting or everting the 
upper lid, while the patient is looking downward and inward; some- 
times it bulges forward in the form of a small lobulated tumor. 
Indications for Excision of the Palpebral Lachrymal Gland. 
The operation is required (i) in the occasional cases in which 
the lachrymation does not spontaneously disappear after excision of the 
sac; (2) in patients who come from a long distance for removal of the 
sac, and who would find it difficult to make a second journey; and (3) 
when the chief symptom of the disease of the sac is a constant epi- 
phora. There is no objection to excision of the palpebral lachrymal 
gland immediately following extirpation of the sac, and this course 
should always be followed when constant lachrymation is associated 
with lachrymal duct stenosis. 
De Wecker’s Method.—The gland is conveniently reached by 
everting the lid with the finger in the usual manner, and inserting 
an opened lock-forceps at the junction of the outer and middle thirds, 
so that one blade is pushed beneath the lid into the conjunctival for- 
nix and the other lies anteriorly on the tarsus. The lock is closed and 
the lid everted the second time by turning the forceps upward. 
If the conjunctival sac has been well cocainized at the outset, the 
lid may be everted without pain. Before the incision is made, one- 
third c.c. of a 1 per cent, solution of cocain should be injected under 
the conjunctiva into the tissues between the point of the forceps and 
23 THE LACHRYMAL APPARATUS 
24 
the external canthus. The gland should be resected in one piece 
and not in fragments. 
Conjunctival Incision.-—The incision through the conjunctiva is 
made with a pair of small curved scissors, and extends horizontally 
from the point of the forceps toward the external canthus for a dis- 
tance of about i cm. The lobules, which may be numerous and well 
developed, at other times few and small, protrude through the wound 
as soon as the connective-tissue membrane which encapsulates the 
lachrymal gland is opened. (The cocain-injection may obscure the 
outlines of the structures at this time.) 
Fig. 13.—Extirpation of the lachrymal gland. The upper lid is turned upward 
twice—i.e., upon itself—and is maintained in this position by a lock pincette held by an 
assistant at the outer third of the lid. The conjunctiva (c.) is freed on both sides of the 
gland. The wound is held open with double tenacula. In it is seen lying perfectly free 
the lower lachrymal gland (gl.), appearing as a small nodule. 
The conjunctiva is carefully dissected loose both in an upward and 
downward direction toward the tarsus and the ocular conjunctiva. 
The assistant retracts both portions of the conjunctiva with a double 
tenaculum. The lachrymal gland, which appears as a small node in 
the center of the wound (Fig. 13), is grasped with forceps and sepa- 
rated from the orbital lachrymal gland with scissors, beginning at the 
nasal end. It is not necessary to dissect high up into the orbit, but it 
is important that the lobules are shelled out for their entire length, as 
only then can all the excretory ducts of the large gland be cut through. 
The amount of glandular substance removed is of no significance. EXCISION OF THE LACHRYMAL GLAND 
25 
The white membrane laid bare in the floor of the wound is the tarso- 
orbital fascia. It lies in front of the gland and does not interfere with 
its extirpation. It must not be injured, as unpleasant consequences 
will follow on account of its connection with the tendon of the levator 
palpebrse and hence the possibility of resultant ptosis. Fastening of 
the forceps at the outer third of the lid will prevent injury even if the 
dissection is carried too deep and the fascia cut. An injury to the 
Fig. 14.—Axenfeld method of gland extirpation, c., conjunctiva; gl., gland 
outer skin or the external rectus muscle can be produced only by 
reckless cutting; this is clearly apparent if the position of the gland is 
considered. The hemorrhage during the operation is slight, although 
usually disturbing, and the assistant is kept busy sponging. One 
catgut suture, bringing the wound together from above downward, 
suffices, and the dressing may be removed after twenty-four hours. 
Axenfeld Method.—Instead of doubly everting the lid, this oper- 
ator employs two blunt double hooks, one inserted directly below the 
external canthus into the border of the lower lid, and one about half a 
centimeter from the canthus in the margin of the upper lid (Fig. 14). 
The hooks are separated upward and slightly backward, and the 
summit of the palpebral lachrymal gland is exposed and pushed 
forward. The usual incision in the conjunctiva and fascia is made, 
the gland seized and drawn forward with forceps, and the branches 
of the Axenfeld peans introduced as deep as possible along each side 
and closed. The gland is excised with scissors close in front of the 
instrument. Sutures are not necessary. 26 
THE LACHRYMAL APPARATUS 
This method of operation avoids the somewhat painful double 
eversion of the lid, makes a smooth exposure of the upper surface of 
the gland, relieves the tissues of abnormal tension, and escapes the 
folding which contributes to injury of the surrounding structures. 
No gland lobules or shreds of tissue should remain in the wound to 
cause conjunctival irritation. 
Fricker’s Method.—Fricker employs a thread to expose the gland. 
After the lid is everted, a medium-sized bent needle is passed through 
the tarsus, 2 to 3 mm. from its free border and somewhat near the 
center. The two ends of the thread are drawn upward and inward, 
which causes the palpebral gland to curve outward. 
Results of Operation.-—After excision of the gland the eye is 
usually ecchymotic for some days because the blood subsides to lower 
levels. Swelling of the upper lid produces slight ptosis, but this soon 
disappears. The final result is generally good, even though occasion- 
ally lachrymation is but little diminished. In one such case, even 
though the operation was performed according to every rule men- 
tioned, weeping persisted to such a degree that it became necessary to 
remove the entire orbital lachrymal gland. This operation is per- 
formed through an incision from the skin. 
Dryness of the conjunctiva or the cornea need not be feared either 
after extirpation of the inferior or the entire lachrymal gland, as the 
glands of the normal conjunctiva provide sufficient secretion. How- 
ever, after extirpation of the lachrymal gland, an obstinate and long- 
lasting catarrh of the conjunctiva associated with thick mucoid dis- 
charge is occasionally seen. 
LACHRYMAL PROBING 
Indications.—Constant epiphora indicates probable stenosis of 
the naso-lachrymal duct, and probing will be required until the 
lachrymation ceases or the duct is large enough to permit a No. 5 
probe to be readily passed. If the epiphora is associated with a 
decided blennorrhea, stenosis exists in nearly all cases. Conservative 
measures (passing of probes and lavage) are only employed in those 
cases of blennorrhea which are not yet too far advanced. If the walls 
of the sac are already markedly thickened, or the sac dilated or per- 
forated after acute inflammation, conservative treatment is of uncer- 
tain value. The blennorrhea itself is treated with a per cent, silver 
solution, in preference to all other agents. LACHRYMAL PROBING 
27 
Diagnosis of Stenosis.—Stenosis of the duct is determined by 
cocainizing the conjunctiva, dilating the canaliculus, and inserting 
the canula of the lachrymal syringe into the sac. If the naso- 
lachrymal duct is passable, very little pressure will carry the fluid 
through into the nose of the patient, as he holds his head forward. If 
the passage is narrow, the fluid will not flow through for a short time, 
and then only in small quantities, while the greater part escapes 
through the superior lachrymal canaliculus. The latter occurs if the 
lachrymal sac and the naso-lachrymal duct are completely occluded. 
Only moderate pressure is to be used or the fluid will be forced into 
the surrounding tissues. After once making certain that the passage 
is narrow or completely occluded, the probes should be employed, 
beginning with No. 2. If cocain cannot be injected before passing 
Fig. 15.—Ariel's syringe. One-half size. 
even the small probe, the attempt will be rather painful; at the second 
trial, however, one can usually force a few drops of a 3 per cent, 
solution through. 
Chronic epiphora does not, however, always mean stenosis of the 
naso-lachrymal duct, nor does this condition always rest on a mechan- 
ical basis. It may be a reflex symptom of diseases of the conjunctiva, 
the lachrymal passages, the nose, etc.; or may depend upon central 
disturbances. 
If a marked blennorrhea of the sac exists, the examination, as be- 
fore, is preceded by testing the permeability of the lachrymal pas- 
sages. In nearly all the cases a stenosis will be found, and the treat- 
ment as above described must be instituted. 
Anesthesia.—Before probes are inserted the naso-lachrymal duct 
is made anesthetic with an injection of a 3 per cent, solution of 
cocain. The best instrument for this purpose is Anel’s syringe 
(Fig. 15). The most suitable model has a ring at each side; the 
second and third fingers are placed in these, while the thumb presses 28 
THE LACHRYMAL APPARATUS 
the piston down. The syringe-point is placed upright into the 
lachrymal canaliculus, is then changed to a horizontal direction and 
pushed into the lachrymal sac just as if it were a probe. In this posi- 
tion the fluid flows in with the slightest pressure. If there is a 
stenosis of the naso-lachrymal duct, a small amount of fluid will 
slowly run from the nose as the patient bends the head forward. If 
considerable resistance is felt, the fluid should not be forced out of the 
syringe under too great pressure, as it will either escape through the 
superior lachrymal canaliculus or it will be forced into the surround- 
Fig. 16.—Introduction of the conical probe into the lower lachrymal canaliculus. 
The lid is pulled outward with one finger, and the lachrymal punctum thus turned 
slightly forward. The probe is inserted vertically. 
ing tissues from the lachrymal sac, setting up swelling of the lids 
which persists for several days, and for which the patient usually 
blames the physician. The douching of the lachrymal sac should 
never be performed with the patient lying down, especially if the 
fluid is a cocain or bichlorid solution, as, should the naso-lachrymal 
duct be open, the solution will flow into the pharynx. 
Dilatation of the Canaliculus.—Before attempting to pass a 
Bowman’s probe, the lachrymal canaliculus must be dilated with a 
conical probe. Before using the probe the patient is asked to look SLITTING THE CANALICULUS 
29 
up, and the lower lid is pulled outward and slightly away from the 
bulb, thus making the lid tense. The lower lachrymal canaliculus at 
first passes for a short distance downward, the upper a short distance 
upward, and each then describe an almost right angle to empty into 
the lachrymal sac. To dilate the left canaliculus, the operator, 
sitting in front of his patient, employs his right hand. For the right 
canaliculus the left hand is used, or the surgeon may stand behind the 
patient and work with the right hand. 
After the point of the vertically applied conical probe (Fig. 16) has 
entered the first portion of the canaliculus, the probe is depressed into 
a horizontal position and then pushed slowly forward, employing a 
slight twisting movement until the bone is reached (Fig. 17). If no 
Fig. 17.—Second step in the dilatation of the lachrymal canaliculus with the conica. 
probe. The probe is placed in the direction of the canaliculus, and is pushed forward 
with short twisting movements to the median wall of the sac. 
retraction of the skin follows lightly drawing the probe backward and 
forward, it is known that its point has passed through the canaliculus 
into the lachrymal sac and has come in contact with its median wall. 
The operator must use no force in dilating the lachrymal canaliculus, 
as the point of the probe penetrates the wall easily, and a false passage 
not only makes proper probing difficult, but opens up a channel for 
fluids injected for anesthesia or cleansing to diffuse through the sub- 
cutaneous tissues, producing marked swelling of the structures in the 
neighborhood of the sac and lids. The conical probe enlarges the 
mouth of the lachrymal canaliculus so that there is usually no diffi- 
culty in passing a No. 5 probe. 
Slitting the Canaliculus.—The slitting of the lachrymal canalicu- 
lus for the purpose of passing these probes is not to be recommended. 30 
THE LACHRYMAL APPARATUS 
The canaliculus is a good guide for Bowman’s probe and with its aid 
the sac is always easily entered. When the canaliculus has been 
slit open, it may become difficult to find the beginning of the portion 
which has been left intact and which forms the point of entrance to 
the lachrymal sac. Bitter experience has shown how fruitless such 
efforts may be, as occasionally the probe cannot be passed at all, 
Fig. 18.—Weber’s knife. 
the aperture after the slitting contracting secondarily through the 
formation of delicate scar-tissue around it. 
The canaliculus should be slit only if through eversion of the in- 
ferior lachrymal punctum the course of the tears has been diverted 
and they trickle down the cheek, or if an ectropion of the lower lid has 
Fig. 19.—Weber’s knife introduced in the lower canaliculus. Cutting edge looks 
upward and slightly backward. 
begun to develop. Slitting the lower canaliculus converts it into a 
channel which communicates freely with the conjunctival sac; the 
tears are thus guided into their normal path and one of the main 
causes of ectropion is removed. This operation is performed with a 
Weber’s knife, which has a delicate probe point, shaped like an olive, 
that rests upon the short neck near the blade (Fig. 18). The knife is 
inserted into the dilated canaliculus and pushed in until the probe PROBING THE LACHRYMAL DUCT 
31 
point touches the bone. The cutting edge of the knife is directed 
upward and slightly backward (Fig. 19). The finger pulls the lid out- 
ward, making it tense, and the knife, the probe point of which remains 
against the bone, is turned up, thus cutting the lateral part of the 
canaliculus (Fig. 20). The hemorrhage is slight. To prevent heal- 
ing, the wound-edges must be separated occasionally during the 
next few days with the conical probe until the epithelium has grown 
over them. 
Probing the Duct.—For this purposes we use Bowman’s probes, 
Nos. 1 to 6. The point of the probe is placed vertically into the 
dilated lachrymal canaliculus, and, after it has passed the lachrymal 
Fig. 20.-—Weber’s knife turned up. 
punctum, its direction is changed to the horizontal, the skin of the 
lid being drawn outward at the same time. When the tip of the 
probe strikes the bone, the lid is released and the instrument raised 
to the vertical position. 
Unless the probe is kept in contact with the bone while it is raised 
from the horizontal to the vertical position, the duct will not be 
entered and a false passage will be made. The common error is to 
draw the point away from the bone as the probe is carried upward. 
Strong pressure should not be made, however, otherwise the probe 
point may penetrate the lachrymal bone. If an attempt is made to 
push the probe down before it has reached the vertical position, the 
oblique angle may lead to perforation of the inner wall of the sac or 
duct, and possibly also the bone. If the probe is in the correct 
position, a slight push downward causes it to glide into the duct 32 
THE LACHRYMAL APPARATUS 
provided there are no adhesions. Stenosis and adhesions will be 
indicated by resistance, but if the probe is positively in the duct 
slight force may be employed to push it through. An indication 
that the probe is in the upper part of the duct is shown by its remain- 
ing standing when the hand is taken away. If the probe has been 
inserted properly, its plate will be on a level with the eyebrows (Fig. 
21) and it will have retained the slightly curved shape and position 
into which it has been brought. If the probe has entered a false 
passage, it can be recognized by its unusual position. Ordinarily 
the rough ends of the perforation in the bone, through which the 
probe has been pushed, may be felt. 
Fig. 21.—Bowman’s probe is passed through the naso-lachrymal duct. The small plate 
of the probe is on a level with the eyebrow. 
The probing is begun with No. i, and is repeated every second or 
third day, the size of the probe being gradually increased until No. 5 
is reached. It is well to remember that a thick probe may at times 
pass by a fold easier than a thinner instrument. The passage of the 
probe may be considerably facilitated by the addition of a small 
amount of adrenalin solution to the cocain. This contracts the 
blood-vessels in the wall of the duct, thus increasing its lumen and 
with it the space for the penetration of the instrument. 
The instrument should be permitted to remain in the naso-lach- 
rymal duct at least fifteen minutes each time. The probing must be 
continued until the fluid from Anel’s syringe flows easily through the 
channel. If epiphora continues it may be considered a proof that, in 
spite of the normal permeability of the lachrymal canaliculus, tear- 
conduction and possibly even tear-secretion is disturbed. Tear-con- OCCLUSION OF THE DUCT IN CHILDREN 
33 
duction, as is well known, is not dependent alone on the normal 
permeability of the nasal duct, but also, and perhaps to a greater 
degree, on the normal activity of the sac. In such cases it does not 
improve the symptoms to continue the ordinary probing or to employ 
the larger instruments. 
Probing through the Superior Canaliculus.—It may be impos- 
sible to pass probes through the inferior lachrymal canaliculus in the 
manner described, owing to occlusion by scars following burns or 
injuries. The probes must then be passed through the superior' 
canaliculus. Its course is analogous to that of the lower; first, 
vertically upward, followed by a curve toward the sac. After dilating 
with the conical probe, cocain is injected into the sac with Anel’s 
syringe. Bowman’s probe is inserted in the direction of the naso- 
lachrymal duct, i.e., in vertical position. 
Occlusion of the Duct in New-born Children—The secretion 
of the sac is occasionally retained in the new-born, leading to con- 
siderable dilatation. This is the result of a congenital, but only 
epithelial, occlusion of the duct, and it is relieved in most instances by 
pressure over the course of the sac, with expression of the retained 
fluid, and the use of a mild alkaline and astringent wash. Should this 
treatment fail the passage of a small probe will effect a cure. The 
operation is not more difficult in the new-born than in the adult, but 
the distance between the lachrymal punctum and the nose is much less 
than in the adult, and therefore the probe does not penetrate so 
great a distance. 
Hollow Probes.—To avoid the inconvenience of having to pass 
Anel’s syringe into the canal after the probe has been taken out, the 
operator may employ hollow probes, to which Anel’s syringe can be 
fastened while the probe lies in the naso-lachrymal duct. When such 
a probe is pulled out, the solution washes the duct most thoroughly. 
A fistula in the tissues about the sac is an indication for the lavage 
of the sac. To determine whether the fistula is connected with the 
sac, a blue douche solution should be used. If a tumor exists in this 
region, it may be necessary to pass probes to determine whether or 
not the sac is free. 
Contraindications to the Use of Probes.—Probes must not be 
passed in acute inflammatory conditions. If the lachrymal-sac 
disease is associated with disease of the bone (tuberculosis), the pas- 
sage of probes is contraindicated; in such cases extirpation of the 34 
THE LACHRYMAL APPARATUS 
diseased sac must be performed. As already mentioned, total steno- 
sis of the naso-lachrymal duct is also an indication for extirpation of 
the sac. 
Suturing the Canaliculi.—If the canaliculus has been recently 
torn or cut through, the severed ends should be united to restore 
the normal channel for the tears. A small conical sound is first 
introduced into the punctum and carried forward into the lateral 
opening of the torn canaliculus, which dilates this portion of the canal. 
The nasal opening of the torn duct is found by using one pair of 
forceps to grasp the skin side of the cut and another pair the conjunc- 
tival side. A conical probe is then passed into the gaping wound 
and carried to the tear-sac, which dilates the canal and renders it 
visible. One needle of double-armed silk thread is now passed from 
the external cut end of the canaliculus out through the punctum, 
and the other needle from the inner end of the wound through the 
canaliculus to the top of the sac and then vertically out through the 
skin (Raupp). As the two ends of the thread are tied gently over a 
piece of gauze, the two ends of the canaliculus glide along the thread 
and come in apposition. Some fine skin-sutures, and if necessary 
conjunctival sutures, close the wound. The thread lying in the cana- 
liculus is removed after several days. 
Elschnig recommends both skin and conjunctival sutures, which 
overbridge the tear in cross direction. After the internal end of the 
torn canaliculus is found, a fine whalebone or hard rubber sound is 
introduced from the punctum through the whole length of the canalic- 
ulus into the tear-sac. As the sutures are tied, the two cut ends of 
the canaliculus glide along the sound and heal in proper position. 
The sound is maintained in place by a suitable bandage. As the 
dressings are changed the sound is held in place by forceps. At the 
end of a week the sound is removed. 
In old injuries the scar is cut through in a perpendicular direction 
and the thickened tissue excised, if necessary. If the openings of the 
canaliculus are found, the sutures are inserted in the manner described. 
Toti’s Dacryocysto-Rhinostomia.—The operation is a substitute 
for excision of the sac, and is designed to secure a broad communica- 
tion between the sac cavity and the nose by resection of the nasal 
wall of the sac and the surrounding bone and mucous membrane. 
This converts the sac into a part of the main nasal cavity. Its lateral 
wall, in which the mouth of the canaliculi is located, thus assumes the DACRYOCYSTO-RHINOSTOMIA 
35 
function of the large piece of the resected nasal mucous membrane. 
The operation is performed as follows: 
The Skin Incision.—A cut is made through the skin, soft parts, and 
periosteum above the inner canthus, 3 mm. in front of the lid attach- 
ment of the internal canthal ligament, and sweeps around in a half 
Fig. 22.—Toti’s dacryocysto-rhinostomia. cr. a., crista lachrymalis anterior; cr. p., 
crista lachrymalis posterior; f. s., fossa sacci lachrymalis; sa., internal wall of the tear- 
sac. 
circle and approaches the lower lid border. After cessation of the 
hemorrhage, the periosteum, with the attached soft parts which 
contain the entire lachrymal apparatus, is detached from the bone as 
far as the posterior lachrymal crest (Fig. 22). 
Resection of the Bone.—The anterior border of the line of bony 
resection corresponds with the periosteum incision, the situation of 
which is 3 mm. in front of the attachment of the canthal ligament. 
From this point the anterior line of resection is upward and outward, 
and ends outward on the prolongation of the base of the posterior 
lachrymal crest and below and outward on the outer border of the 
nasal duct. This anterior border line includes resection of not only 
the anterior lachrymal crest but also its posterior nasal continuation, 
the posterior border of the rising superior maxillary process. Toti 
places particular stress on the resection of this process. The posterior 
resection line lies a little in front of the posterior lachrymal crest, and 
vertically as far as the upper and lower end of the anterior resection 
line. 36 
THE LACHRYMAL APPARATUS 
Resection of the Inner Wall of the Sac and the Piece of Nasal 
Mucous Membrane Exposed after Resection of the Bone.—The 
relation of the resected parts is shown in the illustration (Fig. 23). 
Suture of the Wound.—The incision in the skin is closed by fine 
silk sutures, and a sterile gauze dressing held in place by a bandage. 
Fig. 23.—After Toti. 1, Section of nasal bone; 2, nasal mucous membrane; 3, bone 
suture between nasal bone and superior maxillary frontal process; 4, outer surface of the 
frontal process; 5-6, resection line of the superior maxillary frontal process; 7, insertion of 
the lig. canth. int.; 8, anterior lachrymal crest; 9, central portion of the piece of bone to 
be resected; 10, anterior outline of the posterior sac-wall to be resected; u, anterior out- 
line of the nasal mucous membrane to be resected; 12, sac-cavity; 13, anterior sac-wall 
with common orifice of the canaliculi; 14, posterior sac-wall; 15, bone suture between 
superior maxillary frontal process and lachrymal bone at the base of the lachrymal fossa; 
16, posterior outline of the sac-wall resection; 17, posterior outline of the nasal mucous 
membrane to be resected; 18, resection line of the lachrymal bone at the base of the crista 
lachrym. post.; 19, bone suture between lachrymal bone and os planum; 20, section of 
the os planum; 21, crista lachrymalis posterior. 
Previous resection of a part or the whole middle turbinated bone, 
with possibly some of the ethmoid cells, is usually required, otherwise 
an obstruction is offered to free drainage. The remnant of the sac 
containing the canaliculi must enter freely into the main nasal cavity. 
Unless the entire inner wall of the sac is resected the wound-edges will 
unite from the smallness of the opening. 
Results of Operation.—The ideal result of the operation is not 
achieved if the canaliculi have been slit. west’s operation 
37 
Chronic and progressive affections of the nasal mucous membrane 
are a contraindication to the operation, as the gap in the mucous 
membrane may later close, or the nasal affection implicate the canali- 
culi and the conjunctival sac. 
The pathogenic bacteria in the conjunctival sac disappear less 
rapidly after the Toti operation than following extirpation of the 
sac, so that the latter procedure should be preferred when an intra- 
ocular operation is to be performed. 
Complete restoration of normal lachrymal drainage follows in 
about half of the operated cases. In others no secretion appears by 
pressure over the remains of the sac, although the epiphora continues. 
Occasionally the mucous membrane gap closes, and the symptoms 
of purulent sac disease return. A certain proportion of failures may 
arise from fault in operative technic. 
West’s Operation.—This intranasal method consists of excision, 
under local anesthesia, of the internal wall of the sac and removal of a 
piece of the ascending process of the maxilla, a portion of the lacrymal 
bone, and a corresponding piece of nasal mucous membrane, so that 
there is a new direct communication between the conjunctival cavity 
and the cavity of the nose. The stenosis of the lower part of the 
duct is not corrected, as the author claims it to be unnecessary, so 
long as there is free drainage through the artificial window. The 
operation may be employed in any form of sac disease, and in 
epiphora the result of stenosis, but is contraindicated in small children, 
in old and weak people, and in cases where the nasal passages are 
contracted by cicatricial tissue. The final results are said to be 
satisfactory, but the method is somewhat tedious, and requires 
considerable skill and patience. If the openings in the mucous 
membrane and in the bone are too small, they soon become closed 
with cicatricial tissue, and the original trouble returns. 
Numerous other operations for the relief of chronic inflammation 
of the sac by intranasal drainage have been described by various 
authors. In instances, however, where an intraocular operation is 
to be performed the regular and complete extirpation of the sac is 
to be preferred. CHAPTER III 
SPASMODIC AND SENILE ECTROPION 
SPASMODIC ECTROPION 
Spasm of the orbicularis muscle, provoked by inflammation of the 
conjunctiva, often leads in young persons to eversion of either one or 
both eyelids, usually the lower lid. As the condition increases the 
tarsal portion of the lid forms a sharp angle with that of the orbit, 
and the tarsal conjunctiva which turns forward becomes, with 
Fig. 24.—Snellen suture. Position of the sutures. A suture 3 mm. long overlying 
the conjunctiva corresponding to the most marked anterior curvature. Under the skin 
the sutures extend to the region of the lower orbital margin. 
disturbance of the blood supply, swollen and engorged, and presents 
the appearance of small red tumors bulging from above or below, 
filling the palpebral fissure. In most of the cases the cornea is 
unaffected, or shows only the usual superficial inflammation seen in 
scrofulous subjects. The defect of the lid may be corrected with the 
Snellen suture. 
Snellen Suture.—Two threads, double-armed with long, flat, 
strong needles, are required. One needle is inserted through the con- 
38 SENILE ECTROPION 
39 
junctiva at the junction of the inner and middle third of the highest 
point of the ectropion, i.e., usually at the lower (upper when the 
upper lid is everted) tarsal margin, and carried downward under the 
skin 2 cm., where it is brought out. The second needle is passed 
in the same manner with the other end of the suture, 3 mm. distance 
from the first (Fig. 24). A loop is formed which 
overlies the palpebral conjunctiva at the most 
prominent part of the ectropion, while below the 
two ends of the suture hang free. The second 
thread is passed in the same manner at the junc- 
tion of the middle and outer third of the ectro- 
pion. The two ends of each suture are now tied 
over a small pad of iodoform gauze and tightened 
so as to bring the lid back to its normal position. 
The loops exert their action on the highest point 
of the affected lid (Fig. 25), which is drawn down 
again to its proper position. 
The same suture may be employed in the treat- 
ment of spasmodic ectropion of the upper lid, the threads being drawn 
through the skin slightly above the upper orbital margin. 
The sutures are allowed to remain in position for at least three 
or four days, or until the edematous infiltration of the conjunctiva 
has disappeared, as the swelling tends to push the lid away from the 
eyeball. Since spasmodic ectropion is most commonly associated 
with catarrhal secretion, the eye should not be bandaged, but a strip 
of plaster applied over the knots. 
Fig. 25.—-Vertical 
section through the 
everted lower lid with 
the sutures in posi- 
tion. 
SENILE ECTROPION 
Senile ectropion of the lower lid is the result of alteration in all of 
the lid tissues, produced by age and chronic inflammation of the 
conjunctiva and lid-margin. The skin is relaxed, the conjunctiva 
thickened and everted by inflammatory infiltration, the tarsus 
softened and enlarged in all its diameters, and the muscle weakened 
so that it is unable to retain the lengthened lid-margin in contact 
with the eyeball. Thus, epiphora results, which contributes to an 
increase in the malposition of the lid through its action on the skin, 
and indirectly by forcing the patient to wipe away the tears, whereby 
the lid is pulled down. The Snellen suture is not sufficient to exert a 
permanent effect on the defect, and it is only by shortening of the 40 
SPASMODIC AND SENILE ECTROPION 
elongated lid-margin that it is held in place in contact with the eye- 
ball. One of the first operations employed to correct this condition 
was the excision of a triangular piece from the whole thickness of the 
lid, the base of the triangle corresponding to the lid-margin. As the 
sutures in the wound-margins were tied the lid was drawn into its 
normal position. This simple procedure had the great drawback 
that there remained a coloboma of the lid. The cartilage, always 
soft and friable in lids with chronic ectropion, did not offer sufficient 
support to the sutures, the muscle action of the lid tended to separate 
the wound-edges, and the secretions prevented rapid healing, so that 
the operation usually failed, and is now seldom performed. 
Kuhnt endeavored to avoid the indentation of the lid-margin by 
an incision along the intermarginal border of the lid, securing the 
necessary shortening by the excision of a triangular piece exclusively 
from the tarsus. The surplus fold of skin which remained as an 
ugly prominence, Muller attempted to remove by obliquely suturing 
it to the tarsus. 
Szymanowski suggested that the lid-margin be shortened by the 
excision of a piece of skin from the region of the external canthus, 
and in this way attempted to draw the lid outward and at the same 
time elevate it somewhat. The relaxed skin, however, stretches after 
a time, and the ectropion recurs. 
Kuhnt-Szymanowski Operation.—This is a combination of the 
tarsal and cutaneous operations, yields perfect results, and should be 
employed exclusively for the treatment of senile ectropion. The 
several steps of the procedure are clearly shown in the illustrations— 
the intermarginal incision, the excision of the tarsus, the excision of 
the skin, and the tarsal and skin suturing. 
The Intermarginal Incision.—As there are many conditions in 
which splitting of the lid-border is required, it may be stated here 
that the sound lid at its free border has two edges, the posterior, 
rather sharp, closely applied to the eyeball where the conjunctiva 
and the surface of the lid-margin meet at a right angle, and the 
anterior, rounded, where the surface of the lid-margin joins with the 
skin surface containing the cilia. Between these two edges is a fine 
furrow of grayish color, the intermarginal line, which runs the length 
of the lid-margin, closely behind the anterior border. A lancet, 
introduced with its cutting edge along this line, enters the substance 
of the lid without resistance and splits it into two laminae, the KUHNT-SZYMANOWSKI OPERATION 
41 
anterior, consisting of the skin and the fibers of the orbicularis muscle, 
and the posterior, consisting of tarsus and conjunctiva. For the 
purpose of splitting the lid-border, in the absence of marked deform- 
ity, an assistant introduces a horn plate deeply into the culdesac, 
and by suitable pressure stretches the lid, so that the margin is 
slightly turned out and the furrow visible. The point or lateral 
cutting edge of the lancet is gently carried along the intermarginal 
line until a gaping of the two lid laminae shows that the cleavage is in 
the proper place. The connection of the two laminae is intimate 
along the lid margins, but otherwise the tissues are loose, and the 
separation progresses easily and quickly. The first tracing of the 
incision with the lancet along the intermarginal line is done with 
special care, in order that there is no injury to the free border of the 
anterior or posterior laminae by deviating from this line, which would 
result in a permanent indentation or coloboma. 
Local Anesthesia.—The lid-margin, which is richly supplied with 
sensitive nerves, is rendered anesthetic by injections of the i per 
cent, solution of cocain with adrenalin, which is first injected under 
the skin of the lid, somewhat below the lid-margin, and from this 
position the point of the needle is pushed forward toward the 
margin. If the injection is properly made the whole area becomes 
blanched. The adrenalin lessens the hemorrhage, especially if 
the injection is made not only under the skin and in the intermar- 
ginal area, but also in the tissue of the tarsus, which can be easily 
accomplished when the parenchyma of the tarsus is thickened and 
soft. 
In senile ectropion the method described of splitting the lid- 
border requires to be modified to meet the changes in the form of 
the lid. By its eversion the posterior border becomes indistinct, 
and the intermarginal line indiscernible by the thickening of the 
conjunctiva and epithelium up to the cilia. The relaxed and length- 
ened lid cannot be stretched over the horn plate, and must there- 
fore be grasped with the left hand between the thumb on the skin 
surface and the index finger on the conjunctival side (Fig. 26). 
This fixes the lid and permits the incision to be made without 
annoying hemorrhage. Instead of endeavoring to make the incision 
by carrying the knife along the intermarginal line, which cannot 
well be done on account of the indistinctness of the lid-border, the 
point of the lancet, with the surface of the blade parallel to the lid 42 
SPASMODIC AND SENILE ECTROPION 
surface, is entered at the desired point close behind the cilia and 
slowly pushed down until it has penetrated as far as the length of its 
base will allow. By repeating the same procedure in other points, 
the incision may be lengthened as much as desired. The lengthen- 
ing of the incision by pushing the lancet laterally, after it has passed 
Fig. 26.—Kuhnt-Szymanowski operation. The lid is fixed between the thumb and 
index finger of the left hand. The lance is pressed forward, its flat surface parallel to the 
surface of the lid, in the intermarginal border, at first in the center of the lid. The 
incision is next continued outward to the external canthus, as the line indicates. 
down between the two layers of the lid, is not to be recommended, as 
there is always a risk of the blade leaving the intermarginal border 
and deviating forward, injuring the skin, or backward and penetrat- 
ing the tarsus. It is decidedly safer, after an incision has been made 
corresponding in length to the breadth of the lancet, to insert the 
point of the lancet in another place on the intermarginal border and 
bury it in the tissue; and, when necessary, even to insert it in a third 
place. The several incisions may be readily united by cutting 
through the separating fibers. In this manner the lid is divided with- 
out injury to the anterior or posterior layers. 
The intermarginal incision in the ectropion operation is started 
at the juncture of the middle and the inner third of the lid, and is KUHNT-SZYMANOWSKI OPERATION 
43 
extended to the external canthus. Precaution must be observed not 
to wound the skin, which may produce a coloboma of the lid, or to 
injure the roots of the eyelashes. An injury of the tarsus in the 
Fig. 27.—Kuhnt-Szymanowski operation. Two vertically-held forceps raise a fold 
(f.) of the tarsus, so that it projects prominently forward. In this manner we determine 
how much must be excised from the tarsus so that the lid will subsequently lie properly 
against the eyeball. 
portion to be excised is of no importance, but if it occurs beyond this 
area exact suturing of the tarsal wound is impossible. The two 
laminae of the lid are divided down to the lower margin of the tarsus. 
Fig. 28.—Kuhnt-Szymanowski operation. The measured part of the tarsus has been 
excised. The triangle is drawn in the region from which the skin is to be excised. 
Excision of the Tarsus.—The length of the triangular piece of tarsus 
to be removed depends upon the degree of the ectropion. If too 
little is excised, the ectropion is not corrected; if too much, the two 
edges of the tarsal wound cannot be re-united by sutures. The 44 
SPASMODIC AND SENILE ECTROPION 
operator should raise a fold of the tarsus with two pairs of forceps, and 
determine exactly how much must be removed to allow the shortened 
lid to lie properly against the eyeball (Fig. 27). The forceps should 
be held in a vertical position, near the eye, and the fold (/) allowed to 
protrude forward. The excised portion may be only 5 mm. or 10 
mm. or more. 
The piece of tarsus is taken exactly from the middle of the lid 
with a pair of short, straight scissors. A cut is first made from the 
Fig. 29.—Kuhnt-Szymanowski operation. The triangular piece of skin is excised, 
and the skin of the lid undermined and turned outward. The three sutures through the 
tarsus lie in their proper position. The principal fixation suture of the flap (a.b.) is 
likewise drawn through. The cilia are excised from the corresponding part. 
inner corner through the tarsus, and the piece excised by cutting from 
the other side obliquely downward from the edge of the lid for a cor- 
responding distance. The excision includes only the tarsus and the 
overlying conjunctiva. The conjunctiva posterior to the tarsus must 
not be touched by the incision. The bleeding is usually insignificant, 
but, if severe, may readily be checked by two hemostatic forceps. 
Excision of the Skin.—The excision of the triangular piece of 
skin is made from the region of the external canthus (Fig. 28). The 
first incision is made with a scalpel or lancet from the canthus outward KUHNT-SZYMANOWSKI OPERATION 
45 
and is carried a trifle upward to b. Its length equals, or exceeds 
somewhat, that of the piece excised from the tarsus. 
The second incision starts from the canthus and is carried down- 
ward and a trifle outward. It is easily twice as long as the first, so 
that its lower point lies vertically below the outer end of the first 
incision. The ends of these two incisions are united by a third, and 
the piece of skin so isolated is excised. The skin of the lid is now 
completely undermined so that it may readily be drawn outward to 
cover the defect produced. 
The Tarsal Sutures.—The open wounds are now united. The tri- 
angular opening in the conjunctiva and tarsus is united by three fine 
silk sutures (Fig. 29). The fine, curved needle is inserted below, near 
the point of the triangle, pushed from the conjunctival side through 
the tarsus out to the wound, and carried on the opposite edge from the 
wound side through tarsus and conjunctiva. The needle must not 
be passed too close to the edge of the wound, because the tarsus, as 
has already been mentioned, is easily torn, and, if the sutures have 
once cut through, a second fixation is difficult. Both ends of this 
suture are turned upward. The second suture is inserted through the 
middle of the tarsus, and both ends should be placed horizontally. 
Special care is taken to properly place the last suture, to insure exact 
union of the wound and re-establish the margin of the lid, by passing 
the needles through the tarsus close to the edge. The threads are 
turned downward. 
The pair of sutures turned upward are tied first. Nothing is more 
unpleasant for the operator than to be compelled to search for the 
threads belonging together by drawing one end to find its fellow; for 
this reason, detail description of the arrangement of the suture ends is 
dwelt on. As soon as the first suture is tied, and the edges of the 
wound in the tarsus approximated, the lid begins to roll inward. 
This movement is assisted by holding the threads upward in tying, 
thereby avoiding separation of the lid from the eyeball. After the 
three sutures are tied, the threads are cut off close to the knots. 
On the cadaver the union of the two margins of the wound is more 
difficult than on the living, because the tarsus presents only as a thin 
membrane. In patients, the wound-surfaces lie in much better appo- 
sition in consequence of the thickened tarsus presenting a broad sur- 
face. Usually the help of an assistant is not necessary in bringing 
the margins of the wound together. 46 
SPASMODIC AND SENILE ECTROPION 
If the two portions of the lid-margin do not fit, the small super- 
ficial projecting wedge may be removed from the longer portion by 
scissors. 
Closing the Skin Opening—Before the skin of the lid is drawn 
over to close the triangular opening, a small strip of the skin of the 
lid-margin which would lie beyond the external canthus is excised in 
order to remove the eyelashes. The first suture is inserted to the 
outer angle of the defect (b), and the suture immediately tied. As in 
Fig. 39.—Kuhnt-Szymanowski operation. Appearance after the operation. The 
lower lid lies in its proper position; 4 (ab., c., d., e.) sutures suffice for the fixation of the 
flap. One suture for the fixation of the skin to the tarsus is tied over a bead (f.). 
every skin-suture, accurate approximation of the edges of the wound 
is absolutely necessary. Next follows a suture (e) along the upper 
margin of the flap and the skin to the outer side of the upper lid. In 
addition two skin-sutures, (c) and (d) are inserted. A suture between 
the tarsus and the skin of the lid-margin must be made if not already 
in good apposition. A gaping fissure is occasionally found between 
the tarsus and the center of the lid-margin, so that primary union is 
not possible. This may be corrected by a suture, double-armed, the 
two needles passing from the conjunctival side out, at a distance of i 
mm. from the margin of the lid and 2 mm. from each other, through 
the tarsus and forward through the skin and tied over a small pad of 
gauze or a bead (Fig. 30). An ordinary suture would produce an 
unsightly indentation on the margin of the lid. 
After the operation is completed the shortened lower lid lies 
closely against the eyeball and is at the same time slightly elevated. KUHNT-SZYMANOWSKI OPERATION 
47 
Dressing.—A small amount of iodoform ointment is placed in the 
conjunctival sac, and a light pressure bandage applied to keep the 
flap firmly in contact with the underlying structures. Both eyes 
should be bandaged for four days. This ensures immobility of the 
orbicularis muscle, allows the cornea to rotate upward and lie behind 
the upper lid, avoiding the danger of ulceration from friction of the 
knots, and aids in prompt healing of the wounds. 
The bandage should be carefully lifted on the day following the 
operation to see the condition of the cornea. After four days 
the sutures may be removed from the tarsus, and a day later from the 
skin. Should one or more of the sutures in the tarsal wound tear out 
prematurely, the tear must be allowed to heal by granulation. 
Beyond delay in the course of healing, this occurrence has no 
significance. 
After-treatment and Results.—The result of the operation is always 
brilliant if the excised piece has been of a sufficient size. The resul- 
tant scar is scarcely visible. The existence of a corneal ulcer does not 
contraindicate the operation; on the contrary, it can readily be seen 
how healing of such an ulcer might be effected without any further 
treatment than replacing the protecting lid into its proper position. 
On account of the softness of the tissues, the suture in the tarsus 
may cut through at once, especially if the excised portion has been too 
large and the structures are markedly stretched. For this reason the 
needle must not be passed too close to the margin of the wound, but 
far enough away to allow the suture to have proper support. 
The greatest advantage of this operation is that if the sutures in 
the tarsus should cut through there is no danger of a coloboma, as the 
skin, which forms the plate of the lid, remains uninjured. Care 
must be taken, therefore, not to injure the skin in making the in- 
termarginal incision. As the skin itself is frequently highly friable 
and atrophic, the skin-suture may also cause trouble. 
In excising the triangular skin-flap, the upper incision must not be 
carried directly upward, as Szymanowski has advised, but only 
slightly inclined upward. Otherwise, the skin of the lower lid will be 
drawn too far over the tarsus, and the union made much more diffi- 
cult. If the pressure-dressing is properly applied, no secretion is 
retained beneath the flap to cause rupture of the skin-sutures and 
compel their removal. If the skin is stretched too far outward, it 
exercises so much tension in the region of the lower border of the 48 
SPASMODIC AND SENILE ECTROPION 
tarsus that this pressure backward against the bulb causes the free 
margin of the lid to turn outward, and ectropion again arises. A 
Snellen suture is the only method to bring back the lid to its normal 
position. 
In cases of bilateral ectropion the operation should be performed 
on both eyes at one sitting, because when the operation is confined to 
one eye both eyes must be bandaged, and thus time and annoyance 
are saved. 
If the ectropion is not far advanced, the ordinary Kuhnt operation 
with possibly Muller’s modification, is recommended. In such cases 
the intermarginal incision is made from the middle outward toward 
the can thus; the corresponding piece is excised from the tarsus; the 
tarsal sutures are made as above described; and the skin is attached 
to the tarsus by several sutures inserted obliquely, to avoid the for- 
mation of one large fold of skin. The several small folds of the super- 
fluous skin later become entirely invisible. 
The operation may also be performed on the inner half of the lid, 
if only this portion is everted, as it often is in beginning ectropion, 
the external half being in normal position. 
PARALYTIC ECTROPION 
For correction of this deformity, resort must be had to the opera- 
tion of tarsorrhaphy, which is described on page 104. CHAPTER IV 
CICATRICIAL ECTROPION 
The correction of cicatricial ectropion consists essentially of two 
operative procedures: 
1. The dissection of all cicatricial tissue so as to release the lid 
and allow it to be replaced in normal position. 
2. The covering of the raw surface that remains with epithelium, 
so that no new scar-tissue will form to draw the lid again into faulty 
position. 
Recent Injuries.—The experience of the war has shown that 
much can be done by treatment to prevent the development of 
ectropion, or at least to limit by appropriate measures excessive 
cicatricial changes and marked deformity. Small wounds that are 
clean may be primarily brought together with sutures, but inflamma- 
tory infiltration or traumatic necrosis of the wound-margins and 
the neighboring tissues forbid the use of sutures to entirely close the 
opening. If sutures are applied too early there is increase in the 
inflammation, the discharge is retained, and the sutures soon cut 
through the softened tissues, causing the wound to gape as before. 
It is only by proper antiseptic treatment, and after the tissues have 
regained their normal tone, that sutures may be employed with 
benefit. Extensive wounds, such as follow many war injuries, 
cannot be sutured primarily on account of the extensive loss of 
substance; but in spite of unclean wound conditions or traumatically 
badly damaged wound-margins the position of the lid may occasion- 
ally be improved by one or more sutures, which do not close the 
wound. By this means the lid after cicatrization may either not be 
displaced or if in faulty position the deformity is considerably less 
than if the sutures had not been used. 
If conditions prevent the suturing of the wound-margins during 
the first eight or ten days after injury, operative interference must be 
postponed until cicatrization is complete, at which time the edema 
and infiltration have disappeared and it is possible to determine the 
extent of the plastic work required to correct the position of the lid. 
49 50 
CICATRICIAL ECTROPION 
Some improvement in the ectropion may be secured by early massage 
of the scar-tissue. In extensive burns operation is also postponed 
until all contraction of the scar-tissue has terminated. Immediately 
after some forms of injury the lids must be stitched together either 
in a circumscribed area or completely to prevent outward turning 
of the lid margin. Where it is impossible to secure protection of the 
eye by the lids, the moist chamber bandage may be employed for any 
period desired. 
If the ectropion is due to caries, and there is a discharging fistula, 
operation on the lid is postponed until the diseased bone has been 
exposed and the sequestrum removed. Tarsorrhaphy, which fixes 
the margins of the two lids, is of value in some cases to prevent 
increase of the lid defect during the period of acute inflammation. 
Anesthesia.—Local anesthesia is indicated in all minor lid 
operations, and is obtained by injections of the i per cent, cocain- 
adrenalin solution under the skin and in the cicatricial tissue. For 
extensive plastic operations, general anesthesia is preferred, partly 
because of the long duration of the work. 
Operation: Releasing the Lid.—An incision is made with a 
scalpel, 3 mm. from the lid-margin or, where the lid-margin has been 
destroyed, parallel to the limit of skin and conjunctiva, in the whole 
length of the scar until the lid, entirely free and movable, can be 
placed in its proper position. If the scar-tissue extends to the bone, 
the orbital margin is laid bare. The dense cicatricial tissue which 
is poorly supplied with blood-vessels is excised until sound tissue 
is exposed, which bleeds freely. Frequently the cicatricial tissue 
radiates beneath the healthy skin for a greater distance than 
expected. The original incision must then be lengthened and the 
margins undermined, so as to permit the lid to be released. 
Covering the Wound.—After the loosened lid has been restored 
to its normal position, the upper and lower lid-margins are sewed 
together, and it is then possible to judge the amount of wound 
surface that must be covered. There are three methods that may 
be employed, which are essentially different: 
(a) The adjacent skin is undermined and drawn over the wound 
by sutures. 
(b) Non-pedicled skin-flaps. 
(c) Pedicled skin-flaps from the neighboring area or from other 
parts of the body, usually the arm. NON-PEDICLED SKIN, FLAPS 
51 
(a) Use of Sutures.—It is only possible to close the wound by 
sutures if the incision made to free the lid is short and the surrounding 
skin is normal. Thus, eversion of a portion of the lid after caries 
of the orbital margin may be corrected, after division of the scar 
and replacement of the lid, by undermining the surrounding skin, 
so that the horizontal incision is converted into a vertical line after 
the wound-edges are drawn together with sutures. By this approxi- 
mation of the wound in a vertical direction opposite to the previous 
contraction of the scar, the lid is drawn more closely to the eyeball 
and remains in its normal position. 
The V-Y Operation .—This is another method of closing the 
wound, and is useful in moderate degrees of ectropion of the lower 
Fig. 31.—V-Y operation. The flap of skin bounded by the V-shaped incision is car- 
ried up (direction of the arrow). The wound is then closed, so that it forms a Y. 
lid from cicatricial contraction of the skin following severe ulcerative 
blepharitis or eczema. A V-shaped incision corresponding to the 
extent of the scar is made with the point of the V downwards, and 
the flap of skin bounded by the two cuts is loosened up to the lid- 
margin. Any cicatricial tissue beneath is removed and the lid 
replaced in normal position. As the flap shrinks after detachment 
from the underlying tissue, the lateral margins of the wound are 
undermined, and the lower halves brought together, while the remain- 
ing portions are united with the margins of the flap. After the 
sutures are in place the Y-shaped figure results (Fig. 31). 
(b) Non-pedicled Skin-Flaps.—Sutures alone are insufficient if 
the wound is large, as there is not sufficient skin in the neighborhood, 
and frequently that which is available has undergone cicatricial 
changes from burns or disease and is unyielding. In the majority 
of cases, therefore, the wound must be covered by skin-flaps, and 
since these cannot be formed from the cicatricial tissue in the neigh- 
borhood, delicate flaps without pedicle are to be recommended. 
Flaps with pedicles project from the surrounding skin as thick ir- 
regular elevations, and produce disfigurement, whereas non-pedicled 52 
CICATRICIAL ECTROPION 
flaps apply themselves smoothly against the denuded tissue, and, 
after some time, present the same folds as the healthy lid and are 
differentiated from their surroundings only by their somewhat 
lighter color. The claim that non-pedicled flaps constantly contract 
and destroy the results of the operation is not justified. We have 
formed new upper and lower lids by means of non-pedicled flaps, 
and they are still, after some years, in a faultless position. Utiliza- 
tion of the surrounding skin was absolutely impossible in consequence 
of marked cicatricial contraction following corrosion with vitriol. 
In the use of transplanted non-pedicled flaps, a marked over- 
correction of the defect is the first essential. In severe cases the 
whole upper and lower lids are found turned outward to the region of 
the orbital margin, and the upper lid closely adherent to the eyebrow. 
Occasionally the margin of the lid is relatively well preserved. 
The division of the scar and the releasing of the lid is similar to 
that described for ectropion due to caries. On the upper lid it is 
often difficult to keep within the narrow zone between the eyebrow 
and margin of the lid, since the lid is drawn so far from its normal 
position. If no lid-margin is present, the incision is made, if possible, 
at a distance of 2 mm. from the margin of the conjunctiva. After 
the scar is completely divided or excised, the lid, which is now freely 
movable, is drawn well over the other lid—the upper down over the 
lower, or the lower up over the upper. Three strong sutures are now 
passed through the margin of the freed lid and are fastened, either 
on the cheek (if the upper lid) or on the forehead (if the lower lid); 
both suture-ends must be passed through the skin and tied over a 
small pad of iodoform gauze. Thus, the defect to be covered by a 
flap will considerably exceed in size the dimensions of the normal lid. 
The hemorrhage may be checked either by compression or by 
temporary clamping with hemostatic forceps. The latter may be 
twisted off after a short time. Ligature with catgut is only necessary 
for the larger vessels. The bleeding from the small vessels in the scar 
soon ceases.- The wound has an irregular, obtuse triangular appear- 
ance, its surface showing as a depression below the orbital margin 
and toward the side of the nose. It is now temporarily covered with 
a tampon saturated with warm normal salt-solution. 
Preparing the Skin-graft Flaps.—These are taken from the inner 
side of the upper arm. In order to form an idea of the size and shape 
of the flap to be excised, apiece of gutta-percha tissue, corresponding PREPARING SKIN-GRAFT FLAPS 
53 
to the wound in form and size, is laid on the part from which the skin 
is to be excised. After thorough disinfection, the skin of the arm is 
well stretched in an oblique direction by the assistant. As the skin 
retracts considerably after being loosened, the flaps must be made 
much broader and a trifle longer than the size of the gutta-percha 
pattern. The flap should not be wholly separated at once. An 
incision is first made on one side with lateral prolongations from each 
end for a short distance. The flap is now ready to be dissected with 
the lancet (keratome). Only the superficial epithelial layers should be 
removed in the form of a single flap, and the lancet serves better 
than any other knife for this purpose. If the blade is placed parallel 
and close to the skin, it is not difficult by a stroking motion to 
separate the superficial epithelial layers if done slowly and with 
great care. 
After a small strip has been freed, it is rolled outward with a 
pledget, from which the salt-solution has been well squeezed, so that 
the further dissection can be continued at the adhering point under 
corresponding lengthening of the lateral incisions. The flap detached 
is so thin and superficial that bleeding only occurs from the apices of 
the cut papillan Care must be taken not to button-hole the skin, 
as the openings, although small at the outset, increase in size by 
retraction and are undesirable because their margins roll up and 
later make proper adaptation of the flap to the wound difficult. 
Rapid and careless work in preparing the flap results in deep cuts, 
and the sections are thick and heavy and retract too much. When 
a section of the desired size has been prepared, it is separated from 
the point at which it is still attached to the skin, and is covered at 
once with two pledgets saturated with warm salt-solution. Before 
transferring the flap, the denuded surface of the wound should be 
stroked with the edge of the lancet in different directions, in order 
that a small amount of blood and serum may exude to ensure rapid 
adhesion of the flap to the wound. Deep incisions are to be avoided, 
because accumulated blood from the larger vessels detaches the 
flap from the surface of the wound. 
Adaptation of the Flap to the Surface of the Wound.—The flap, 
which until now has been spread out on the pledget, is placed with its 
wound-surface on the defect. The middle of the flap is then pressed 
well against the raw surface by means of a pair of closed forceps, and 
the pressure continued until it conforms to the surface of the wound. 54 
CICATRICIAL ECTROPION 
Care is taken not to allow spaces to separate the various pits in the 
wound from the flap, more particularly at the inner angle. Then 
follows the exact adaptation of the margin of the flap to the margin of 
the wound. To properly spread out the flap, as its margins roll up 
in every instance, the latter should be drawn out with Carlsbad 
needles,1 and applied to the margin of the wound so that not even 
the slightest interstice remains between the two. If the flap is 
somewhat too large, and the margins project over the edges of the 
wound, it must be reduced to the proper length with a pair of scissors. 
This adaptation must, naturally, be made along the whole periphery 
of the flap. Sutures are not recommended, although one or more 
may be required if the flap does not remain in proper position. 
Dressings.—After completing the adaptation, the flap and its 
surroundings are covered with an oiled gutta-percha paper, over 
which is loosely placed sufficient dry gauze to cause slight compression. 
The gauze is held in position by two broad strips of adhesive plaster. 
The other eye is also included in the bandaging, in order to prevent 
all movements of the lid. An outer starch-bandage makes the 
dressing stiff within a short time. The operation is performed under 
general anesthesia. The wound on the arm need not be sutured; 
the skin regenerates within a short time from the islands of epithe- 
lium remaining between the papillae. 
The dressing is changed for the first time on the second day after 
operation. It is encouraging, when the bandage is taken off, to find 
the flap in the desired position and already adherent. As no wound- 
surface exists, there is naturally not the slightest secretion. The 
flap is usually quite white, but occasionally the upper epithelial 
layers are somewhat darker in color. Simply because of this, no 
necrosis of the flap need be feared. Within a few days the delicate 
normal young skin makes its appearance beneath. Two days later, 
the bandage is again renewed. The fixation-sutures of the lid have 
by this time usually cut through, and are now removed. The lid 
remains at first in the abnormal position, but the flap has, by this 
time, healed sufficiently to prevent its being displaced during a 
change in the position of the lid. Gradually and slowly the lid 
returns to its normal situation. The final results in most cases are 
excellent. The skin is gradually thrown into folds as is the normal 
1 A kind of long hat pin, the end of which has the form of a small lancet. EPIDERMAL INLAYS 
55 
skin of the lid, and is differentiated from its surroundings only by its 
paler color. 
A non-adhering flap is of a greenish-black color at the first change 
of dressings, and separated by profuse secretion from the granulations 
beneath. Nothing remains to be done in these cases but to wait 
until the cicatricial process is concluded; then the original condition 
returns, and the same operation may again be tried. 
If, however, the first operation is completed without error in 
technic, this undesirable occurrence will be met with only exception- 
ally. Should an ectropion exist on both lids, the upper lid should 
be operated on first, and, some weeks later, the lower lid. 
Epidermal Inlays.-—During the past few years a method different 
from that above described has been employed by some operators in 
the management of cicatricial ectropion—the so-called epidermal 
“inlays” and “outlays.” The results are reported to be so success- 
ful that a brief description of the method is here given. After the 
usual separation of the scar formation, a mold of the exact size and 
shape of the denuded area to be covered is made of a dental compound 
which becomes soft and pliable when immersed in hot water. A 
flap of epidermis, usually from the arm, is wrapped about this molded 
form, entirely covering it, with the raw surface of the skin exter- 
nally. The edges of the skin-wound of the lid are slightly under- 
mined, the epidermal-covered mold placed in the denuded area, and 
the skin-edges brought together over it, so that the mold and graft 
are imbedded in the tissues. At the end of a week the skin-sutures 
are removed, and an incision made with a sharp knife through the 
tissue of the graft deep into the mold, and the latter removed. This 
leaves the original denuded area lined with epidermal tissue. The 
depression in which the mold rested opens up in a few days, the edges 
flatten down, and the new skin occupies the place of the former 
cicatricial masses which caused the deformity. Massage with a 
mild ointment is later employed. If the denuded area which follows 
the incisions to relieve the scar formation is large, or the surrounding 
skin unyielding, so that it is impossible to bring the skin-edges over 
the epidermal-covered mold, excellent results may be secured by 
placing the same perfectly-formed mold with the epithelial covering 
in the denuded area and employing a thin sheet of the dental com- 
pound softened and molded to fit over and beyond the graft. This 
method insures that the epidermal tissue is firmly pressed into the 56 
CICATRICIAL ECTROPION 
raw surface of the wound. A gauze pad and bandage is applied and 
not disturbed for several days. 
In the preparation of the skin-grafts with which to cover the mold 
it is essential that an extremely thin graft be secured, entirely free 
from the true skin. The grafts are taken from the inner surface of 
the arm, in a somewhat different manner from the method previously 
described for the preparation of skin-flaps. The grafts are cut with 
an extremely sharp razor, preferably flat on one side and concave on 
the other, or with a larger knife, similar to that used for the cutting 
of microscopical sections. The skin of the arm is first sterilized, and 
the hand held in the prone position by a nurse. The assistant, with 
the four fingers of each hand, grasps the skin on the outer aspect of 
the arm, and draws the inner surface fairly taut. The skin from 
which the flap is to be taken is gently massaged with liquid petroleum, 
and some of the oil is placed on the razor blade. The surgeon with 
one hand either elevates or depresses the skin to secure a flat surface, 
and with to and fro motions of the razor, with the blade slightly 
inclined so that it will not adhere to the skin, cuts a large thin flap. 
A perforation of the graft is unimportant. Some surgeons advise 
small openings in the graft to allow the escape of any secretion that 
might prevent apposition of the raw surfaces. The operator should 
wear rubber gloves in the massage of the skin and in the handling of 
the graft to insure perfect asepsis. 
(c) Pedicled Skin-Flaps.—Pedicled flaps are adapted to cases 
in which the scar-tissue extends to the bone, and the latter is laid 
bare after dividing the scar. Non-pedicled skin-flaps only heal to a 
tissue well supplied with blood-vessels, and are therefore unsuitable 
to deep scarring, and, in addition, the latter conditions require a 
thicker mass of tissue to fill up the difference in level with the normal 
integument. Cicatricial ectropion following severe inflammation, 
complicated with necrosis of the lid tissues, infections with anthrax, 
and extensive and deep injuries of the lids are the chief conditions 
in which plastic operation with pedicled flaps is indicated. 
The character of the operation selected in the correction of lid 
deformities will depend upon whether there has been loss of the 
anterior layers, with the tarsus and conjunctiva unaffected; whether 
the lid has been completely destroyed in all its layers, either in a cir- 
cumscribed area or in its entire extent; and whether the whole or a 
part of the lid must be excised on account of a malignant growth. PEDICLED SKIN-FLAPS 
57 
The method of making the flap to cover the lost tissue does not 
materially differ in any of the operations, but in the cases where 
there has been destruction of the lid lamina, or loss by surgical 
measures, provision must be made to supply not only the skin but 
also provide a substitute for the lost tarsus and conjunctiva. In the 
second group are included the cases of serious destruction to the 
structure of the lids as seen in war injuries; total absence of the lid 
by crushing, to which there is added opening of the frontal, eth- 
moidal, and maxillary sinuses, and often injury to the brain; tearing 
off of the lid from its internal insertion, most frequently the lower 
lid; and cutting of the lid, with the formation of a coloboma, the 
edges of which may be everted by cicatricial shrinkage and often 
attached to the bony orbital margin. In the cases included in the 
group of malignant disease, if only the skin is involved, a pedicled 
flap from the surrounding tissues is sufficient, but if the disease 
attacks the margin of the lid, and new growths usually spring from 
this situation, a large part of the lid must be sacrificed. As a recur- 
rence is only prevented by cutting at least 5 mm. away from the 
visible margin of the tumor, the whole lid must often be excised. 
There is no advantage in retaining the small remnants of the lid 
at either end of the incision. The tear-ducts are to be spared only if 
they are beyond the field of operation. 
Preparation of the Flaps.—The flaps are nearly always taken from 
the neighboring skin. It is rare that the method of using a pedicled 
flap from the skin of the upper arm (Italian method) need be con- 
sidered, since even the cicatrized skin of the face may be used in case 
of need for a pedicled flap. Few patients have sufficient per- 
severance to undergo the discomfort of the elevation of the arm in an 
unmovable bandage until the flap formed from the skin of the arm 
has healed to the lid-margin. 
Plastic work with flaps from the neighboring skin requires careful 
study of the conditions which are present in each individual case to 
achieve a successful result. The following general points may be 
considered: 
The flap must be made one-third larger than the area to be 
covered, as the skin shrinks after it has been detached and also 
when applied to the wound, where it must be adjusted without strain. 
The flap must not be too thin, but should contain sufficient sub- 
cutaneous tissue to insure a plentiful blood supply for nutrition. 58 
CICATRICIAL ECTROPION 
The wound of the lid to be covered is to be freed of all cicatricial 
tissue, especially so far as it is badly supplied with blood-vessels, the 
surface of the wound made as smooth as possible, and the hemor- 
rhage checked, chiefly by compression. Only the larger vessels are 
twisted off or ligated with catgut. The wound-edges are undermined, 
partly because they may assist in covering the wound, providing there 
is no disturbance of the position of the lid, and partly to permit better 
suturing with the edges of the flap. After the flap has been turned 
over the wound, the sutures are inserted. In tongue-shaped flaps, 
the end of the flap is first sutured in place; in angular flaps, the edges 
are anchored first. The other sutures follow, and, as the edges of 
the wound are apt to roll in, the assistant holds them in proper 
position with dressing forceps. 
The surface from which the flap has been taken may often be 
closed by sutures after thorough undermining of the edges, but if a 
small area remains it may be allowed to close by granulation or a 
Thiersch graft implanted. 
The flap must correspond in shape to the area to be covered. 
For this purpose a pattern of gutta percha is cut the exact size of the 
wound, and is then laid on the skin from which the flap is to be cut, 
in order to estimate more readily the size of the latter. A large 
pedicle insures more nutrition than a small one. 
The flap for the upper lid is excised from the skin of the forehead 
or temple, and that for the lower lid from the zygomatic region and 
the cheek. The base of the flap for the upper lid is placed somewhat 
below the lid-fissure; for the lower lid, slightly above it, so that the 
upper lid is drawn down and the lower lid up, a direction that is 
opposite to the traction exerted by the scar. 
The flaps may be differentiated according to their relation to the 
original situation in respect to the wound and the change of position 
necessary to bring them over the wound. 
I. Turn Flaps.—The axis of the flap to be excised forms an angle 
with the axis of the wound, and when freed is brought over the wound 
by rotation. 
i. The base of the flap joins the lid-wound, and the flap is turned 
on its axis, usually at about a right angle with its original position. 
A typical example of this form of flap is seen in the Fricke operation 
(page 63). The flap should not be turned more than 90°, otherwise 
there will be interference with the blood supply. SLIDING FLAPS 
59 
Another method of turning a flap is exhibited in the operation 
of Rogman in cases of symblepharon. Here the flap makes a com- 
plete rotation of 180°, so that the wound surface is forward and 
the epithelial surface backward. Such rotation of the flap is 
employed as a substitute for the conjunctiva, where the lid is adher- 
ent to the eyeball, the skin surface next to the lid preventing 
recurrence of the attachment. 
2. The flap and its base directly join the wound. The latter is 
covered by moving the freed flap over a short distance. A typical 
example is the formation of the flap after the method of Dieffenbach 
Fig. 32.—Formation of a flap after Celsus 
(sketch). D, loss of tissue; F, flap. 
Fig. 32a.—After suturing, 
(page 64). The shape of the flap may essentially differ from that of 
the wound which has to be covered, as in the instance above men- 
tioned the defect is triangular, the flap quadrangular. 
► 3- The flap and its pedicle are entirely separated from the 
wound. When the flap is rotated over the defect, the pedicle 
Fig. 33.—Formation of a sliding flap, F, 
with excision of two triangles, d; of the skin 
at each side, in case of superfluous skin, for 
covering the loss of tissue, D. Method of 
Burow (sketch). 
Fig. 33a.—After suturing. 
overbridges the skin between its root and the wound. After the 
flap has healed in the wound, it is cut off from the pedicle, and the 
tissue not used in covering the wound is reimplanted at its original 
site. (See page 68, formation of an eyebrow by a flap from the 
head.) 
II. Sliding Flaps.—These are of several varieties: i. The flap 
directly joins the wound, and the pedicle lies on the side of the flap, 60 
CICATRICIAL ECTROPION 
separated from the wound. The flap remains in its original direc- 
tion, but is pulled over the wound. A representation of this is 
shown in Figs. 32-35 after Celsus. This method has been used by 
Knapp (Fig. 36) for restoration of a portion of the lower lid. The 
Fig. 34.—D, loss of tissue made in the form of a V, with a sliding flap, F, at each side. 
Sutured to a T (sketch). 
defect of the lid is made quadrangular by straight cuts, and 
flaps are made, Fi with its base on the temple and F2 on the nose. 
The incision to form Fi is made from the external canthus, outward 
Fig. 35.—Formation of two sliding flaps, F, to cover the loss of tissue, D, To the right 
appearance after suturing (sketch). 
and slightly upward, with a second cut horizontal outward, to the 
lower edge of the wound, and bending slightly downward at its end. 
Fig. 36.—Covering a loss of tissue, D, of the lower lid by two sliding flaps, Fi and Fs. 
(After Knapp.) 
The skin of the flap is made movable by undermining. The flap 
F2 is much shorter, and is created by two horizontal incisions lengthen- 
ing the upper and lower edges of the wound. Both flaps are pulled SLIDING FLAPS 
61 
over the defect, and their perpendicular edges sutured together 
(Fig. 37)- 
2. The flap and its base are both separated from the wound. The 
flap, transported from a remote situation, has a pedicle which 
bridges over an area covered with skin, and after the flap is healed 
Fig. 37.—After suturing. 
to the wound the pedicle is cut through. An example of this pro- 
cedure is the method of Wicherkiewicz for correction of a defect 
of the lower lid. The flap, formed from the skin of the upper lid, 
with pedicle situated near the eyebrow, is pulled down over the 
palpebral fissure to the wound of the lower lid. After the pedicle is 
Fig. 38.—Method of Wicherkiewicz for covering a coloboma of the upper lid. Forma- 
tion of a triangular flap of the lower lid (full black line). 
cut through the skin of the upper lid becomes permanently a part of 
the lower lid. Unless there is an excess of skin of the upper lid, the 
method is not to be followed, as shortening of the lid would endanger 
the eye through exposure of the cornea. 
The method of Wicherkiewicz may be used to correct a defect 
of the upper lid, even a coloboma, if limited to the area of the tarsus. 62 
CICATRICIAL ECTROPION 
The flap is taken from the lower lid, and may contain all the layers 
of the lid (Fig. 38). 
The area of the lower lid from which the flap was taken is closed 
by sutures in a vertical line. Tension is relieved by incisions made 
along the two lower edges of the wound. After the transferred flap 
has healed in position, the pedicle is severed, usually in a week. 
3. The flap may have two pedicles, and is spoken of as a bridge 
flap. It may be taken from the skin adjoining the open wound, or 
may be drawn from another situation. Several methods of using 
the flap may be mentioned: 
Loss of Lower Lid.—Kuhnt forms a bridge flap, more than 2 cm. 
long, from the remaining tissues of the lid and the skin of the upper- 
most part of the cheek. Landolt makes a bridge flap from the upper 
lid, base out and in, and draws it down and sutures the lower edge 
to the skin-margin of the defect. 
Upper Lid Cicatrized with Eyebrow Drawn Down by Scar.—Forma- 
tion of a bridge flap from the forehead by two arched-shaped in- 
cisions above and parallel to the eyebrow; flap drawn down into 
wound left after scar incised and upper lid in normal position; ends 
of wound united with ends of lower incision in skin of forehead; and 
skin containing eyebrow sutured to upper margin of defect in fore- 
head from which flap was taken. 
III. Wandering Flaps.—Pedicled flaps may be used as wandering 
flaps (v. Hacker). The free margin of the flap, after rotation of 180°, 
is first healed into a skin-wound, made in the desired position, and 
this serves later as a pedicle after the original pedicle has been 
severed. In this way the flap changes its position the second time. 
Restoration of an absent conjunctival sac, after L. Muller, is an 
example of the use of this method. A flap from the forehead, base 
above the eyebrow, with free margin at the limit of the hairs, is 
rotated 180° downward and the free margin sutured in a wound 
made in the upper lid. After healing, the pedicle is severed and the 
flap again tilted downward for 180° and sutured to the posterior 
surface of the lower lid. Finally the flap is cut off from the upper 
lid and sutured into the orbit. 
Operations with Flaps.—The following are examples of the pre- 
viously described principles in the use of flaps, with detailed steps 
of the operations: OPERATIONS WITH FLAPS 
63 
Fricke Operation.—This method is used in case of an extensive 
skin-defect in either the upper or lower lid. A flap is taken from the 
neighboring skin, as is shown in the illustration (Fig. 39), and the 
base joined to the defect in the tissue (d). Because of possible retrac- 
tion of the skin after it has been dissected free, the flap (f) must be 
cut about one-third larger than the area to be covered, and the base 
wide enough to insure perfect nutrition. For the same reason, rota- 
Fig. 39.—Restoration of a skin-defect in the upper and lower lid (after Fricke). d., 
defect; g., pattern of gutta-percha paper, cut the same size as the defect, and laid on the 
place selected before the excision of the flap, in order to estimate more readily the size 
of the latter; f., flap to be cut out. 
tion of the flap should be made as easy as possible by an adequate 
undermining of the underlying tissues. The flap, which now covers 
the excised area, is held in its new position by sutures. The opening, 
caused by the removal of the flap, is dissected sufficiently back of the 
margins, and the skin-edges brought together, at least in part, by 
sutures, the remainder being left to heal by granulation or covered by 
transplanting epidermis, according to the method of Thiersch, or by a 
small non-pedicled flap (Wolfe graft). The bulging at the base of the 
flap produced by the necessary rotation soon disappears, so that no 
subsequent disfigurement exists. 64 
CICATRICIAL ECTROPION 
Dieffenbach Operation.—The defect of the lid is excised so that a 
triangle is formed, the base of which corresponds to the lid-border (b c 
Fig. 40.) In the direction of the base of the triangle an incision (a b) 
is made outward toward the temple, somewhat larger than the defect 
to be repaired, as the flap contracts after it is freed. From the outer 
end of this incision another cut is carried downward, parallel to the 
outer side of the triangle and a little longer. A flap can now be 
dissected off, the base of which lies below. Sufficient freeing from 
the underlying tissue affords easy rotation inward upon the defect. 
The upper edge of the flap is sutured to the remains of the conjunc- 
Fig. 40.—Restoration of a lower lid after Dieffenbach. The lower lid is excised in 
triangular fashion; that is, a pre-existing defect is brought into this form. Formation of 
a quadrangular skin-flap (a b), which is freed from its underlying tissues. 
tiva, and corresponds to the lid-margin, while the inner edge is secured 
to the neighboring skin by strong sutures. The surface from which 
the flap was taken is closed in as much as possible by sutures after a 
thorough undermining of its edges. The remainder of the exposed 
area is left to heal by granulation, or a skin-graft inserted and stitched 
in position. 
Restoration of the Lower Lid.—If the entire lower lid has been 
destroyed or requires excision, the method of Dieffenbach must 
be combined with the operation of Biidinger, which consists in the 
transplantation of a portion of the ear-cartilage as a substitute for the 
tarsus. The skin-flap of the Dieffenbach procedure is not of itself 
an equivalent substitute for the lower lid. As the flap lacks a 
cartilaginous substratum, it yields and sinks downward, and becomes 
attached to the eyeball. The conjunctiva is also materially shortened, 
the mobility of the eyeball impaired, and fine hairs grow from the BUDINGER OPERATION 
65 
skin of the partly turned in flap and irritate the lower portion of the 
cornea. 
Biidinger Operation.—The employment of a flap made from the 
cartilage of the ear, as suggested by Biidinger, is a decided improve- 
ment over the Dieffenbach and Fricke operations in appropriate 
cases. After the skin has been freed, as in the description of the 
Dieffenbach or Fricke methods, a flap, including both skin and 
cartilage, is excised from the posterior surface of the ear. It should 
be as long as the lower lid, with a straight edge 
to correspond to the lid-margin, and another 
somewhat convex edge to approximate the 
shape of the lower border of the tarsus. Be- 
cause of the narrowness of the normal tarsus of 
the lower lid, only a small piece of cartilage is 
removed from the ear, but to cover the wound- 
surface a much larger portion of skin is re- 
quired. A vertical incision of adequate length 
is made on the posterior surface of the ear. This will at once retract 
somewhat, and at the point of retraction an incision is made through 
the cartilage, corresponding to the length of the tarsus. This 
edge of the flap forms the new lid-margin. Next, the dissection is 
continued 3 mm. further beneath the cartilage, that is, between carti- 
lage and skin of the anterior surface of the ear, and the cartilage is 
cut through from in front without wounding the skin. In order to 
free the skin, it is dissected an additional 5 mm. with a slightly convex 
incision. The freed flap shows the shape viewed from the raw surface 
(Fig. 41). 
As the ear-cartilage is too thick, it is shaved down by cutting away 
thin lamellae with a scalpel applied flatwise, until it approximately 
equals the thickness of a normal tarsus. This flap is fastened by 
sutures to the previously dissected skin-flap (Fig. 42), so that the 
wound-surfaces are apposed to each other; that is, the skin of the ear- 
flap is directed posteriorly toward the eyeball and the straight edge 
comes to lie against the free upper margin (ab) of the pedicled skin- 
flap. In order to avoid unsightly indentations of the new lid-margin, 
the sutures, armed with two needles, are pushed from behind forward 
through the skin and the cartilage, 2 mm. below the free margin, and 
tied over a glass bead. At least three sutures are necessary. In like 
or two sutures are brought through the lower border of 
Fig. 41.—Flap from 
the posterior surface of 
the ear; (c.,) cartilage; 
(w.s.,) skin seen from the 
wound-surface. 66 
CICATRICIAL ECTROPION 
the flap of skin and cartilage in an anterior direction and tied, to secure 
a firm approximation of the flap to its new base. The flap of the 
ear-cartilage is covered by skin on both sides, and is not prominent. 
The pedicled flap, with its posterior surface thus provided with a 
sufficiently large cutaneous surface, is sutured, after adequate rota- 
tion, to the edges of the defect, as in the Dieffenbach or Fricke original 
methods. To prevent mechanical injury to the cornea by the flap, 
which is somewhat stiff at first and readily produces erosions and 
ulcers, the upper lid is drawn far downward by two stitches passing 
Fig. 42.—Dieffenbach-Budinger operation. The flap represented in Fig. 41 is here 
so sutured to the posterior side (that is, the raw surface) of the pedicled skin-flap that the 
skin (s.) comes to lie posteriorly toward the eye. The flap is now twisted into the defect 
of the lid and sutured in such a fashion that b. comes to lie in apposition to c. and a. of 
the flap in apposition to b. of the canthus. 
through its margin, and both ends of each suture are brought through 
the base of the flap, which has been rotated inward; not until then is 
the flap fastened to its new position. Thus, the new lower lid lies at 
first against the upper lid. The defect produced externally is covered 
in exactly the manner described by Dieffenbach. The flap of skin 
and cartilage heals in promptly. Both eyes are bandaged and the 
dressing changed for the first time after two days. The fixation- 
sutures of the upper lid, which were tied over small gauze pads, are 
allowed to remain until they cut through, which is usually in from 
five to six days. However, the upper lid continues to hang down 
for several days more, completely covering the cornea, but by the 
time it can be elevated, the flap of skin and cartilage have long RESTORATION OF THE UPPER LID 
67 
since healed, and in its moist environment the skin has become so 
delicate that an injury to the cornea need no longer be feared. 
The flap, which at first appears thick and bulging, later becomes 
gradually thinner, resembling a lower lid deprived of its eyelashes, 
especially as is stands up freely owing to its cartilaginous substratum, 
and is not drawn against the eyeball through the formation of a 
cicatrix. 
This method is particularly valuable, because the motility of the 
eyeball remains unaffected, and a deep conjunctival sac is created, 
similar to the normal. Furthermore, the transplanted flap, which is 
free of hairs, does not give rise to corneal irritation. The ear-flap 
may be sutured first into the lid-defect if desired, and then the skin- 
flap turned over and fixed in position. 
The method of excising a wedge from the entire thickness of the 
ear in the area of the helix, and using it as a substitute for the lid, 
is not to be recommended because of the curving of the ear margin. 
The transplanted tissue does not always heal properly. 
Knapp, in cases where there is sufficient healthy conjunctiva, 
uses the ear-flap with the skin surface forward to form the outer 
portion of the lid, while the cartilage facing backward is covered with 
conjunctiva. 
Kuhnt makes a new lower lid from the remnants of the lid and the 
immediately adjacent skin of the uppermost part of the cheek, which 
forms a bridge flap sutured to the periosteum of the orbital margin. 
The portion of the flap towards the eye is covered with a skin-carti- 
lage flap from the ear. 
Restoration of the Upper Lid.—The upper lid, if entirely destroyed 
or requires to be removed on account of disease, may be restored in 
the skin portion by a flap after the method of Fricke, and in its pos- 
terior surface with a skin-cartilage flap from the ear. The upper 
margin of the flap is sutured to the conjunctival wound, the sutures 
including the tarso-orbital fascia and the levator, and the lower 
margin caught by mattress sutures to the lower edge of the skin-flap. 
In order to protect the cornea, the conjunctiva is completely de- 
tached at the limbus and drawn together with a purse string suture, 
so that the cornea is entirely covered. After the flap has healed, 
and the posterior surface of the new upper lid has become soft and 
delicate, the purse string suture is cut, allowing the conjunctiva to re- 
turn to its normal position and the cornea to be exposed. 68 
CICATRICIAL ECTROPION 
Landolt endeavored to form an upper lid from the lower lid by 
suturing the remnants of the upper fold, which had been severed 
from the scar and pared at its inner surface, into the space between 
the two laminae of the split lower lid. With cicatrization, there is 
stretching of all the tissues, and several months later a new palpebral 
fissure is made. 
Kuhnt makes a new lid by the aid of a bridge flap, similar to his 
procedure for the lower lid, if the orbital portion of the upper lid is 
saved. 
Another application of the transplanted ear-cartilage flap is as a 
substitute for the tarsus and conjunctiva, if excision of the structures 
is required, as in the removal of tuberculous granulations or in the 
operation for symblepharon. The flap covers the raw surface of the lid. 
Substitute Eyebrows and Lashes.—Burns and severe injuries 
sometimes destroy the lid and the eyebrows, and if both structures 
must be restored, a flap is excised from the skin of the forehead, so 
that its upper margin contains the hair limit. If only the eyebrow 
is lost, the pedicled flap is taken from the skin above the ear, and 
turned into the space where the eyebrow is to be formed. Later the 
flap is severed, and the eyebrow made of proper length by suitable 
excisions. 
If the lid including the lashes is lost, or the entire upper lid 
replaced by scar-tissue, the lashes may be formed from the eyebrow 
by a bridge flap from the forehead. For this purpose two arch- 
shaped incisions are made parallel to the eyebrow, the lower so 
situated that the upper margin of the eyebrow is part of the flap 
(Hirschberg). The lower border of the incision is joined by lateral 
sections to both ends of the lid-defect, and the bridge flap drawn 
down in front of the eyebrow and fixed with sutures. The eyebrow, 
which is frequently drawn down by the scar, is sutured to the upper 
margin of the opening produced by removal of the flap and thereby 
lifted. 
For restoring the lashes Lexer transplants small pieces of skin 
covered with hair, selecting the scruff of the neck where the hairs 
are finer than elsewhere on the head. As the hairs of the head 
perforate the skin in a slanting direction, the incision is made some- 
what obliquely so that a minimum amount of injury is done to the roots 
of the hairs. The strip is cut one to two mm. broad, and is inserted 
in a wound made along the lid-margin, if no raw surface exists. Two RECENT COLOBOMA 
69 
silk threads are carried through the margin of the wound and tied 
loosely over the transplanted flap. The hairs are cut from time to 
time. This method is essentially useful for replacing eyelashes on 
eyelids which have been created by plastic operation. 
The eyebrow may also be restored by non-pedicled flaps. The 
flap is excised from a suitable part of the head well-covered with hair, 
and inserted in an opening made to correspond in length and breadth 
to the eyebrow. 
Recent Coloboma.—A recent coloboma of the lid should be 
immediately closed by sutures unless severe damage of the borders 
of the wound or extensive necrosis or infection prevent such a pro- 
cedure. Inequalities of the margins of the wound and torn and 
macerated pieces of tissue are excised, and the borders smoothed 
for exact adaptation. If the wound is not fresh, a small strip of 
skin is excised from the entire thickness of the lid along the edges 
of the coloboma before the sutures are inserted. A coloboma is 
triangular in shape, and the base corresponds to the lid-margin. 
The wound in the posterior lid lamina, and its continuation in the 
tarso-orbicular fascia, is sutured with catgut, over which the skin- 
wound is closed with silk sutures. In order to exactly adapt the 
two sides of the open wound at the lid-border, a strong fixation- 
suture of silk is carried through the intermarginal line for a distance 
of several millimeters from the border of the wound. If this suture 
is inserted early, and the ends of the thread drawn together, the 
points where the catgut sutures are to be carried through the tissues 
may be easily determined. They must be situated in the tissue 
on both sides of the cut at the same distance from the lid-border. 
One or two other strong silk sutures may be carried through the whole 
thickness of the lid on each side of the opening and tied on the skin 
over pieces of gauze. These sutures relieve the tension on the wound 
and are the more necessary the broader the loss of tissue. If it is 
found after uniting the borders of the wound that the tension is 
excessive, it may be diminished by a canthotomy and by undermining 
the skin of the lid. Vertical incisions through the skin are efficient 
in reducing the tension, but are avoided whenever possible, as 
permanent scarring follows. After complete closure of the wound, 
both eyes are bandaged for four to five days. Until healing is 
complete any movements of the lids would lead to tearing out of 
the sutures. 70 
CICATRICIAL ECTROPION 
Lindner has recently recommended that the entire external 
ligament and fascia be severed to relieve the tension on the closed 
wound in the lid-margin. For this purpose a vertical incision of the 
skin about 5 mm. long is made a short distance outward from the 
external canthus, the latter gripped with strong toothed forceps and 
drawn towards the median line, and the underlying bands of tissue 
severed with scissors. This causes the ligament and fascia to be 
well stretched, so that all tension is relieved on the wound-margins, 
and healing rapidly occurs. 
In extensive injuries that require removal of the eyeball, it is 
unnecessary to take measures to relieve tension even in a large 
Fig. 43.—Method of Landolt for covering a loss of tissue at one (here inner) end of 
lid. The skin is already carried over the lost tissue and fastened by sutures. The 
incision made at the other end of the lid to diminish the tension has become a triangular 
skin wound. 
coloboma, as, with the absence of the eyeball, there is no pressure 
exerted that would tend to force open the closed wound of the lid- 
margin. Even where a fresh wound cannot be accurately closed by 
sutures because of severe contusion or edema of surrounding tissues, 
one or more fixation-sutures are to be used to bring the wound-edges 
of the lid in as close apposition as possible. The coloboma which 
finally results after healing has taken place is much smaller and more 
easily corrected than if no attempt had been made to partially close 
the wound. 
In a recent injury the coloboma may be readily closed by sutures 
if the lid has simply been cut through and there is no extensive loss 
of tissue. Even if there has been some loss of lid structure, providing 
it does not exceed one-third of the breadth of the lid, the opening may 
be closed by sutures after tension has been relieved in the manner 
recently described. OLD COLOBOMA 
71 
An extensive loss of tissue at one end of the lid, whether by a 
recent injury or following a removal of a malignant growth, requires 
a plastic operation, of which the method of Landolt is well suited. 
This consists of splitting the remaining portion of the lid at the 
intermarginal line, after which the skin of the lid is dissected up by 
thorough undermining at the end of the lid opposite the defect, and 
an incision made through the skin from the lid-margin perpendicularly 
upward to the eyebrow. The two skin-margins of the wound can now 
be sutured without tension. This restores the surface of the lid 
by bridging over of the wound with skin, leaving a triangular wound 
by the displacement of the flap (Fig. 43). This heals by granulation 
and cicatrization, and slowly pulls the neighboring skin over the 
defect. 
Old Coloboma.—If the margins of the coloboma are cicatrized, 
a small strip is pared off before the sutures are inserted. Colobomata 
limited to the area of the tarsus, that are not broader than 1 cm., 
may be closed by sutures if at the same time an external canthotomy 
is made and the skin dissected from the underlying tissue. If a 
small flap of skin excised from the wound-margin is bridged over 
the coloboma (method of Pflugk), an indentation of the lid-margin, 
which otherwise frequently occurs, is usually prevented. 
Colobomata that extend through the entire heighth of the lid 
are usually crossed by dense cicatricial bands, so that all the scar- 
tissue must be excised, a horizontal incision made near the orbital 
margin at least through the fascia, and, if necessary, also through the 
skin of the lid, before the margins of the wound are closed. If 
there is still tension on the sutures, the whole temporal side of the lid 
must be loosened, after the method of Kuhnt. This necessitates 
splitting of the external canthus with lengthening of the incision 
1.5 mm. beyond the margin of the orbit, and making a second incision 
from this point upward at an angle of 40° toward the median line, 
if the defect is in the upper lid, and downward if in the lower lid. 
The whole flap of skin is then detached from the underlying tissue to 
the orbital margin, and the lid fascia loosened from its external inser- 
tion. Kuhnt recommends that the sides of the coloboma be bor- 
dered by oval-shaped cuts. After the sutures which bring the wound- 
edges together are inserted, the lid-margin is slightly prominent at the 
point of union. This method avoids indentation of the lid-margin, 
which otherwise would occur after suturing the edges of the coloboma. 72 
CICATRICIAL ECTROPION 
When the sides of the coloboma are turned outward and attached 
to the bone, the scar is excised and the tissues freed by long hori- 
zontal incisions along the orbital margin. The margins of the 
coloboma may now be brought in proper position and sutured. 
The open wound that remains is covered by pedicled flaps, with the 
cavity beneath filled with fat taken from the thigh. 
In extensive defects,-with cicatrization of the temporal or nasal 
border of the lid, the latter is first freed and placed in proper position, 
and the resulting cleft covered by a pedicled flap from the surround- 
Fig. 44.—The lower lid is torn from its inner insertion. A triangular area of the 
cicatricial tissue is excised, similar to the preceding of Szymanowski. There is added a 
short incision through the skin of the lid below and parallel to the margin. The corner, 
a, of the flap is sutured to the upper inner angle, b, of the wound. 
ing tissue. A skin-ear cartilage flap joins the posterior surface, and 
is united with the border of the conjunctiva and tarsus. 
Plastic operations with pedicled flaps, and ear-cartilage as a 
substitute for the tarsus, are to be preferred if the traumatic coloboma 
is large, because they provide sufficient skin and prevent excessive 
tension which would cause the sutures to cut through before healing 
is complete. 
Tearing the Lid from Its Insertion.—A rather common form 
of war injury was the tearing of the lid from its insertion, usually the 
lower lid. Most of the cases of deformity which followed cicatriza- 
tion could have been avoided if primary sutures had been inserted, 
or the defect at least made insignificant by a few fixation-sutures. 
In its healed condition the inner end of the lid is attached below to the 
bony orbital margin, so that the lid runs obliquely down and in from 
the external canthus. In order that it may be restored to its normal 
position, an incision is made, starting at the inner end of the lower 
lid along the boundary between the conjunctiva and the scar, and KUHNT AUTOMARGINO-PLASTIC OPERATION 
73 
rising to the insertion of the upper lid and several millimeters beyond 
it in a direction up and in. A second incision starts at the same 
point in a direction down and somewhat inward, while a third cut 
unites the ends of the two other incisions in nearly a perpendicular 
direction (Fig. 44). The triangle thus circumscribed contains the 
scar, and its form therefore varies according to the extent of the 
cicatricial tissue. The latter, situated within the triangle, is excised. 
The lid is now thoroughly freed from its adhesions and replaced in 
proper position. Before the sutures are inserted the skin of the lid is 
incised somewhat below and parallel to the lid-border for a length of 
several millimeters. A small flap from the skin of the lid is thus 
formed, the point of which is first fixed in the inner and upper angle 
of the triangular wound. After the remaining sutures have been 
inserted the lid nestles closely to the eyeball in a faultless position. 
Kuhnt Automargino-plastic Operation.—If the lid-margin must 
be excised in its entire thickness for the removal of tumors likely 
to become malignant, the operation of Kuhnt is to be recommended. 
The tumor is first circumscribed in the form of an arch on the skin- 
surface (Fig. 45). On the conjunctival surface two perpendicular 
incisions are made at each side from the margin of the lid toward the 
lower border of the tarsus and a horizontal one parallel to the lid- 
Fig. 45.—Kuhnt automargino-plasty. The tumor, T, is limited by an arch- 
shaped incision of the skin, I. 
margin beyond the growth (Fig. 46). The tumor, bounded by these 
incisions is removed, and the conjunctival-tarsal lamina severed 
toward the transitional fold by lengthening the two lateral per- 
pendicular incisions for about 1 cm. Properly applied sutures lift 
the flap so that it fills the marginal defect. On either side one needle 
of a double-armed thread is carried through the wound-margin of the 
lid from behind forward, a distance of about 1 mm. from the limiting 
border, and the second needle through the corner of the conjunctival- 74 
CICATRICIAL ECTROPION 
tarsal flap and then through the skin a distance of about 2 mm. from 
the incision (Fig. 47). When the threads on the two sides are tied, 
the conjunctival-tarsal flap is lifted and exactly fills the gap. Healing 
is complete in from six to eight days. 
Fig. 46.—Kuhnt automargino-plasty. On the conjunctival surface, c., the tumor 
is bounded by straight incisions, ac, bd, and cd (full lines). The flap, F, is formed by 
continuing the incision sac and bd (dotted lines). The lid is turned out on the lid 
plate (P). The points indicate the spots where the sutures are carried through.] 
Malignant neoplasms which have advanced from the lid-margin 
to the inner surface of the lid require for their removal an incision in 
sound tissue at least 5 mm. from the visible border of the tumor, 
so that the whole tarsus must be excised. After the removal of 
tumors of this character the principle of the operation is similar to 
those given for recent coloboma. 
Fig. 47.—Kuhnt automargino-plasty. Sutures in. position. One end of the thread 
is situated in the corner of the lid-wound, the other in the corner of the_flap and comes 
out in the skin. 
Restoration of the Lids—Kollner has devised an operation for 
restoration of the lower lid, which also gives satisfying results in 
the repair of the central portion of the upper lid. The method 
suggested for the lower lid is as follows: The upper lid is everted and 
extended over a Gronholm spoon, and an incision is made through the RESTORATION OF THE LIDS 
75 
conjunctiva and posterior layers of the tarsus, 2 mm. above and 
parallel to the lid-margin, slightly longer than the defect of the lower 
lid. From the ends of this incision two cuts are carried perpendicu- 
larly upward through the tarsus and into the transitional fold (Fig. 
48). The flap of conjunctiva and tarsus may be readily peeled off 
Fig. 48.—Formation of a flap from the posterior lamina of the upper lid, after 
Kollner. Full line, I, incision through conjunctiva and tarsus. Loss of tissue in lower 
lid made in quadrangular form. 
from the anterior lid lamina. The upper lid is replaced in proper 
position, and the flap, which hangs down from the upper fold, is 
fixed by several sutures into the quadrangular-shaped defect of the 
lower lid. The sutures are inserted at the lower margin as well as at 
both lateral borders (Fig. 49). In this way the lower lid has gained 
Fig. 49.—The flap, F, of the upper lid, is sutured in the loss of tissue in the lower lid. 
The dotted line in the upper lid indicates the place from which the flap was taken. Two 
lateral sutures are inserted for temporarily closing the lid fissure. 
both conjunctiva and tarsus. The anteriorily exposed wound-sur- 
face is covered with epithelium, either with pedicled or non-pedicled 
flaps. The lid fissure is closed at both sides by sutures, and the 
eyes bandaged for several days until firm healing has taken place. 
At the end of about seven days the conjunctival bridge between the 
upper and lower lids is cut through and the lid-margin smoothed 
with scissors. 76 
CICATRICIAL ECTROPION 
The same operation may be employed in symblepharon of the 
lower lid, especially after cauterization and burns, and proves its 
superiority in cases where the transplantation of epidermis or flaps 
of mucous membrane have been tried without success. 
Ectropion with injury of the bones is usually an operation for the 
general surgeon. Lexer believes that the orbital margin is best 
restored by strips of cartilage taken from the ribs. The bottom of 
the orbit may likewise be restored by cartilage inserted beneath the 
globe, so that the sunken eye is lifted up and with it the entire lid 
fissure. 
SYMBLEPHARON 
In view of the difficulties which accompany operation for the 
relief of extensive adhesion of the eyelids to the eyeball, it should be 
the endeavor to prevent as far as possible the development of these 
attachments after extensive cauterizations and burns. Excellent 
results are secured by the use of a prothesis of glass, which is inserted 
into the conjunctival sac a few days after the injury. The surface 
of the prothesis must be absolutely smooth, and the centre perforated 
to permit the escape of secretion. If the glass is properly vaulted, 
there is no pressure or injury to the underlying cornea, although the 
latter may have been injured. Usually the prothesis is well borne. 
After the orbital tissues have been entirely cicatrized, it may be 
possible to use such a glass body after freeing the lids from the scar. 
If the eyeball is destroyed, such a course keeps the lids free, and 
saves sufficient space for the wearing of an artificial eye later. 
Partial Symblepharon.—If the lid is attached to the eye only 
by single bands, causing impaired mobility of the eye and diplopia, 
they may be severed, and the wound covered to prevent reattach- 
ment of the two raw surfaces. Properly placed sutures are sufficient 
when the cicatricial bands are small, even if the adjacent conjunctiva 
must be loosened and drawn over the open wound. Incisions into the 
neighboring conjunctiva are of value to relieve tension on the sutures. 
If the destruction of the conjunctiva has been extensive, causing a 
broad symblepharon, there is not sufficient conjunctival tissue in the 
immediate vicinity to cover the wound, and there must be used 
either a pedicled flap from the neighboring conjunctiva or a flap 
without pedicle from the upper transitional fold or from the con- 
junctiva of the sound eye. SYMBLEPHARON 
77 
Operations for symblepharon are usually required for the area 
of the lower lid. A defect in the lower inner or outer portion of the 
eyeball may be covered by a pedicled flap from the adjacent con- 
junctiva, rotated over the bulbar wound and fastened with sutures. 
The area produced by the excision of the flap may be allowed to 
cicatrize, as, lying to the outer side of the original defect, it does not 
cause new adhesions, or it may be possible to loosen the neighboring 
conjunctiva sufficiently to close the wound. Pedicled flaps are 
usually prepared with difficulty, and it is therefore preferable to use 
a flap taken from the upper conjunctival fold, providing this portion 
of the conjunctiva shows no cicatricial changes. The normal fold 
offers ample conjunctiva for broad flaps, but if the membrane in this 
situation should be contracted, the use of a flap from the patient’s 
other eye offers the best chance of a satisfactory result. A few fine 
silk sutures fasten the non-pedicled flap in its new position. 
The use of mucous membrane from the rabbit has been shown by 
personal experience to be worthless. Even if the graft adheres suc- 
cessfully, subsequent contraction is so great that the good effect 
secured is entirely lost. 
All methods of covering the defect with conjunctiva must be 
limited to the eyeball, as flaps large enough for the wound in the eye- 
lid cannot be obtained. Though the covering of the one defect is 
sufficient in most cases, it is always better to have both wounds pro- 
vided with epithelium, not only to prevent the formation of a new 
symblepharon in case the single flap does not heal in properly, 
but because the scar arising from the uncovered wound may contract 
later on and gradually draw the lid inward and cause trichiasis; or 
result in limitation of motion of the eyeball. Many plastic methods 
have been devised, therefore, to cover the wound in the lid with 
mucous membrane from the lip or with a pedicled flap from the 
neighboring skin or a free flap of epidermis. 
In total symblepharon of the lower lid the wound of the lid must 
be covered, as the defect on the eyeball is too large to be relieved by 
conjunctiva alone. Excellent results may be obtained by a com- 
bination of conjunctival and skin-flaps. After thorough separation 
of the lid from the globe, the wound on the eyeball is covered with 
a pedicled flap from the upper conjunctival fold and that on 
the lid with a skin-flap from the lower lid, by Rogman’s method 
(Fig- 5o). 78 
CICATRICIAL ECTROPION 
Rogman’s Operation. An incision is made in the skin of the 
lower lid, and the flap {abed) formed, the base {ad) of which is situated 
directly at the upper level of the conjunctival fold in need of recon- 
struction. This flap is as long and as high as the lid. After the flap 
has been dissected up, the deeper tissue-layer on the level of the con- 
junctival fold is completely severed, leaving only the skin intact. 
It is then easy to rotate the flap in through the slit so made, so that its 
raw surface is turned toward the wound in the lid, after which the 
edge {be) of the flap is fastened with sutures to the lid-margin. The 
flap is certain to become attached, as its base remains connected to 
Fig. 50.—Operation for symblepharon after Rogman. After separation of the 
symblepharon between the eyeball and the lower lid, there is formed from the skin of the 
lower lid the flap (a., b., c., d.); it has its base at a.d. This flap is rotated backward 
through a slit \n such a fashion that the edge (b. c.) can be sutured to the palpebral 
margin and the skin—serving the function of a palpebral conjunctiva—is turned toward 
the eyeball. There is rotation of 1800. 
the surrounding tissues. The wound on the outside of the lid is, as 
far as possible, tied by sutures. At first, however, there is a slit left 
through which the new conjunctival sac can be reached from the 
outer side. After about eight days, the connection is severed, and 
the slit rapidly closes by cicatrization. 
Rogman, in his original method, repeated this procedure at a later 
date by rotating through the slit another flap formed from the still 
remaining skin on the lower lid. I much prefer the foregoing com- 
bination to Rogman’s original method, as there is too little skin 
available for the second plastic operation on the lid. 
Total Symblepharon.—The most satisfactory operation for 
relieving a total symblepharon is performed as follows: After divid- TOTAL SYMBLEPHARON 
79 
ing the scar binding the lid to the eyeball, a canthotomy is made, 
and from the end of the skin incision a cut 3 cm. long is made out- 
ward and downward and the skin is dissected loose toward the lid, 
until finally the whole lower lid, as a free flap, can be tilted toward 
the nose. The dissection extends into sound tissue beyond the 
area of cicatricial change. In this way a large raw surface is secured 
which stretches in one plane from the limbus to the lid-border. A 
large skin-graft of a suitable shape is dissected from the delicate skin 
of the upper arm, and fitted accurately to the raw surface up to the 
palpebral fissure. The graft may be sewed with several fine sutures 
to the lid-margin on the one side, and to the limbus on the other. As 
the lid is now turned back again into its original position, the new 
skin folds up properly of itself, the place doubled down representing 
the new fornix. The fold is fixed in position with two sutures, which 
form a loop and are carried through from this spot out to the cutane- 
ous surface, and their ends tied outside over gauze. The operation 
is completed by the suturing of the incisions made at the beginning. 
Both eyes are bandaged and the dressing changed for the first time 
at the end of three days. 
The fornix is at first abnormally deep, but, later, diminishes in 
size through contraction, without, however, shrinking so much as to 
prevent free movement of the eye or the comfortable wearing of a 
prothesis. A prothesis is inserted early, and eventually a properly 
fitting one is made from Stent’s composition, a substance used by 
dentists for taking impressions. Such protheses extend deeply into 
the fornix. 
An operation which is of value in making a free space where 
the entire orbit is filled with cicatricial tissue is performed as follows: 
After the lid has been completely severed from the eyeball, a pedicled 
flap of skin from the temple is drawn into the orbit through a vertical 
incision which is made at the outer end of the upper lid. The flap 
is stitched in the desired position, and heals to the wound-surface. 
After healing the pedicle is severed, and the vertical incision 
in the lid closed. The raw surface of the lid is covered with 
a non-pedicled flap of skin or mucous membrane from the lip, 
fastened with mattress sutures. Several weeks later the same 
operation is performed on the lower lid, the skin-flaps secured from 
the zygomatic-cheek area, and turned behind the lower lid through 
a perpendicular incision at the outer end. The raw lid surface is 80 
CICATRICIAL ECTROPION 
covered with a non-pedicled flap. A specially formed prothesis with 
central opening, to which mention has been previously made, is 
inserted to hold the pedicled flap in place at its base, and keep the 
lids separated. 
The operations with a non-pedicled flap are not particularly 
recommended unless the incision separates the entire thickness 
of the lid, as previously described. In the limited space perfect 
adaptation of the graft to the wound is not easily secured. The 
results are better if the non-pedicled flap from the inner surface of 
the upper arm is placed over a glass ball, which is inserted back of the 
lid after the usual separation and excision of the cicatricial tissue. 
This method was first employed by Morton and May. Haitz recom- 
mends plates of celluloid, which may readily be modeled the desired 
size and shape. The plate for the lower fornix is half-moon shaped, 
3 cm. long and 13 mm. high in the center (Fig. 51). At its border, 
which corresponds to the lid-margin, six holes are made for the sutures 
to fasten the plate to the lid. The cicatricial tissue which attaches 
the eyelid to the eye is cut through with a knife the whole length of 
the lid down to the bone. The eye is held in complete upward rota- 
tion by forceps, and the flap from the arm is laid with its raw surface 
next to the eyeball, so that the upper margin corresponds to the lim- 
bus. The plate of celluloid with its concave surface posteriorly and 
the convex edge downward is placed on the flap and pressed in posi- 
tion with the fingers of the right hand. The index finger of the left 
hand is carried from below under the flap, 
and the lower lid drawn outward, so that it 
glides over the lower border of the plate, 
carrying with it the lower portion of the 
flap which thereby tilts upward. The fingers 
of the right hand now push the plate and 
the portion of the flap next the eye down in 
the pocket made, and, as the pressure is con- 
tinued, the transplanted skin is smoothed with a spatula. Three 
double-armed sutures fasten the upper edge of the plate to the 
border of the flap and to the lid-margin, the needles passing 
through the holes in the plate, the flap, and the lid, and emerging in 
the skin about 3 mm. below the lid-margin, where they are tied over 
small pledgets of gauze. Two fine silk sutures unite the limbal 
border of the flap to remnants of conjunctiva near the cornea. A 
Fig. 51.—Plate to be 
inserted in the lower cul- 
desac after the method of 
Haitz. (Natural size.) TOTAL SYMBLEPHARON 
81 
mild ointment is put back of the plate. The eyes are bandaged for 
three or four days, and afterwards only the operated eye. At the 
end of eight days the sutures and plate are removed. 
Skin-flaps, placed over suitable molded material for support, are 
also used to form a socket for the wearing of an artificial eye in cases 
of extensive cicatricial destruction of the conjunctival culdesac, when 
the eye is shrunken or absent. As in other similar conditions, the 
eyelids are freed of all cicatricial adhesions, the shrunken eyeball 
removed, and the cicatricial tissue of the orbit which lacks vascularity 
removed. The mold, which has been shaped to fit the cavity and 
covered with the skin-flap, raw surface externally, is placed into the 
orbital space, and the lids stitched together if possible. When a mold 
is not employed the extensive raw surface of the posterior positions 
of the lids and the bottom of the orbit is covered with a delicate skin- 
flap from the inner part of the arm, fastened by sutures to the borders 
of the wounds of the upper and lower lids. A prothesis of suitable 
size and form is then inserted, which exerts pressure to hold the flap 
in contact with the raw surfaces of the lids and the orbit. Glass 
shell eyes of various forms and shapes are made by Mueller, of Wies- 
baden, some of which have a central perforation through which the 
condition of the transplanted flap may be inspected. After insertion 
of the artificial eye, the lids are closed with adhesive, and a firm band- 
age applied. After healing the artificial eye must be worn constantly 
to prevent contraction of the socket. By increasing the size of 
the prothesis the cavity may in time dilate slightly. 
Special apparatus has been devised by Bruhn to prevent the 
artificial body from being expelled with the shrinkage of the cicatri- 
cial tissue. An unmovable portion attached to the head and teeth 
has an arm with ball and socket joint by which the artificial eye may 
be continually pressed into the orbit in any desired position and 
firmly held until cicatrization is complete. CHAPTER V 
ENTROPION AND TRICHIASIS 
If the tissues of the lid are altered by senile degeneration, the skin 
relaxed, and the layers of the lids more movable upon each other, the 
margin of the lid is turned in by the contraction of the orbicularis 
muscle—senile entropion. The pressure of a bandage against the 
margin of the lids favors its formation. With the irritation of the eye 
produced by the inturned lashes, there is increased spasm of the 
muscle, and the altered position of the lid becomes permanent. 
The narrow cartilage of the lower lid is more easily turned in than the 
broader tarsus of the upper lid, so that spastic entropion only occurs 
in the lower lid. The defect is relieved by operations which exert 
a pull on the margin of the lid to draw it into a perpendicular direc- 
tion, as is done by the shortening of the skin of the lid by the excision 
of a horizontal fold, or by the insertion of a properly placed suture 
(Gaillard suture). Other operations exert pressure toward the con- 
vex margin of the tarsus in a backward direction, which influences 
the position of the lid and corrects it. (Graefe’s method) (Group I.) 
Another cause of the development of entropion is trachomatous 
conjunctivitis. Among the conditions which cause the free border 
of the lid to turn upward and finally inward, with permanent irrita- 
tion of the cornea from the inturned cilia, may be mentioned the 
influence of muscular contraction (Schnabel); alteration of the skin, 
with relaxation and the formation of folds; and the mechanical 
consequences of the shrinkage of the conjunctiva and the anatomical 
changes in the tarsus by the development of connective tissue from 
long lasting infiltration, especially in its posterior layers adjacent to 
the diseased conjunctiva, with consequent shrinkage and distortion. 
Of the many operations proposed for this form of entropion, those 
which remove the pathological condition by excision of the cicatricial 
tissue and the thickened dense tarsus, and fasten the loose and 
relaxed skin of the lid to the convex margin of the tarsus, give the best 
results. The lid with the thinned tarsus may be brought by these 
measures from its distorted position (stretched), and the cilia restored 
to normal situation. (Method of Hotz-Anagnostakis) (Group II.) SPASTIC ENTROPION 
83 
If, in addition to inward turning of the lid-margin, the hair 
follicles are diseased, there is associated a true trichiasis, and the 
cilia no longer grow forward from the lid-margin in a normal position, 
but slant backward through the tarsus and are frequently curved 
and mangled. The previously mentioned operations for the restora- 
tion of the normal position of the tarsus and the lid-margin do not 
suffice for trichiasis, as the alteration in the position of the lashes is 
not due to the inward rotation of the lid, but is the result of the 
misgrowth of the cilia. 
Several operations, of which those of Snellen and Panas are 
examples, do not take into consideration the cause of the lid-defect, 
but remove not only the inward rotation but also the trichiasis 
(tarsoplasty). These methods are therefore a combination of the 
entropion and trichiasis operations (Group III). 
Another class of operations acts only to relieve the trichiasis, 
and is applicable to any misgrowth of the lashes irrespective of the 
cause. The pernicious effect of the cilia on the cornea is thereby 
relieved, without an attempt being made to relieve a possible 
entropion (Group IV). 
To the latter group belong the methods by which the lashes are 
extirpated; a zone of hair follicles ablated (Flarer); or the bed of 
the hair follicles drawn away from the lid-margin, and the wound 
produced covered with epithelium (plastic of the lid-margin). Ped- 
icled or non-pedicled skin-flaps or flaps of mucous membrane are 
used. Of the operations suggested, mention may be made of Stell- 
wag’s modification of the Flarer operation, Waldhauer’s modified 
Jaesche-Arlt procedure, Spencer Watson’s method, and van Millin- 
gen’s plastic with mucous membrane. If only individual lashes are 
turned backwards, electrolytic epilation is employed. 
The excochleation of the cartilage by the method of Kuhnt 
occupies a special position under the different methods, and is 
employed in entropion due to the cicatricial form of trachoma. It is 
described as a supplement to Group III. 
i. Shortening the Skin by Mechanical Means.—If the inward 
rotation is recent, as following bandaging of the eye, relief may be 
secured by strips of plaster about i cm. broad and 2 cm. long, 
fastened by slight pressure close to the lid-margin, and the lid drawn 
GROUP I. SPASTIC ENTROPION 84 
ENTROPION AND TRICHIASIS 
into normal position and maintained there by fixing the lower end of 
the strip to the cheek. A plaster is selected that does not cause irrita- 
tion of the skin, and before being applied the skin is carefully dried. 
Frequently the lid returns to the proper position as soon as the 
bandage is removed. In such cases the bandage is not to be replaced, 
but the eye is protected from injury by the Fuchs lattice, with the 
wire netting covered with black cloth. No gauze or cotton is 
placed beneath the mask. Even on the first day of a cataract 
extraction this mechanical protection may be employed instead of the 
bandage, and the eye remain uncovered, providing the incision 
does not gape. 
2. Shortening by Excision of the Skin.—The method of excising 
a horizontal oval piece of skin of the lid pulls the margin down in a 
Fig. 52.—Gaillard suture. At the highest point of the inverted lid lies a'suture 3 mm 
long, the ends of which are passed under the skin to the lower border of the orbit. 
perpendicular direction and brings the lid into normal position. By 
picking up a fold of the skin with the fingers, an approximation can 
be made of the amount of excision necessary. The skin should be 
about cm. wide at its greatest width, and is readily removed with 
scalpel or lancet, after the usual ivory plate is placed between the 
eyeball and the lid. The wound, the upper edge of which should gaillard’s suture 
85 
correspond with the border of the lid, is then closed by several vertical 
sutures. The resulting scar is hardly visible. 
As the skin soon stretches, the operation is useful only in cases of 
a transient character. The result, however, may be made permanent 
if the sutures which close the wound are inserted after the method of 
Hotz (see page 86). 
3. Gaillard’s suture corrects the inward rotation of the lid by a 
fold of the skin which leads to a temporary shortening in the per- 
pendicular direction (Fig. 52). A long needle curved on the flat is 
introduced through the skin at the highest point 
of the inverted lid and carried downward to 
emerge at the lower border of the orbit, and the 
process is repeated with the other end of the 
suture. Both ends of the suture are then tied 
over a small gauze compress. It is evident (Fig. 
53) that by this suture the highest part of the in- 
verted lid is drawn downward, a fold of the skin 
obliterated, and the edge of the lid everted and 
turned away from the eyeball. Two sutures are 
introduced, one at the junction of the inner and 
middle thirds, and the other the middle and outer 
thirds, of the lid. The sutures remain four or 
five days, and are removed by cutting the threads 
close to the skin near the gauze compress, and 
drawing them through the wound. 
4. Graefe’s operation shortens the skin in the horizontal direction. 
It consists in the excision of a triangular piece from the skin of the 
lower lid (Fig. 54). The first incision, 3 cm. long, runs parallel to 
the edge of the lid at a distance of 3 mm., and from both ends (be) 
of the middle third of this cut, two other incisions (be and ce) are 
made downward, which, uniting (e), form with be an equilateral 
triangle. The area of skin thus circumscribed is excised, and the 
edges of the wound at b and c are slightly undermined. The first 
suture approximates the two lateral angles (be) of the wound. The 
skin is, therefore, shortened and stretched horizontally, exactly at the 
lower border of the tarsus, and the latter pushed toward the eyeball, 
while the free border of the lid is rotated outward away from the 
globe. The rest of the wound is closed by two additional horizontal 
sutures. 
Fig. 53.—Gaillard 
suture. Vertical sec- 
tion through the inT 
verted lower lid with 
the suture inserted. 86 
ENTROPION AND TRICHIASIS 
Immediately after operation the lid is in a state of marked ectro- 
pion, indeed, its middle portion forms a protuberance, but this dis- 
appears within a few days as the skin relaxes and the lid slips back 
into its normal position. If the first suture is too near the edge of the 
lid, the stretched skin presses the free border of the lid backward 
against the eyeball and increases the entropion, and if inserted too 
Fig. 54.—Graefe operation. Horizontal incision (a. d.) through the skin 3 cm. long, 
parallel to and 3 mm. from the edge of the lid. From the middle centimeter (b. c.) two 
incisions (b. e. and c. e.), converging below. The circumscribed section of the skin is 
excised. Suture of the two lateral sides (b. e., c. e.) of the triangle. 
low, below the tarsus, it naturally has little or no influence on the 
position of the lid. It is, therefore, important that the first incision 
is parallel to the edge of the lid, and corresponds approximately 
with the lower border of the tarsus; i.e., 3 mm. from the edge of the 
lid. Occasionally the lid has a tendency to slip back from the posi- 
tion of ectropion into that of entropion. This may be prevented by 
a small gauze-compress, applied along the lower border of the tarsus, 
which will press it backward against the eyeball. In three or four 
days the sutures may be removed. 
GROUP II 
Hotz-Anagnostakis Operation.—This may be described as a 
representative of this group. 
Local Anesthesia.—The conjunctiva is rendered anesthetic by the 
usual 3 per cent, cocain solution, and the whole length of the lid 
injected with the i per cent, cocain-adrenalin solution, the needle 
also being carried into the deeper muscle of the lid and pushed down 
into the tissues of the thickened tarsus. HOTZ-ANAGNOSTAKIS OPERATION 
87 
Operation.—After an ivory or hard-rubber plate has been placed 
beneath the lid to protect the eyeball and provide a firm base, and by 
compression assist in checking hemorrhage, an incision is made along 
the entire length of the lid, either with a scalpel or a lancet, 3 mm. 
above and parallel to the border. Lying exposed in the wound are 
the reddish fibers of the orbicularis muscle, parallel to the edge of the 
lid. After the skin has been freed downward for a short distance, 
and upward to the upper border of the tarsus, the fibers of the mus- 
cle are lifted up at one end of the lid with forceps (Fig. 55) and 
excised, in a breadth of about 4 mm. to the other end of the lid, with 
the scissors, applied flat. This frees the entire surface of the tarsus. 
Fig. 55.—Hotz-Anagnostakis operation. Excision of the fibers of the orbicularis 
muscle (m.) covering the tarsus (ta.). With forceps the fibers are grasped at the left 
angle of the incision; a pair of small curved scissors is applied close to the tarsus, and 
with short cuts the muscle is separated along the entire length of the lid. 
In most cases of trachoma, the tarsus is several millimeters 
thick, is firm in texture and curved convexly forward. The normal 
striations of the Meibomian glands are not shown in the tarsus 
of a trachomatous patient, as only some indistinct traces of the 
glands remain. It is best to excise, or rather to diminish, the thick- 
ness of this useless scar-tissue, which is the cause of the distortion of 
the lid. For this purpose a sharp scalpel is entered (Fig. 56) some- 
what below the upper margin of the tarsus and parallel to its plane, 
and with a sawing movement downward thin slices are cut away. 88 
ENTROPION AND TRICHIASIS 
In a normal tarsus, as found in the cadaver, this procedure cannot be 
demonstrated, as the fibrous structure is thin and would immedi- 
ately perforate. In a trachomatous patient there is little danger of 
cutting through the thickened tarsus. 
Fig. 56.—-Hotz-Anagnostakis operation. With the knife applied against the con- 
vex anterior surface of the thickened tarsus (ta.), thin slices are cut. The upper 
border of the tarsus and the margin of the lid are not disturbed. 
The upper portion of the tarsus is not thinned, as it must remain 
thick to fasten the sutures and also to act as a support about which 
the lid rotates in taking its normal position. The lower margin of the 
tarsus is not touched, but the furrow in the anterior surface of the 
cartilage is made sufficiently thin so that after the sutures are applied 
the lid-margin is turned out. A perforation of the tarsus is to be 
avoided. 
Insertion of the Sutures.—The purpose of the sutures is to stretch 
and straighten the tarsus which has been bent backward by the disease. 
This is effected by fastening the lower margin of the skin-wound to the 
upper border of the tarsus. Because of the difference in the height 
of these two points, union is possible only if the lower border of the 
tarsus bends forward on itself and carries the cilia into the desired 
position. The sutures which include only the cutaneous wound- HOTZ-ANAGNOSTAKIS OPERATION 
89 
edges and the upper border of the tarsus are inserted as follows 
(Fig- 57): 
The central suture is entered through the upper wound-border at 
a point corresponding to the middle of the lid. The skin is then 
retracted by an assistant, and the needle passed through the upper 
border of the tarsus in a horizontal direction, which prevents perfora- 
Fig. 57.—Hotz-Anagnostakis operation. Two of the sutures are applied. They 
pass from above through the skin (u.); then through the upper border of the tarsus (ta.), 
in which they are firmly fastened; and lastly through the lower margin of the skin (1.) 
above the cilia. Corresponding to the convex form of the upper tarsal border, the tarsal 
point of insertion of the outer and inner suture is nearer the lower margin of the wound 
than that of the middle suture. 
tion through the conjunctiva, an accident, however, of little conse- 
quence. The assistant releases the upper cutaneous wound, and the 
needle pierces the lower border of the skin-wound in a line corre- 
sponding to the upper point of entrance. One suture is inserted in 
exactly the same manner on either side of the first, making three in all. 
In long lids more sutures may be required. The central suture 
is tied first. The two margins of the skin-wound are approximated 
with two tissue-forceps in the hands of the assistant. As the suture is 
tightened, the tarsus with the free border of the lid bends forward and 90 
ENTROPION AND TRICHIASIS 
somewhat upward (Fig. 58). It is well to induce moderate over- 
correction at first, so that the margin of the lid is at a slight distance 
from the eyeball. The remaining sutures are tied with the same 
care, and the ends are cut off short. 
Dressing.—A simple dressing is then applied and kept from 
adhering to the wound by gutta-percha tissue covered with ointment. 
The other eye need not be bandaged. The dressing, 
as in every other lid-operation, is changed on the 
following day. The sutures should be removed after 
four days. 
Results.—If performed in the manner indicated the 
operation gives good results. As the edge of the lid is 
not injured, its normal outlines are preserved, which 
from a cosmetic standpoint is of great importance. 
The main advantages of the operation are that the 
pathologically heavy tarsus is rendered light by the 
excision, and the lid returns to its normal position 
without becoming shortened in the slightest. There 
are several disadvantages. The tarsus is crescentic in shape, 
broadest in the middle of the lid and tapering off somewhat toward 
both angles. Therefore, the effect of the operation is better in the 
middle of the lid than at the ends. As it is not necessary to turn up 
the ends far enough to attach the cutaneous wound-margin to the 
upper border of the tarsus, the entropion at the margin of the lid may 
not be completely overcome. The excision of a small piece of skin 
will, however, slightly shorten and raise the lid. At the same time a 
small incision may be made into the intermarginal border at a cor- 
responding point, so that the sutures raise the cutaneous layer of the 
lid with its cilia away from the eyeball. The small wound produced 
in the intermarginal border is allowed to undergo cicatrization. 
Beyond this provisional incision no cut is made into the intermar- 
ginal border; in fact, a primary intermarginal incision would prevent 
the stretching of the tarsus, for, as soon as the anterior cutaneous 
layer of the lid is separated from the tarsus by such an incision, the 
rolling forward of the lower tarsal border can no longer be accom- 
plished by the suture. Correction of the position of the tarsus is not 
intended in the secondary provisional intermarginal incision, but 
rather a displacement of the layer of skin containing the hair-roots, 
similar to that in the Jaesche operation. This latter operation, 
Fig. 58.—The 
tarsus has been 
bent forward dur- 
ing the closing of 
the skin-wound. 
The eyelashes are 
directed forward 
and slightly up- 
ward. HOTZ-ANAGNOSTAKIS OPERATION 
91 
unsupported by the Hotz method, would allow the thickened and 
heavy tarsus to retain its curvature toward the cornea, keeping up the 
irritation as before. Again, the wound produced in the intermarginal 
border must heal gradually by cicatrization, which would interfere 
with the best cosmetic results. Below, the suture may be fastened 
Fig. 59.—Snellen operation. A wedge-shaped piece (e.) of the tarsus is excised, 
Sutures in place, s., skin; m., muscle; ta., tarsus. 
not only in the edge of the skin-wound but also in the tissue of the 
tarsus immediately above the lid-margin. This method of fixation 
of the suture exerts a greater influence on the stretching of the tarsus, 
especially if the skin incision has been made high up, along the upper 
border of the tarsus, than the original method. If the incision 
through the skin is made closer to the lid-margin, as here described, 
the narrow border of skin that remains attached to the lid-margin is so 
intimately united to the lower portion of the tarsus that it is only 
necessary to enter the thread through the skin-border to bend the 
cartilage forward. The lower suture must be kept above the eye- 
lashes and not carried through the intermarginal border, otherwise 
it will cut through the skin, injure the hair bulbs, and possibly cause 
an ugly indentation in the edge of the lid. 
Results—-The possibility of recurrence need not be feared if the 
tarsus has been thoroughly thinned, but if the tarsus is allowed to 
remain thick the sutures are unable to cause the necessary stretching, 
and the little effect secured is lost by ultimate cicatricial shrinking. 
The operation is not as satisfactory for the lower lid, owing to 
the less width of the tarsus, but the effect may be increased by the 
excision of a small piece of skin. 92 
ENTROPION AND TRICHIASIS 
By the tray-shaped thinning of the tarsus, the operation in some 
respects resembles the methods described in the next group. 
GROUP III. TARSOPLASTY 
Snellen Operation.—The incision in the skin of the lid and the 
excision of the muscle fibers on the anterior surface of the tarsus are 
the same as in the Hotz-Anagnostakis operation. The thickened 
tarsus is then incised horizontally across its 
entire lepgth with a thin scalpel, two cuts being 
made 2 'to 3 mm. apart, the lower one 2 mm. 
above the lid-margin. The two incisions cut 
through the tarsus obliquely and meet near its 
posterior portion without injuring the'conjunctiva 
or opening into the culdesac. The-wedge-shaped 
section of the tarsus is then completely excised 
(Fig. 59). The two needles of the double-armed 
silk suture are passed through the upper edge of 
the tarsal opening near its center, and then entered 
at the lower cut and passed in the tarsus to emerge 
from the skin immediately above the cilia fFig. 
60). The two ends of the suture are knotted 
over a small glass bead, which causes the lid-margin 
to turn upward. The skin-wound is closed by several sutures. 
The broader the wedge of tarsus excised, the greater will be the 
eversion of the border of the lid. The operation is indicated in 
thickened lids with deformed tarsus, especially if the entire lid- 
margin is filled with hairs. The skin-sutures may be removed in 
three to four days. 
Panas Operation.—This is a more radical procedure. It does 
not restore the normal position of the tarsus and the lid-margin 
but it relieves the entropion and the inward rotation of the cilia. 
The eyeball is protected by an ivory plate, and an incision made 
through the skin of the upper lid, as in the Hotz operation, dividing 
the muscle bundle of the orbicularis, which need not be excised. 
The tarsus is freed as far as its upper margin. With a sharp scalpel 
a cut is made through the tarsus and conjunctiva immediately above 
and parallel to the margin of the lid along its entire length, converting 
the margin into a movable flap, connected with the surrounding 
tissues only at both lid-angles. The object of the operation is to 
Fig. 60.—Snellen 
operation. Vertical 
section through the 
upper lid, showing 
the cuneus-shaped 
excision (e.) of the 
tarsus (ta.), with the 
suture (s.). TARSOPLASTY 
93 
fasten the exposed tarsus so that the eyelashes are directed forward. 
Four sutures are inserted, doubly armed with thin and strongly 
curved needles. The needle of one of the sutures is passed deeply 
into the tarsus at the upper margin of the wound close to the cut, 
and brought out horizontally close to its point of insertion. This 
fixes the suture firmly into the anterior portion of the tarsus, and 
Fig. 61.—Panas operation. After cutting through the skin (s.) and muscle (m.), the 
tarsus (ta.) and conjunctiva are incised, over an ivory plate placed between lid and bulb, 
along the entire length of the lid. The central suture has already been introduced. 
Above it is fastened to the tarsus near the edge of the tarsal wound. Both ends of the 
suture pass downward between tarsus and muscle and emerge in the intermarginal 
border behind the cilia. Over one end of the suture a glass bead is drawn. 
both ends of the thread are passed between the muscle and tarsus 
of the free flap and brought out in the intermarginal border. The 
other sutures are introduced in a similar manner (Fig. 61). 
Perforation of the thickened tarsus is easily avoided, but should 
it occur, is of little importance, as the suture is drawn into the con- 
junctiva without injuring the cornea. 
The assistant now turns the edge of the lid forward with forceps, 
thus bringing it perpendicular to the plane of the tarsus, and the 
operator ties the central suture, drawing a glass bead over it (Fig. 
62). He should be careful that the suture is not tied so tightly that 
the glass bead will press upon the edge of the lid and lead to circum- 
scribed necrosis and subsequent loss of eyelashes, but tight enough 
to allow firm attachment of the flap. The other sutures are treated 
in exactly the same manner, and the ends of the threads cut off short. 94 
ENTROPION AND TRICHIASIS 
The cutaneous wound must then be closed with several sutures, and 
an ointment-dressing applied. The sutures may be removed as early 
as the fourth or fifth day. 
The same rules are followed in operation on the lower lid. 
Results.—By the Panas method marked degrees of entropion 
and trichiasis are permanently relieved, and recurrence is rare. 
Cosmetically it is inferior to the method of Hotz. If the sutures 
have been properly inserted, the flap accurately fits, and the un- 
Fig. 62.—Sagittal section through the upper lid after completion of the operation. 
The margin of the lid, now placed vertically to the plane of the lid, is so adjusted to the 
tarsus (ta.) that no part of it projects into the palpebral fissure; in fact, only a small 
portion of the wound-surface (the cut edge (c.) of the tarsus) remains exposed. 
natural position of the lid-margin—at right angles to the tarsus—is 
not striking, but faulty placing of the sutures results in disfigure- 
ment. If fastened at too high a point, the free edge of the lid is 
pulled up above the margin of the tarsal wound, and the tarsus 
projects free into the palpebral fissure. The wound-surface then 
heals by slow granulation, and terminates finally in the formation 
of a scar. As this rough cicatrix is directed inward, owing to the 
pathological curve of the tarsus, irritation of the cornea follows. A 
serious disfigurement of the lid may also be produced if the tarsus is 
incised at too great a distance from the lid-margin. The flap of the 
lid, which is turned forward, projects like the shade of a cap, and 
the lid itself is excessively shortened. 
There are several disadvantages which must be considered. The 
base, from which the flap derives its nourishment, is small in propor- 
tion to the length, and is, therefore, in danger of necrosis. The 
sutures must therefore be carefully tied, so that the incision wound 
of the flap is joined to the anterior surface of the tarsus, from which it 
soon derives nourishment. If the sutures are tied too tightly the flap 
is rotated too much, so that the two raw surfaces are not in apposi- 
tion, and necrosis of the skin is probable. Should this unpleasant TARSAL ENUCLEATION 
95 
complication arise, the patient has not only been disfigured by the 
operation, but is probably even in worse condition than before, as now 
the upper lid is shorter by the necrosed piece, and a resultant lagoph- 
thalmos may be produced. Even if the operation is without com- 
plication, the upper lid has been shortened by the width of the flap, 
which has been turned out of the plane of the lid to one perpendicular 
to it. Short lids in patients seeking surgical aid must, therefore, be 
considered another contraindication to the operation. 
The lower lid may be operated on after the methods of Hotz and 
Panas in exactly the same manner as the upper lid. Because of the 
small size of the tarsus, however, the Hotz operation is less favored. 
Tarsal Enucleation (Kuhnt).—'This procedure is of especial value 
in entropion of the lower lid, but is only employed in the cicatricial 
stage of trachoma, as the conjunctiva is then readily detached from 
the shrunken and deformed tarsus. At an earlier period the gela- 
tinous infiltration prevents separation of the two tissues without 
fenestration of the conjunctiva. Both entropion and trichiasis are 
permanently relieved by removal of the tarsus, and healing of the 
trachoma is materially hastened. (See page 340.) 
After the lower lid has been everted with forceps, an incision, 
to 2 mm. from and parallel to the lid-margin, is made through the 
conjunctiva and tarsus from the lachrymal punctum to the outer 
commissure. The conjunctiva is separated by flat cuts of a knife 
from the tarsus, and the latter dissected from the underlying attach- 
ments as far as its inferior margin and removed. Double-armed 
sutures are now placed in the edge of the cut conjunctiva, each loop 
about 2 mm. broad, and passed on the inner surface of the remaining 
margin of tarsus and brought out through the skin near the border 
of the lid. The threads are drawn taut until the cilia and lid-margin 
are in proper position, and fixed with adhesive to the skin. They 
may be removed in four or five days. The results of the operation 
are permanent. 
GROUP IV 
i. Method of Flarer.—After the usual intermarginal incision, a 
cut is made in the skin 3 mm. back of the lid-border and parallel to 
it, the two ends of the incision turning to join the opening made in 
the margin of the lid. The flap formed, containing the cilia, is 
removed with scissors, and the wound-edges brought together with 96 
ENTROPION AND TRICHIASIS 
line thread. As this excision sacrifices all the cilia, it is only indicated 
in severe affections of the lids in which only a few deformed lashes 
remain, and is then usually combined with the plastic mucous mem- 
brane operation. 
v. Stellwag covered the wound produced by the excision of the 
skin-flap by the same flap, transplanting it again to the wound-surface 
after it had been rotated an arc of i8o°. No sutures are inserted, 
but the wound is covered with rubber tissue with a bland ointment, 
and a bandage applied. 
2. Method of Jaesche-Arlt.—By this method the border of the 
intermarginal incision containing the hair bulbs is displaced upward 
by the excision of a crescent-shaped piece of skin from the upper 
lid. The wound is closed by vertical sutures. The excised piece 
of skin serves to cover the exposed anterior surface of the tarsus 
along the lid-margin. Like all skin-transplantations on the lid- 
margin, it sets up fresh irritation of the cornea because of the fine 
hairs always present in the skin. Skin-transplantations should 
therefore only be used in the area of the lids beyond the cornea. In 
all other cases the method of Hotz is to be preferred. 
3. Method of Spencer Watson.—This operation may be employed 
if the trichiasis is limited to the region of the external canthus. 
(Figures 63 and 64.) An intermarginal incision is made the length 
of the affected area, and a cut made in the skin of the lid, 2 mm. dis- 
tant from and parallel with the margin. By turning downward 
the lid-margin, the cutaneous incision is made to terminate at the 
canthus and join the intermarginal incision. In this way the cilia 
are contained in a flap, the base of which lies on the side away from 
the canthus. A second skin incision, 2 mm. above and parallel to 
the first, is made, forming another flap, the base of which lies on the 
side of the canthus. The flaps are undermined and exchanged, 
the flap with the lashes moved above, while the upper is placed at the 
margin of the lid. The flaps are held in the new positions by sutures 
passing through their angles, and within a few days permanent union 
takes place. \ 
If this method were applied to trichiasis extending the whole 
length of the lid, the flaps would have too small bases as compared 
to their length, and in consequence would easily break down. Like 
all skin-transplantations, the operation has the drawback of inducing 
renewed symptoms of irritation from the fine hairs in the skin-flap. MUCOUS MEMBRANE FLAPS 
97 
However, as the flaps lie to one side of the cornea, this is not an 
important disturbing factor. 
Mucous Membrane Flaps.—If there is irregularity in the arrange- 
ment of the cilia, a characteristic of severe types of trichiasis, with 
corneal complications, a plastic operation must be performed. An 
Fig. 63.—Spencer Watson operation. Position of the intermarginal and skin-incisions, 
a., base of the skin-flap containing the eyelashes, b, base of the upper skin-flap. 
incision is made along the intermarginal border, and the skin, with the 
cilia, is separated from the tarsus to about its upper border. As the 
skin is usually short, there is some retraction, and a few fine silk 
sutures are used to attach the edge to the tarsus a few millimeters 
Fig. 64.—Spencer Watson operation. The flaps interchanged, 
above the margin of the lid. The wound-surface produced is covered 
with a flap obtained from the mucous membrane of the inner surface 
of the lower lip. After the flap has been separated from the lip, it 
is placed on a pad saturated with warm, normal salt-solution, with 
its mucous surface downward, and a pair of scissors, applied flat to 98 
ENTROPION AND TRICHIASIS 
the surface, is used to free it of all adhering shreds of fat, so that 
only the delicate mucous membrane remains. This flap is then 
placed upon the defect in the lid with its wound-surface down, and 
its edges are brought into exact coaptation. Sutures are not neces- 
sary and not to be recommended. The operated eye is then 
bandaged, after a piece of gutta-percha tissue covered with ointment 
is applied over the upper lid to prevent adhesion of the dressing. 
The flat soon heals firmly, and in four to five days the dressing can 
be omitted. 
The operation is successful in relieving the trichiasis, but the con- 
trast between the white flaps and the normal skin is conspicuous. In 
Fig. 65.—Cilia-forceps. 
these severe cases, however, cosmetic appearance is not considered, 
as the danger of grave ocular complications makes reliable interfer- 
ence absolutely compulsory. Skin from the arm must not be used. 
We have repeatedly been compelled to remove a skin-flap from indi- 
viduals in whom a plastic lid-operation for trichiasis had been per- 
formed, because the fine hairs of the flap irritated the eye. In such 
instances the skin-flap should be replaced with mucous membrane. 
The patient suffers more from the fine hairs of the skin-flap than from 
misdirected eyelashes; the latter he can at least see sufficiently well 
to pull out regularly with forceps, while the fine hairs of the skin are 
almost invisible. 
Electrolytic Epilation.—Trichiasis affecting individual lashes is 
treated by the electric needle. The lid is thoroughly cocainized by 
injection into the skin near the margin of the lid, so that the region 
to be treated becomes completely white or anemic after the injec- 
tion (infiltration-anesthesia). The epilating needle, corresponding 
to the negative pole of the battery (the other pole, attached to a 
moistened, flat electrode, is placed over the forehead), is then inserted 
close to the cilia and pushed into the sheath of the hair-bulb. If the 
right spot is chosen, this can be done without difficulty. A current 
from one-half to one milliampere, passed for thirty seconds, causes 
fine vesicles to rise from the hair-bulb, and permits the hair to be ELECTROLYTIC EPILATION 
99 
extracted with ease by the cilia-forceps (Fig. 65). A magnifying lens 
materially aids in the detection of the exact point of exit of the 
hair. The epilating process must be performed in several sittings, 
as occasionally cilia, which have not been destroyed, grow again and 
cause fresh irritation. CHAPTER VI 
CANTHOTOMY—CANTHOPLASTY—TARSORRHAPHY 
The purpose of canthotomy is to temporarily, and of canthoplastv 
to permanently, lengthen the palpebral fissure. 
CANTHOTOMY 
Indications.—(1) In cases of marked secretion of the conjunctiva 
(blennorrhea, trachoma, etc.), in which narrowness of the fissure 
Fig. 66.—Canthotomy. By means of two fingers the external canthus is separated 
and at the same time pushed slightly toward the nose. A pair of straight scissors is 
ntroduced horizontally with the blunt blade posterior. 
makes it difficult to carry out the treatment and promote removal 
of the secretion. 
2. In children with blepharospasm and edema of the lids. 
3. Occasionally to permit a larger field in operations on the eye 
or in entering the orbit, for instance, in iridectomy, especially if the 
lid-fissure is small (children) or the eye is pathologically enlarged 
(buphthalmos); before an operation for cataract upon patients whose 
lid-fissures are short; or to assist in the performance of certain opera- 
tions on the posterior portion of the eyeball, the removal of tumors 
or foreign bodies from the orbit, exenteration of the orbit, etc. CANTHOPLASTY 
101 
Anesthesia.—A 3 per cent, solution of cocain is dropped into the 
conjunctival sac, and during the second part of the operation a sub- 
cutaneous injection of a 1 per cent, solution is made in the neighbor- 
hood of the external canthus. 
The Incision.—The operation is performed by thrusting the blunt 
end of a pair of straight, moderate-sized scissors horizontally outward 
into the conjunctival sac beneath the canthus, which is then cut in a 
horizontal direction with one stroke of the scissors (Fig. 66). Prior 
to making the cut the skin in the region of the canthus is stretched 
by the thumb and forefinger of the other hand, which are placed upon 
the outward halves of the upper and lower lids, separating and drawing 
them toward the nose. If the cut of the scissors is to be made on the 
left eye with the right hand, the hand must be strongly flexed dor- 
sally to bring the scissors into the proper position, or the operator 
must stand behind the patient. Bleeding is stopped by compression. 
The wound closes in a short time without leaving a permanent 
increase in the width of the palpebral fissure. Only the faint 
external scar remains as a visible sign of the operation. 
CANTHOPLASTY 
Indications.— (i) The same as in the first two indications for 
canthotomy, if the effect of the operation is to continue for more than 
a few days. 
2. In spasmodic entropion, as the cut made by the scissors in- 
cludes the point of insertion of the orbicularis muscle, namely, the 
external canthal ligament. 
3. In ankyloblepharon and blepharophimosis. 
Local Anesthesia.—The same as in canthotomy. 
Operation.—In order to secure a permanent widening of the 
palpebral fissure, sutures are introduced in the opening made at the 
external canthus, uniting the conjunctiva and skin. In addition to 
the ordinary incision as described under canthotomy, an additional 
cut should be made with a pair of small scissors into the connective- 
tissue strands which attach both lids to the edge of the orbit, so that 
the lids are freely movable and may readily be separated from each 
other. 
The appearance of the rhomboidal wound at the canthus is seen 
by drawing the lids apart (Fig. 67). If the conjunctiva is slightly 
undermined, it can readily be drawn outward, so that the angle of 102 
CANTHOTOMY—CANTHOPLASTY—TARSORRHAPHY 
the conjunctival wound (a) may be connected with the angle of the 
cutaneous wound (b). All that is then necessary to unite the lateral 
sides of the conjunctival and cutaneous wounds is to introduce one 
suture above and one below. 
Fig. 67.—Canthoplasty. Position of the sutures for closure of the wound. The 
first suture unites the angle of the conjunctiva (a.) with the angle of the cutaneous 
wound (b.). 
Kuhnt Operation.—In trachoma, with markedly contracted’con- 
junctiva, it may be difficult or even impossible to unite the conjunc- 
Fig. 68.—Kuhnt operation. The lidplate is inserted outward under the canthus. 
The direction of the incision, to be made later through the canthus, is marked on the 
patient with ink dots (i. i'.). A flap of skin (f.) is cut out of the lower lid, the base corre- 
sponding to the outer half of the marked line. 
tiva with the skin. The sutures tear out, so that the wound closes 
and the palpebral fissure returns to its former small size. These are 
usually urgent cases, eyes in which trachoma has caused pronounced CANTHOPLASTY 
103 
infiltration of the cornea that has resisted all treatment. This class 
of cases is best managed by Kuhnt’s modification of canthoplasty, 
which is performed as follows: 
A few India-ink dots are drawn to indicate the line of incision for 
the canthoplasty, the line being a straight prolongation of the palpe- 
Fig. 69.—Kuhnt operation. The flap (f.) is separated, and has shortened somewhat 
by contraction of the tissue. The incision through the canthus is accomplished so that 
the same wound-angles in the skin (b.) and conjunctiva (a.) are produced as in Fig. 67. 
But here the angle (a.) has receded toward the cornea, as a result of retraction of the 
contracted conjunctiva. 
bral fissure from the external canthus to the outer border of the orbit. 
An ivory plate is then inserted under the outer commissure, and, 
while stretching the skin a little upward and toward the temple, the 
Fig. 70.—Kuhnt operation. The wound on the lower lid is sutured, the flap of skin 
(f.) being fitted into the angle of the conjunctival wound (a.). 
operator cuts a flap of skin 2 mm. wide from the lower lid (Fig. 68). 
The base of the flap is so situated that it remains adherent to the 
upper edge of the wound after the incision for canthotomy is made 
(Fig. 69). The length of the flap corresponds approximately to one- 104 
CANTHOTOMY CAXTHOPLASTY TARSORRHAPHY 
third the length of the lid, but is cut a little longer, as the skin always 
retracts after it is detached. The orbicularis fibers, which appear in 
the lid after removal of the flap, are excised. The horizontal external 
incision is then made as in ordinary canthotomy, so that the skin-flap 
hangs free from the upper edge and several millimeters from the 
outer angle of the wound. All adhesions of the lids to the edge of the 
orbit are thoroughly cut, so that the lids can be moved freely, and the 
bulbar conjunctiva is undermined to the boundary of the cornea. 
After arrest of hemorrhage the wounds are closed by sutures. Three 
sutures are sufficient for the wound on the lowTer lid, and a fourth 
fastens the temporal border of the lower lid obliquely outward near 
the outer angle of the wound. The cutaneous flap itself is laid in the 
wound, so that its apex is inserted either under the angle of the con- 
junctival wound or is fixed to the later wfith a suture (Fig. 70). 
As there is usually a coexistent entropion of the lower lid the 
removal of a cutaneous flap exerts a favorable influence on this ano- 
maly. If the upper lid should need correction, the flap could be 
taken from it instead of the lower lid. 
In severe cases of trachoma we have repeatedly observed a favor- 
able influence of the operation upon the condition and the further 
treatment of the conjunctival disease. Certainly, from a cosmetic 
standpoint, the operation cannot be recommended, but in these 
severe types of disease the personal appearance need no longer be 
considered. The healing of the cutaneous flap occurs promptly, and 
the palpebral fissure remains permanently and considerably widened. 
The sutures may be removed in a fewT days. 
TARSORRHAPHY 
The object of tarsorrhaphy is to shorten the palpebral fissure. 
Indications.—The operation is indicated in cases of facial paralysis 
that will presumably exist a long time or will never recover, and in 
marked exophthalmos resulting from Basedow’s disease or from 
tumors. It is also indicated when the lagophthalmos is caused by 
congenital shortening of the eyelids; it serves to overcome paralytic 
ectropion, as it raises the drooped eyelid; and is recommended as a 
preventive of cicatricial ectropion in persistent carious fistula on the 
border of the orbit. Even though the operation in itself is disfiguring, 
it may still be indicated for cosmetic reasons in rare cases, such as 
widening of the palpebral fissure after strabismus operations, or EXTERNAL TARSORRHAPHY 
105 
unilateral enlargement of the eyeball (unilateral, high grade myopia) 
and its consequent widening of the palpebral fissure. Tarsorrhaphy 
is also performed occasionally as a preliminary to plastic operations. 
External Tarsorrhaphy.-—The method of Fuchs is the operation 
of choice in the majority of cases. At the outset the required 
shortening of the palpebral fissure must be clearly determined. This 
is best done by holding the two eyelids together, with the fingers 
Fig. 71.—Fuchs operation. From the external part of the lower lid a flap of skin (f.) 
is formed, and the cilia removed. From the skin of the upper lid a corresponding long 
strip is excised. The suture is already introduced; above near the edge of the lid, below 
near the base of the flap. 
placed at the external canthus, and shortening the palpebral fissure 
by advancing the fingers until the patient is able, completely or almost 
completely, to close the eye. At most, a few millimeters will be 
sufficient, and even in severe cases should not exceed 8 mm., on 
account of the marked and unsightly asymmetry of the palpebral 
fissure that would be produced. This would necessitate the same 
operation at the internal canthus, of which mention will be made later. 
The Incisions.—After cocain injection into the upper and lower 
lids, particularly toward the intermarginal border, and protection of 
the eye with the ivory plate, a small vertical incision is made through 
the skin of the upper and lower lids, not only to indicate how far the 
operation is to be conducted, but also to secure equal distances for 
both lids. An intermarginal incision is made on the lower lid, 
beginning exactly at the external canthus and extending to the point 
previously outlined. The incision is best made with a lancet, which 106 
CANTHOTOMY—CANTHOPLASTY TARSORRHAPHY 
is held parallel to the surface of the lid, so that the point perforates 
neither the skin nor the tarsus posteriorly. While drawing the skin 
of the eyelid outward, the assistant presses the obliquely-held ivory 
plate forward, so that the eyelid is well stretched. By light pressure 
the operator himself holds the eyelid against the plate and places the 
point of the lancet upon the intermarginal border. If the lancet is 
sharp, it will readily penetrate between the two plates of the eyelid. 
At the same time a little undermining can be done. 
The previously made vertical cutaneous incision, 3 mm. long, 
forms with the intermarginal cut a small cutaneous flap (Fig. 71,/), 
Fig. 72.—Fuchs operation. Appearance of the palpebral fissure after the tying 
of the sutures, Both ends of the first suture introduced are tied over a small gauze- 
compress. 
with the eyelashes still in position on the edge corresponding to the 
border of the lid. The roots of these lashes are then destroyed by 
scissors applied flat against the raw side of the flap, so that the cilia 
later fall out. 
A similar intermarginal incision is made on the upper lid from the 
external canthus to the previously made vertical cut, and also a 
cutaneous incision parallel to the lid-border and at a distance of 
about 2 mm. from it and of the same length as the intermarginal 
incision. The lancet undermines the bridge of skin thus formed, and 
two cuts with the scissors sever its connections externally and 
internally. In this way a raw surface is produced on the edge of the 
upper lid. The flap formed from the lower lid is now adjusted so 
that it covers this raw surface and unites with it. The tarsi are 
not injured in this operation, and the tarsus of the lower lid slips 
in beneath that of the upper lid. ELSCHNIG TARSORRHAPHY OPERATION 
107 
The Sutures.—The two needles of a double-armed suture are 
passed through the upper lid near its border, 2 mm. apart, proceeding 
from the conjunctival surface outward. A short loop of thread, 
therefore, lies on the conjunctival surface side of the upper lid, but 
this is of no consequence, as it does not come in contact with the 
cornea, which lies farther inward. The two threads then pass 
through the base of the flap on the lower lid from the raw surface 
outward to the cutaneous side, with about the same distance between 
the perforations as before. The ends of the thread are then tied over 
a small compress of iodoform gauze, which draws the base of the 
flap to the wound-edge of the upper lid, and causes the flap itself to 
cover the raw surface. Several fine cutaneous sutures are introduced 
to unite accurately the edges of the flap with those of the wound on 
the upper lid (Fig. 72). A light dressing is applied over the eye, 
the other eye being uncovered. The stitches may be removed on the 
third day. 
Results.—The advantage of the operation is that a surface union 
of the lids is produced, which prevents a separation of the suture— 
an occurrence which is often encountered in other methods. The 
disadvantage lies in the sacrifice of a part of the normal cutaneous 
border of the lids. If at some future time it should be desirable to 
re-open the palpebral fissure, it is not difficult to free the upper and 
lower tarsal borders, as the tarsus has not been injured, and a few 
sutures will unite the edge of the cutaneous wound with this edge of 
the tarsus, but the border of the eyelid thus made would naturally 
have no cilia. Tarsorrhaphy is, therefore, performed only when 
presumably no recovery is to be expected, e.g., in many cases of facial 
paralysis. The operation may be accompanied by unpleasant results, 
caused by an inequality in the length of the intermarginal incisions 
on the upper and lower lids. If, for example, a longer piece is excised 
from the upper lid than will be covered by the flap from the lower lid, 
the latter will, of necessity, be pulled obliquely upward and inward, 
producing an ugly fold resembling an epicanthus. At the same time 
the cilia on the neighboring part of the lower lid may assume an 
oblique direction, and be turned back toward the cornea. Should 
this occur, additional eyelashes must be destroyed by electrolytic 
depilation. 
Elschnig Tarsorrhaphy Operation.—In order to save the cilia, 
Elschnig excises a piece of the posterior layer of the upper lid, and 108 
CANTHOTOMY—CANTHOPLASTY -TARSORRHAPHY 
sutures in the defect a flap of the posterior layer of the lower lid, the 
skin of the lids and the row of cilia being left intact. 
Local Anesthesia.—The same as for canthotomy. 
Operation.—An incision is first made in the intermarginal line of the 
lower lid from the external canthus inward the desired extent. A ver- 
Fig. 73.—Tarsorrhaphy after Elschnig. Intermarginal incision in the upper and 
lower lid, beginning from the external canthus. (In the figure the intermarginal incision 
is made somewhat longer, in order to demonstrate more distinctly the incisions in the 
tarsus.) Vertical incision through the tarsus of the lower lid. A triangular piece is 
excised from the cartilage of the upper lid. 
tical cut, three to four mm. in length, is then made in the posterior lid- 
lamina from the lid-margin downward (Fig. 73). A small section of 
Fig. 74.—Tarsorrhaphy after Elschnig. Suture applied in the tarsal flap of the 
lower lid. A short portion of the thread (dotted lie) is situated on the conjunctival 
side Both ends of the thread are carried from behind through the skin of the upper lid, 
several millimeters above the lid-margin. The excision of the tarsus of the upper lid is 
indicated by dotted lines. 
the upper edge of the two lid-laminae is removed, but the cilia saved. 
A corresponding intermarginal incision of the upper lid is made, and 
a similar vertical cut made in the posterior lamina as in the lower lid. INTERNAL TARSORRHAPHY 
109 
The flap of the posterior lamina of the upper lid thus formed is 
grasped with tooth-forceps and excised with scissors, the cut starting 
at the end of the vertical incision running parallel with the lid-border 
and then curving toward the external canthus and ending at or 
or slightly below it. In this way a triangular piece of the tarsal- 
conjunctival lamina is removed from the upper lid, the base of the 
triangle corresponding to the vertical cut, and the apex at the external 
canthus. The margin of the anterior lid-lamina is pared as in the 
lower lid, but the cilia saved. 
Sutures.—Both needles of a double-armed thread are passed 
through the tarsal-conjunctival flap of the lower lid, 2 mm. from the 
Fig. 75.—Tarsorrhaphy after Elschnig. Appearance of the palpebral fissure after tying 
the fixation-suture. Two skin-sutures. 
lid-margin, from the conjunctival side outward, and pushed from 
behind through the skin of the upper lid about 4 mm. from the ciliary 
border (Fig. 74). 
The ends of the thread are tied over a piece of gauze. In this 
way the posterior lamina of the lower lid is drawn into the space from 
which the posterior lamina of the upper lid was removed, and heals in 
this situation. The two anterior laminae are now united by two or 
three sutures of fine silk, which may be removed after four days. 
The fixation-suture is removed in about a week. 
Results.—The advantage of this surface union of the lids is that 
there is marked resistance to excessive stretching of the tissues, such 
as may follow in cases of exophthalmos, and the cosmetic result is 
good, due to the regular rows of cilia at the area of closing of the lid- 
fissure (Fig. 75). Should it be necessary to subsequently re-open the 
palpebral fissure, the separated lid-margins will have the normal row 
of lashes. 
Internal Tarsorrhaphy.—If Fuchs’ tarsorrhaphy is to be per- 
formed at the internal angle of the lids, two precautions must be 110 
CANTHOTOMY—CANTHOPLASTY— TARSORRHAPHY 
observed: (1) The internal eanthus itself should not be touched by 
the operation and (2) the lachrymal canaliculi must not be wounded. 
The intermarginal incision is, therefore, made from the previously 
determined point to the end of the tarsus, i.e., to the lachrymal 
punctum. If the incision is made accurately in the intermarginal 
border, and the lancet penetrates between the two surfaces of the 
lid, there is no danger of wounding the lachrymal canaliculus, as it is 
situated further internally from the incision, in the lower leg of the 
Fig. 76.—Arlt operation. Horseshoe-shaped excision along the inner eanthus from the 
skin of the upper and lower lids. 
internal canthal ligament. The same is true of the upper lid. In 
other respects the operation is the same as in the external angle. The 
horseshoe-shaped excision is retained and appears as a shallow de- 
pression. Should it be desired to re-open the palpebral fissure in the 
future, a normally formed internal palpebral angle can be obtained. 
In marked cases of exophthalmos it may be absolutely necessary 
to perform the operation simultaneously at the outer and inner angles 
of the lids, in order to transform the palpebral fissure into a short 
central aperture. 
Arlt Operation.—Median tarsorrhaphy may also be accomplished 
by removing, by means of forceps and scissors, a strip of skin from 
the upper and lower lids near the inner angle, in such a manner that 
the wounds thus produced meet in a sharp angle at the internal 
can thus of the eye (Fig. 76). Three sutures introduced vertically 
unite the wounds and close the palpebral fissure from its inner side. 
This operation has the advantage that the cilia are not injured, so 
that an eventual re-opening finds the edges of the lids intact. CLOSURE OF PALPEBRAL FISSURE 
111 
Complete Closure of the Palpebral Fissure.—This procedure is 
only undertaken in rare cases, as after an extensive corrosion, in 
which the skin of the upper and lower lid has been partially destroyed, 
and the production of a cicatricial ectropion seems unavoidable. 
The latter can be prevented by complete suture of the palpebral 
fissure. In order not to destroy all the eyelashes, the lancet denudes 
the edges of the lids behind the cilia, and the lids are then sutured 
together; or, if possible, a narrow strip may be cut out of the skin of 
both eyelids near their borders, and the two raw surfaces united by 
sutures. If the lid has been completely destroyed, without serious 
injury of the eye, the latter is protected by a moist chamber dress- 
ing until cicatrization has ceased, and it is possible to perform a 
plastic operation, such as described for cicatricial ectropion. 
If tarsorrhaphy is performed for pronounced exophthalmos, the 
rest of the palpebral fissure should be temporarily closed by several 
sutures without denudation of the lid-margin, in order that the flap 
may adhere firmly, and the sutures not tear out prematurely, owing 
to the strong tension. 
In paralytic ectropion, a triangular fold of skin may be excised, 
as in senile ectropion, and tarsorrhaphy also performed, a combined 
operation resembling the Szymanowski method. In this manner the 
somewhat enlongated lid is shortened and brought to lie more closely 
against the eyeball. CHAPTER VII 
PTOSIS 
Most of the cases of ptosis requiring operation are congenital. 
The muscular apparatus of the eye in other respects is normal or, in a 
few instances, is associated with pronounced weakness or absence of 
the superior rectus muscle from defective development. In paralysis 
of the levator muscle, operation is only indicated after other forms of 
treatment have failed. In acquired ptosis not caused by a lesion 
of the levator muscle, other muscles supplied by the oculo-motor 
nerve are frequently also affected, and binocular vision is impossible 
because of outward deviation of the affected eye. Complete paraly- 
sis of the third nerve of one side is therefore usually a contraindica- 
tion to the ptosis operation, since the correction of the ptosis makes 
manifest the latent diplopia, which may constitute a more unpleasant 
symptom than the lid deformity. It is only in bilateral ptosis the 
result of palsy of the oculo-motor nerve that operation on the lid 
of the better and more movable eye is advisable. 
Of the operations devised for the relief of ptosis, only those are 
of value which have as their object the substitution of a new muscular 
power for that which has been lost. If the levator is not completely 
paralyzed, a shortening of the muscle may restore its original func- 
tion (Eversbusch and allied methods). If, on account of total disa- 
bility, the power of the levator cannot be restored, a substitute is 
sought in the occipito-frontalis muscle, which, by its contraction, is 
able to raise the skin of the lid (method of Pagenstecher, Hess, and 
others). Many ptosis patients instinctively contract this muscle, 
draw up the eyebrow above its normal position at the upper orbital 
margin, and thereby raise the lid. As the contraction of the frontalis 
is usually bilateral, there is an abnormal dilatation of the palpebral 
fissure of the healthy eye, unless the patient prefers to relinquish the 
raising of the drooping lid. This widening of the fissure is equally 
evident after ptosis operations in which the occipito-frontalis muscle 
is employed to raise the lid, and often detracts from the cosmetic 
results of the operation. 
112 EVERSBUSCH OPERATION 
113 
Since the superior rectus and the levator palpebrae muscles are 
associated in elevation of the eyelid, the substitution of the action 
of the former for the paralyzed levator is theoretically a commenda- 
ble procedure (Motais operation). Ptosis partially corrected by the 
assistance of the frontalis muscle becomes more pronounced in upward 
rotation of the eyeball, but this is obviated if the superior rectus 
muscle has been employed to raise the lid. In this operation, 
however, a mechanical connection between the upper lid and the 
eyeball is created which does not physiologically exist, so that the 
motions of the lid are dependent under all circumstances upon 
the innervation of the rectus muscle. The attachment of a muscular 
tongue of the rectus muscle to the tarsus must in itself cause a retrac- 
tion of the upper lid from mechanical reasons, as the sagittal distance 
from the insertion of the superior rectus to the tarsus is considerable. 
Undesirable secondary symptoms of the position of the lid may 
therefore be produced from the occasional contrary innervation of the 
two muscles. In winking, for instance, the upper lid falls while the 
eye remains practically fixed. In sleep, the eyeball turns upward, 
the same as in voluntary tight closure of the palpebral fissure. If the 
movement of the upper lid is therefore entirely dependent upon the 
superior rectus, abnormal phenomena in movements of the lid and eye 
may result. The superior rectus is therefore not perfectly adapted to 
act as a substitute for the paralyzed levator. 
EVERSBUSCH OPERATION 
The object of the operation is to strengthen the weakened muscle 
by shortening and suturing its attachment further forward. 
Anatomy.—In order that the operation maybe readily understood, 
it is well to briefly recall the topographical relations in this region. 
If a sagittal section is made through the orbit near its middle, the 
appearances seen are approximately as follows (Fig. 77): The border 
of the orbit, b; attached to this is the fascia tarso-orbitalis (f.o.), which 
hangs down like a curtain and becomes thickened below at the tarsus 
(ta); in front of it, the fibers of the orbicularis (m.o.) and the skin 
with the lashes of the free border of the lid; behind it, and passing 
forward on the roof of the orbit, the levator palpebrae (m.l.), which 
spreads out at the orbital opening like a fan; its aponeurosis joins 
the fascia tarso-orbitalis, so that immediately above the upper border 114 
PTOSIS 
of the tarsus no more than a membrane is visible—the tarso-orbital 
fascia, united with the aponeurosis of the levator palpebras. 
Indications.—The operation is only suitable when the levator 
is not completely paralyzed. To ascertain the extent of the paralysis 
the patient is asked to close both eyes as in sleep, so that the super- 
ciliary ridge may be brought in its normal position on the upper 
border of the orbit. The skin of the superciliary region must then 
Fig. 77.—Sagittal section through the lids and the anterior portion of the orbit, b., 
upper border of the orbit; f. o., the tarso-orbital fascia, which is attached to the bone, 
hangs down and blends with the tarsus (ta.). The levator muscle (m. 1.) passes forward 
above the superior rectus (r. s.), changes here into a fan-like tendon, which, joined by the 
tarso-orbital fascia, is inserted into the upper part of the tarsus. Behind the tarsus is 
seen the conjunctiva (c.), in front of it the orbicularis muscle (m. o.). 1. 1., represents 
the transverse section through the lower lid. 
be fixed in its position on both sides by firm pressure with the thumbs. 
If now the patient at command can open the eye, even though only 
to a limited extent, there is proof of some action of the levator, and 
the muscle is not completely paralyzed, so that success from the 
operation may be expected. 
Anesthesia is produced at the beginning by cocainizing the con- 
junctiva, and later by injecting i c.c. of a i per cent, cocain solution 
under the skin and into the deeper parts of the lid. EVERSBUSCH OPERATION 
115 
The Dissection.—A longitudinal incision is made through the 
skin of the lid and the orbicularis muscle, midway between the arch of 
the eyebrow and the border of the lid. The eye is protected by a 
horn plate placed between it and the lid. By undermining to some 
extent both borders of the lid-wound, it is easy to expose'below, the 
upper border of the tarsus, and above, the thin tarso-orbital fascia. 
Fig. 78.—Eversbusch operation. The incision made midway between eyebrow and 
border of the lid through the skin (s.) and orbicularis muscle (mo.) is held open by tena- 
cula. The tarso-orbital fascia is also cut near the upper margin of the wound (the 
border of the wound (c.) is visible as a white line) and turned down in such a way that 
the transition of the levator palpebras muscle into its tendon is plainly visible in the 
wound; at m. it blends with the tarso-orbital fascia. 
The fascia is incised at from 5 to 6 mm. above the tarsus, at which 
point the muscle bundles of the levator palpebrae will be exposed (Fig. 
78). The muscle may readily be traced upward into a compact body. 
If the cut through the fascia is made too low down, near the upper 
border of the tarsus, it would come directly upon the conjunctival 
fornix (c) and would not touch the muscle. If made too high up the 
fatty tissue of the orbit protrudes, covers the field of operation, and 
renders it difficult to find the muscle. If the fascia is raised with 
forceps, somewhat above the upper tarsal margin, the correct point 
for making the opening will be indicated. Close above the spot 
where it can be first detached from the underlying tissue it is split 116 
PTOSIS 
with the scalpel, and in the opening appears the radiating red bundles 
of the muscle. 
The Sutures.—Three catgut sutures are now passed through the 
muscle in the same manner in which they are inserted in the advance- 
ment of the recti muscle—first through the middle. With the horn 
plate remaining in place, a fairly strong, curved needle transfixes the 
middle of the muscle in its entire thickness, at as high a point as pos- 
sible, and the needle brought out, forming a loop by which the middle 
Fig. 79.—Eversbusch operation. The middle thread has already been inserted. 
The second stitch is just being inserted; to do this the operator lifts the lateral part of the 
muscle with forceps in the form of a fold and pushes the needle through the entire thick- 
ness of the tissue. 
fibers of the muscle are constricted. A second loop is placed to the 
inner side of the muscle (Fig. 79), and a third loop to its outer, all 
three at the same height. The muscle is then cut through, 2 mm. 
below the threads, along the entire length of the lid, and a piece 
excised 3 to 5 mm. downward to the upper border of the tarsus or even 
including a small piece of the tarsus itself. The conjunctiva, as far 
as it comes within the area of the piece to be excised, need not be 
saved, but may be removed with the muscle. With slight care, how- 
ever, it is not difficult to excise the piece of muscle without injuring 
the conjunctiva; but when a strip of the tarsus is included the EVERSBUSCH OPERATION 
117 
conjunctival covering cannot be preserved, as it is too intimately 
adherent. 
The gaping wound is closed either by bringing all six ends of the 
threads between the tarsus and the orbicularis muscle through the 
intermarginal space, and tying them over small rubber tubing; or, 
by sewing the ends of the catgut threads to the anterior surface of 
the tarsus so that the upper cut-edge of the muscle is drawn over 
Fig. 8o.—Eversbusch operation. After excising a strip of muscle (and conjunctiva) 
5 mm. broad, the middle pair of threads is first fastened to the anterior surface of the 
tarsus (ta.); during the tying the end of the cut muscle is pulled upon the anterior surface 
of the tarsus and heals there. 
the cut-edge of the tarsus to its anterior surface, to which it heals 
(Fig. 80). 
The skin-wound is closed over these sutures with several stitches 
(Fig. 81). This method of operation has the advantage that the 
margin of the lid is in no way disfigured. 
If the sutures are carried through the intermarginal border, the 
peripheral lid-portion should be pushed upward along the threads 
until it approaches the central muscle portion containing the thread 
loops. The threads are then lightly knotted to preserve the lid in 
the correct position. If drawn too tight, there is caused even with 118 
PTOSIS 
the rubber tubing a circumscribed necrotic spot of the lid-border, 
with loss of the eyelashes. 
Results.—The operation is successful in most cases, although it is 
not possible to determine exactly just how much muscle should be 
excised to attain the desired elevation. Caution must be exercised to 
limit the excision of the lid, sufficiently to prevent resultant 
Fig. 8i.—Eversbusch operation. Appearance of the lid after the operation. The 
skin-wound is exactly approximated by several sutures. The edge of the lid remains 
perfectly intact. 
lagophthalmos. On this account the piece to be excised should never 
be broader than 5 mm. 
HESS OPERATION 
Indications.—The operation is of value only in cases of ptosis in 
which the patient absolutely shows distinct contraction of the fron- 
talis muscle. In those who make no attempt to improve their ptosis 
by contraction of this muscle, the operation promises little. 
Anesthesia.—The operation may be most satisfactorily performed 
under cocain-anesthesia. One syringeful of a i per cent, solution 
(i c.c.) suffices as an injection into the skin of the eyebrow and lid. 
Before the threads are brought out at the upper point, a second 
syringeful must be injected into the tissues about the periosteum. 
The Skin Incision.—After the eyebrow has been shaved, a hori- 
zontal incision is made through the skin of the eyebrow parallel 
and of equal length to the palpebral fissure. The incision should be 
so placed that the short scar is completely covered by the eyebrow. 
The section includes only the skin, as a deeper incision injures large HESS OPERATION 
119 
vessels and causes bleeding which would disturb the further course 
of the operation. After the incision has been made, the skin is under- 
mined downward with the knife along the convex border of the tarsus 
to a point near the edge of the lid. The beginning of the dissection 
is made slightly more difficult by the numerous muscle-fibers which 
are inserted into the skin near the brow, but further down the sub- 
cutaneous tissue is loose and easily separated. As the blood, even if 
Fig. 82.—-Hess operation. Method of undermining the flap. The forceps grasp the 
skin at as low a point as the progress of the undermining permits. The knife held 
vertically presses downward behind the skin and is observed by the operator from the 
front through the skin, (c.), section through the skin. 
moderate, interferes by collecting in the pocket constituting the field 
of operation, it is recommended to control the position and progress 
of the knife from without through the skin. This may be done by 
pushing the knife downward in a perpendicular position, parallel with 
the skin, and fixing the skin at as low a point as possible (Fig. 82). 
The skin is thus undermined in the whole length of the incision with 
a few strokes, and a four-cornered pocket produced. This avoids 
button-holing of the skin, which would follow an attempt to operate 
along the posterior surface of the skin with an insufficient view into 
the pocket, a difficult procedure with a small incision. 
The Sutures.—After the undermining is completed, the sutures 
are inserted. The strong silk threads are doubly armed with long, 
flat needles. In all, three sutures are employed, the first in the center 
of the lid, the two others to the sides. Both needles of the first 120 
PTOSIS 
thread are pushed through the lower part of the skin, at a distance 
of approximately 4 to 8 mm. from the edge of the lid. The skin is 
fixed with the forceps, one blade of which remains in the pocket, and 
the other lies on the skin at the point of intended transfixion, in order 
to prevent retraction of the lax skin when the sutures are inserted 
(Fig. 83). The needles with the thread are now brought out through 
the opening in the skin and directed upward. In like manner, the 
Fig. 83.—Hess operation. Application of the sutures. The forceps, one blade of 
which should be in front of the other in the wpund, grasp the skin just where the needle is 
to be inserted. One end of the thread has already been drawn through, the needle 
mounted on the other end has only just been inserted. 
outer and the inner sutures are inserted, each about i cm. from the 
middle stitch. The needles of the middle thread are then pushed 
upward behind the upper edge of the wound near the periosteum, 
behind the muscle, therefore, and are brought out through the skin 
close to one another at about a distance of to 2 cm. from the inci- 
sion. The outer threads are treated in the same way. The needles 
of the inner thread are not inserted directly perpendicularly, but are 
inclined a little inward toward the median line. 
The three threads are next tied over iodoform pads. This raises 
the lid and at the same time forms a fold in the skin, corresponding to 
the point of entrance of the threads, similar to the normal fold of the HESS OPERATION 
121 
lid. The insertion of the threads through the skin of the lid, which 
as stated vary from 4 to 8 mm., must be adjusted according to the 
position of the fold of the lid of the other eye. A fold lying too high 
is just as disfiguring as one too near the edge of the lid. 
Slight traction on the threads raises the lid so that the palpebral 
fissure readily attains its normal width, but in tying the threads they 
must be drawn up sufficiently to lift the lid higher than normally, and 
cause an over-correction. The threads should not be drawn too 
tightly, or they will cut through quickly, without materially elevating 
the lid more than with threads drawn moderately tight. The skin- 
wound is closed with several silk sutures. 
The Dressing.-—Immediately after the sutures are tied, total 
lagophthalmos is naturally produced, and the eye is to be covered 
with a celluloid shield, so as to produce a comparatively air-tight 
covering (Fig. 84). The shield is fastened along its border with 
adhesive strips, and, if extensive spaces exist between shield and 
underlying parts, they should be filled in with absorbent cotton. 
Within a few minutes the shield becomes moist, and under this 
dressing the eye may remain for weeks without the slightest sign 
of irritation. As the celluloid shield is sufficiently transparent to 
permit a view of the eye, the dressing is changed only when secretion 
is present and the eye must be cleansed. 
After-treatment.—The sutures closing the skin-wound may be 
removed in three days, but the sutures retaining the lid in its elevated 
position should remain undisturbed as long as possible—at the least, 
fourteen days, and even longer if they have not become loosened. At 
the end of three weeks they are usually so loose as to have lost their 
hold and may be easily withdrawn after being cut. The object of 
retaining the stitches is the formation of cords of scar-tissue along the 
threads, which not only unite the lid with the frontalis muscle, 
through which the threads have been brought, but also serve as 
tendons by means of which this muscle elevates the lid. 
If the threads produce an over-correction, it is not necessary to 
form a loop and tighten this frequently in order to maintain the lid 
in its elevated position. The chances and results of the operation 
are always improved if the threads are moderately tight at the outset. 
As the lid is not shortened by excision, but only by the pushed-up 
anterior (skin) flap of the split lid, which unites at a higher point with 
the posterior flap and raises the lid, lagophthalmos need not be 122 
PTOSIS 
feared. Of the many cases of the Hess ptosis operation that the 
author has performed personally or has seen, lagophthalmos has not 
occurred, a strong point in favor of this method. It is, however, to 
the disadvantage of the operation that we are not certain at the 
beginning of the terminal results, but this is true of any one of the 
Fig. 84.—Hess operation. The skin-wound has been closed by several sutures. 
The three fixation threads, of which the inner inclines a little toward the median line, are 
tied over pads. The lid, strongly elevated, stands off a little from the bulb, the new fold 
of the lid corresponding to the puncture points of the threads. For the protection of the 
eye, which cannot now be covered by the upper lid, a celluloid shield is employed; it is 
fastened at its circumference by strips of zinc oxid plaster, only a few pieces of which 
show. 
many operations for ptosis which have been recommended. There is 
no method that will with certainty make the palpebral fissure of the 
affected side exactly the same width as that of its normal fellow. 
Results.—The results of the Hess operation are in the great 
majority of cases good; occasionally they are excellent, and but 
rarely unsatisfactory. Permanent over-correction need never be pagenstecher’s sutures 
123 
feared. In bilateral ptosis especially, it should be the operation of 
choice. The scar at the point of incision is later covered by the 
eyebrow, and, if the sutures are properly inserted, a good position 
of the fold of the lid is obtained. 
Occasionally, after the Hess operation, the patient, having the 
same degree of ptosis as before, lifts the operated lid, even to the 
normal breadth of the lid-fissure, only at the moment when the sound 
eye is closed. The explanation for this may be found in the fact that, 
so long as the patient can use his healthy eye, he is not inclined to put 
the frontalis muscle in action. Likewise, after operation on one side, 
the patient can open this eye to its normal width, but only with great 
elevation of the lid of the other eye through excessive simultaneous 
contraction of the frontalis. The bilateral innervation of the fron- 
talis muscle brings about in such individuals an excessive widening 
of the palpebral fissure on the sound side, while effecting only the 
normal opening on the affected side. 
Contraindications.—The operation is contraindicated in insuffi- 
cient contraction of the frontalis and in cases of paralysis of the 
superior rectus muscle or total ophthalmoplegia. If the eye, during 
sleep, is not drawn upward under the upper lid, there is danger of 
resultant disease of the cornea. Complications may also be brought 
about by swelling of the skin of the upper lid after operation, pro- 
jecting it downward over the border of the lid. The direct contact 
of this tissue with the cornea may produce erosions and ulcerations, 
as has been my personal experience in two cases. 
In this, as in every other correction of ptosis, the possible occur- 
rence of diplopia must be considered because of pre-existing paralysis 
of the ocular muscles. This is just as important a contraindication 
to the operation for ptosis as an abnormal position of the affected 
eye, for example, by secondary contractures after paralysis. 
PAGENSTECHER’S SUTURES 
The stitches in the Hess operation are essentially the same as those 
recommended by Pagenstecher. The great efficacy of the former 
is due to the change in position of the anterior layer of the lid brought 
about by the sutures. Pagenstecher’s sutures should be used only in 
the slightest forms of ptosis. As the sutures are allowed to remain in 
place for a long time, it is best to employ wire, the upper end of which 
is twisted, thus shortening the wire and elevating the lid. In order 124 
PTOSIS 
to avoid cicatrices in the skin, the sutures are introduced subcuta- 
neously (Fig. 85). From the point of entrance at the one end, the 
suture is carried up and brought out above the eyebrow at c. The 
other end of the suture is carried outward subcutaneously for 2 mm. 
from a, and then withdrawn at b. The needle is re-inserted at the 
same point b and brought out above, at d. It is then twisted over a 
gauze, pad. The one suture is inserted at the inner third, and the 
second suture at the outer third of the lid. 
Fig. 85.—Pagenstecher’s sutures. 
Other Forms of Operation.—A number of other operations have 
been devised, which similarly depend for their success upon the union 
of the skin of the lid with the frontalis muscle. Panas’ operation is 
the best known, but the deformity of the lid which follows this pro- 
cedure has led to its general abandonment. 
MOTAIS OPERATION 
This method consists in attaching a narrow tongue formed from 
the center of the superior rectus muscle to the upper border of the 
tarsus through an incision in the conjunctival surface of the everted 
lid. The operation was suggested by the synergic action of the 
levator and superior rectus in elevating the ball. 
After thorough cocainizing of the conjunctival sac, the upper lid 
is everted and the convex tarsal margin is drawn upward by a hook, 
while the eyeball is rotated downward by a thread fixed in the con- 
junctiva near the upper limbus. This fully exposes the conjunctival 
culdesac. The deeper tissues are rendered anesthetic by injections 
of i per cent, cocain solution (one-half contents of Pravaz syringe). MOTAIS OPERATION 
125 
An incision is now made through the conjunctiva over the in- 
sertion of the superior rectus, beginning about 6 mm. back of the lim- 
bus and parallel to it, for a length of 8 mm. From the center of this 
Fig. 86.—Motais operation. The upper lid is turned over and the convex border of 
the tarsus drawn upward by a double hook, so that the conjunctival fold is exposed. 
The horizontal and vertical lines designate the place of incision into the conjunctiva. 
The eye is drawn downward by a thread inserted at the upper limbus. 
opening a long conjunctival cut is made through the culdesac to the 
convex margin of the tarsus (Fig. 86). The straight strabismus hook 
Fig. 87.—Motais operation. A strabismus hook is pushed beneath the insertion of the 
rectus superior. 
is pushed beneath the tendon of the rectus muscle from within out- 
ward, the tendon thoroughly exposed, and the eye drawn down by 
the assistant (Fig. 87). 126 
PTOSIS 
The middle portion of the tendon is grasped with forceps, freed 
with a pair of closed scissors from bordering muscle-fibers, and a 
curved strabismus hook is introduced beneath this portion. The two 
Fig. 88.—Motais operation. A thread-loop is placed through the middle portion of the 
muscle. 
small, curved needles of a double-armed fine, strong silk ligature are 
passed directly back of the insertion of the tendon from back to front 
through this muscle portion, and the ligature firmly tied (Fig. 88). 
Fig. 89.—Motais operation. The scissors are brought to the anterior surface of the 
tarsus through a button-hole of the orbital fascia, and advanced to the lid-margin. 
The tissue included by the thread is severed with the scissors, and a 
narrow tongue composed of the middle third of the tendon is isolated, 
and held at its free end by the ligature. MOTAIS OPERATION 
127 
From the conjunctival cut at the convex margin of the tarsus 
two small lateral incisions are made, and the blunt-pointed scis- 
sors are introduced through this button-hole and passed along the 
anterior surface of the tarsus, dissecting a passage down to the free 
palpebral margin (Fig. 89). 
Both needles of the thread are introduced through the button-hole 
above the tarsus, conducted downward between the skin and anterior 
Fig. 90.—Motais operation. One end of the thread has been led through the skin 
above the cilia, the other is on the point of being pierced. The prepared muscular tongue 
already appears somewhat drawn upward toward the lid. 
surface of the tarsus, and passed through the skin about 2 mm. from 
the palpebral margin, the two needles separated a distance of about 
4 mm. 
By carefully drawing upon the two threads equally, the tendinous 
tongue is made to pass between the tarsus and skin, with its end near 
the center of the lid-margin (Fig. 90). The threads are then tied over 
a bead or small gauze compress (Fig. 91). 
The conjunctival wound is carefully closed with several catgut 
sutures, the suture in the conjunctiva at the culdesac being passed 
rather deeply to prevent prolapse of the fornix. Both eyes should 
be bandaged, and the dressing renewed daily. At the end of eight 
days the sutures are to be removed. 
The operation has the advantage of leaving no visible scar, and is 
the only method that re-establishes the normal adjustment between 
the eyeball and upper lid in upward rotation. There is no lagging 128 
PTOSIS 
of the lid when the eye is directed upward. The operation, however, 
sometimes fails. 
Complications.—Among the disadvantages claimed for the oper- 
ation is a protrusion of orbital fat into the conjunctival wound, but 
this is remedied by care in closing the conjunctival incision. 
Fig. 91. Motais_operation. The thread is knotted over a bead. The lid is strongly 
drawn upward. 
Corneal ulceration and staphyloma may follow the knotting of the 
threads on the conjunctival surface of the lid. As a certain amount 
of over-correction is necessary to the success of the operation, the 
lagophthalmos which arises, at least for a time immediately after 
the operation and particularly during sleep, may lead to injury of the 
cornea from exposure. The protective dressing employed by Hess 
after ptosis operation is the best preventive. 
The weakness of the superior rectus muscle, and the double vision, 
which follow immediately after operation seem to be transient in most 
cases. CHAPTER VIII 
OPERATIONS ON THE OCULAR MUSCLES 
TENOTOMY 
Tenotomy is usually performed under anesthesia of the conjunc- 
tival sac alone. In sensitive patients, or if the operator is inexperi- 
enced, it will be advisable to make a subconjunctival injection of 
H c.c. of a i per cent, cocain-adrenalin solution immediately over the 
tendon of the muscle. 
Tenotomy of the Rectus Internus.—The operator, with a pair 
of toothed forceps in the left hand, raises a fold of the bulbar conjunc- 
tiva at a distance of 3 mm. from the limbus, and with slightly curved 
scissors makes a vertical incision, from 5 to 7 mm. long. The nasal 
border of the wound is then lifted up, the subconjunctival tissue sev- 
ered and undermined by short cuts, and the closed forceps, held paral- 
lel to the sclera, introduced until they reach the insertion of the 
muscle (5 mm. from the limbus). They are then opened, pressed 
against the sclera, and the tendon is grasped. The forceps are now 
rotated into a position perpendicular to the surface of the eyeball, so 
that the tendon, covered by Tenon’s capsule, is somewhat raised from 
the sclera. The insertion of the tendon is seen as it glistens through 
the capsule. The scissors, held in the right hand, make a short 
incision at the lower margin of the insertion of the tendon, which at 
the same time opens Tenon’s capsule. Through this gap one blade 
of the scissors is pushed behind the tendon, and the other in front of 
the insertion (Fig. 92). The convexity of the blades is directed 
toward the sclera, so that the points are therefore turned away from 
the eyeball. In this position of the scissors no injury of the sclera can 
occur. If the tendon is properly severed, only a slight ridge remains 
on the sclera marking the point of the tendinous insertion. The 
incision includes only the width of the insertion of the tendon, and 
does not touch the attachments of Tenon’s capsule to the eyeball 
beyond. 130 
OPERATIONS ON THE OCULAR MUSCLES 
The muscle is immediately released, as pulling with the forceps is 
painful, the scissors laid aside, and a curved strabismus hook (Fig. 
93), taken in the left hand, is pushed into the wound, close to the 
sclera, and moved upward and downward in order to determine 
whether all of the tendon-fibers have been severed. Any fibers 
which have not been divided will offer a tense resistance to the hook 
when the latter is drawn forward. These fibers must also be 
Fig. 92.—Tenotomy of the rectus internus. The eye is placed in the position of 
abduction. A small incision is made in the conjunctiva (c.). The forceps, after seizing 
the muscle, are held perpendicular to the curvature of the eyeball. One blade of the 
open scissors is introduced immediately behind the muscle at its insertion, the other 
blade lies in front of it. The tendon (t.) is severed at its insertion. In order to demon- 
strate how the blades of the scissors are placed and the tendon detached from the sclera 
close to its insertion, the muscle in the drawing is fully exposed, but on the patient both 
tendon and muscle remain covered by Tenon’s capsule and the margins therefore are not 
distinctly visible as here shown in the drawing. In the operation the capsule is not 
separated from the tendon or from its insertion to the sclera. 
separated close to the sclera. If the hook becomes caught in the 
capsule of Tenon, it pulls out a delicate membranous fold, which must 
not be mistaken for tendon-fibers. Incisions of Tenon’s capsule are 
likely to produce undesirable results. After all the fibers are separ- 
ated, the wound is closed with one or two catgut sutures, which 
are introduced in a direction from above downward. While the 
needle is being passed through the conjunctiva the membrane should TENOTOMY 
131 
be firmly fixed with toothed forceps, and the needle held close against 
it, as pulling on the conjunctiva will cause the patient unnecessary 
pain. In order to clearly see the position of the scissors the muscle is 
exposed in the illustration. In the patient, however, the muscle is 
covered with Tenon’s capsule, and hence neither its upper nor lower 
margin is visible. 
The manner of holding the instruments is the same whether the 
tenotomy is performed on the right or left eye. After the operation a 
slight dressing is applied, which may be removed the following day, 
or at most two or three days later. 
Fig. 93.—Curved strabismus hook. 
Tenotomy of the Rectus Extemus.—The incision through the 
conjunctiva is made somewhat further from the limbus than in 
tenotomy of the internus, as the insertion of the muscle is a greater 
distance from the limbus (7 mm. in comparison with 5 mm.). The 
other details of the operation are the same. 
Accidents and Complications.—Among the unpleasant sequelae 
that may follow a properly-performed tenotomy are widening of the 
palpebral fissure, protrusion of the eye, and retraction of the caruncle. 
Orbital cellulitis or tenonitis are extremely rare complications, and 
are the result of infection. 
Hemorrhage.—A severe hemorrhage may follow tenotomy, and 
the blood passing backward beneath Tenon’s capsule cause protrusion 
of the ball. A firm bandage should be applied, and in a few days the 
proptosis will subside. 
Retraction of the Caruncle.—This may occasionally be observed 
immediately after the tenotomy, and is due to the retracted muscle 
stretching the fibers which pass from it to the caruncle, and causing 
sinking of the latter. Under these circumstances, the fibers should 
be divided by undermining the conjunctiva toward the caruncle with 
small clips of the scissors. This can also be done some time after 
the tenotomy through a freshly made opening in the conjunctiva. 
Widening of the Palpebral Fissure.-—Protrusion of the eye and a 
conspicuous widening of the palpebral fissure are usually the result of 
faulty incisions of the insertions of Tenon’s capsule, and are therefore 
nearly always combined with over-correction of the squint, that is, 132 
OPERATIONS ON THE OCULAR MUSCLES 
with divergence. These disappear if the muscle, which has slipped 
too far back, is properly advanced later, but if the symptoms are not 
accompanied by a divergent squint, the deformity is corrected by a 
tarsorrhaphy. 
ADVANCEMENT 
Anesthesia.—In the advancement operation, the conjunctival 
sac is first cocainized, followed by a subconjunctival injection of 
Vi c.c. of the i per cent, cocain solution. A fold of conjunctiva is 
lifted up over the tendon of the muscle, and the needle of the syringe 
introduced against the sclera and directed along the axis of the 
muscle. As the injection is being made, the needle is pushed farther 
in, in order to better anesthetize the deeper parts. The resultant 
swelling may be dispersed by slight massage. 
Operation.—Sufficient space is obtained by a short vertical incis- 
ion through the conjunctiva, as in tenotomy, in addition to which a 
long horizontal incision is made, beginning at the middle of the first 
cut, and running backward. The wound is thoroughly undermined 
by small cuts with the scissors, after which the muscle is seized with 
the forceps, the eye rotated in the direction opposite to the muscle, 
and the muscle loosened from its bed by a few strokes with the 
point of the closed scissors, which is made to glide along its upper and 
lower margins. A straight strabismus hook (Fig. 94) is then passed 
beneath the muscle, either from above or below. If the point of the 
Fig. 94.—Straight strabismus hook. 
hook is covered by the conjunctiva or the capsule of Tenon, it must 
be freed, and the second strabismus hook introduced in the opposite 
direction. Muscle-fibers will frequently be caught by this hook 
which escaped the first one. If the muscle is not yet cleanly dissected, 
the overlying tissue must be separated with the scissors, the cutting 
always following the direction of the muscle, and not transversely, 
or the entire muscle or part of it may be severed, thus complicating 
the operation. A piece of the muscle slightly more than i cm. in 
length is exposed. ADVANCEMENT 
133 
The Sutures.—While the sutures are being inserted, the assistant 
must stretch the muscle. This is effected by the anterior strabismus 
hook drawing the eye in a direction opposite to the action of the mus- 
cle, while the other strabismus hook is moved in the direction of the 
muscular contraction. The assistant should stretch the muscle only 
when desired by the operator, as the tension causes pain. A full 
curved, thin, flat needle, carrying a moderately thick silk thread, 
upon the strength of which we can rely with certainty, is passed from 
Fig. 95.—Advancement of rectus externus. The eye is placed in the position of 
adduction. The freed muscle is stretched over two strabismus hooks. The upper 
suture has already been pulled through; the lower suture is being introduced. 
within outward through the muscle near its middle close to the 
posterior strabismus hook. Half of the suture is drawn through, and 
the needle is again passed in a like manner close to its previous point 
of entrance. The loop thus formed is made to firmly grasp the 
muscle-fibers. It makes no difference whether the needle is first 
passed through the upper or lower half of the muscle. The other 
half of the muscle is then included in a loop of a second thread 
introduced at the same distance from the insertion of the tendon (Fig. 
95). The ends of the suture containing the upper half of the muscle 134 
OPERATIONS ON THE OCULAR MUSCLES 
are laid upward, and those of the lower half downward, or a white 
and a black suture may be used in order that the wrong ends of the 
threads may not be tied. The operator now divides the muscle 
with one snip of the scissors, about 2 mm. in front of the threads; 
closer than this, the loops are liable to slip off. The stump of the 
muscle still adhering to the sclera is now removed close to the scleral 
surface, leaving only a short piece at one end of the insertion, to 
allow fixation of the eye with the forceps. 
Fig. 96.—Advancement of the rectus externus. The muscle is divided; a piece 
excised; the eye is held fast by forceps applied to the stump of the tendon, which has been 
allowed to remain. The upper suture has already been drawn through the sclera near 
the limbus and also through the conjunctiva. The needle of the lower suture, which has 
been applied flat against the sclera, has already penetrated slightly the superficial 
lamellae. 
The shortened muscle must now be not only re-attached to the 
bulb, but fastened so that its influence is more strongly felt, i.e., its 
insertion must be brought nearer to the limbus, hence the term: 
advancement. For this purpose, the needle of either suture is 
passed near the limbus through the superficial layers of the sclera, 
the thread of the upper loop corresponding to the upper half of the 
original insertion, and vice versa. The sclera in front of the insertion 135 
ADVANCEMENT 
must first be laid bare by separation of the conjunctiva, as the 
muscle naturally can only unite with a raw surface. 
Scarification of the sclera near the limbus and wounding of the 
under surface of the muscle immediately back of the sutures will 
ensure rapid adhesion of the two surfaces. A thin, flat needle is 
superior to those of triangular cross-section, as the latter must be 
introduced deeply to prevent cutting through. 
With a normally thick sclera there is no danger of perforating the 
globe, if the needle is held parallel to the curvature of the sclera, so 
that only the most superficial layers are taken up. The needle point 
must not be placed vertically against the sclera in order to penetrate 
its fibers. The only unpleasant feature is that the needle may be 
passed too superficially and cut through. If this happens, a fresh 
attempt must be made to catch some of the adjacent scleral fibers, a 
few of which are sufficiently strong to allow the operator to draw the 
eye, by means of the suture, in the direction of the muscle and to 
fasten the latter firmly to the globe. The attachment is made as 
close as possible to the limbus, but care should be taken that the 
pressure of the knotted thread does not injure the cornea. The 
needle should therefore pass through the sclera parallel to the limbus, 
i.e., perpendicular to the axis of the muscle, that of the superior 
suture brought from the horizontal meridian upward, while that of 
the inferior suture from the same point downward. Such a direction 
of the sutures has also the advantage of lying perpendicular to the 
direction of the scleral fibers (Fig. 96). 
After the needle has been fixed into the sclera, it is passed a little 
further upward or downward through the conjunctiva. This affords 
not only an additional hold for the suture, if the attachment to the 
sclera is not sufficiently firm, but closes simultaneously the wound in 
the conjunctiva. Only one end of each suture is passed through the 
sclera. 
The assistant then seizes with the forceps the eyeball at the oppo- 
site limbus and rotates the globe in the direction of the operated 
muscle, and each suture is drawn as tight as possible, a second knot 
being made over the first (Fig. 97). The sutures must be drawn 
firmly in order to be certain that the muscle has actually been 
brought forward to the limbus and fastened there. If the sutures 
have not been brought together properly, the muscle will be weakened 
rather than strengthened by the advancement. 136 
OPERATIONS ON THE OCULAR MUSCLES 
If the conjunctiva is not completely closed by the advancement 
sutures, a separate thread is inserted horizontally. The threads are 
cut off short, and care exercised that they do not come in contact with 
the cornea. A dressing is applied to both eyes to prevent ocular 
movements that will disturb the recently sutured muscle. The 
operation is the same for either the rectus internus or externus. 
After-treatment.—Both eyes should be kept closed for four to 
five days, but the dressing is changed on the day following the opera- 
tion, in order to ascertain whether or not the cornea is uninjured. 
The sutures may be removed on the fifth or sixth day after the opera- 
Fig. 97.—The operation is almost completed. The eye is rotated outward by the 
forceps, which are fastened at the inner side. The lower suture has already been tied; 
the upper has still to be pulled together. The conjunctiva covers the wound 
automatically. 
tion, but if a pronounced swelling of the conjunctiva prevents ready 
access to the knots, there is no objection to allowing the sutures to 
remain longer, as they can be removed later with much greater facil- 
ity. The reaction of the conjunctiva to this operation is usually 
slight. The eye exhibits no irritation or pain, and in a short time 
there is only a slight thickening of the conjunctiva to mark the point 
of operative interference. 
If the patient’s other eye cannot be bandaged (as in the case of 
ambulant patients, who must go home alone), it is advisable to keep 
the muscle at rest by introducing a suture through the conjunctiva 
close to the external limbus, and carrying the ends through the can- ADVANCEMENT 
137 
thus to the external skin, where they are tied. In this way it be- 
comes impossible to rotate the eye toward the side opposite to that 
of the advanced muscle. 
Conjunctival Fixation of the Muscle.—While it is our custom to 
suture the muscle directly to the sclera, by passing the needle 
through its most superficial layers, it is proper to discuss here another 
method. This consists in passing one end of the upper suture upward 
beneath the conjunctiva along the limbus, going almost as far as the 
upper end of the vertical meridian, and, in a similar manner, one end 
of the inferior suture is passed beneath the conjunctiva as far as the 
lower end of the vertical meridian. In this way an attempt is made 
to obtain sufficient hold for the muscle in the conjunctiva. When the 
sutures are tied, the muscle is, of course, drawn forward to the limbus, 
and must naturally split. On the other hand, the conjunctiva also 
yields to the tension, and is stretched in the direction of the tendon, 
obliquely across the cornea. Quite apart from the fact that this 
attachment is not dependable, on account of occasional friability of 
the conjunctiva, a greater objection is that the conjunctiva is tensely 
drawn in a fold across the cornea, and it can easily happen that the 
suture will come to lie upon the cornea, especially if it is not drawn 
sufficiently tight, a fact which may pass unnoticed by the operator, 
as the knot is covered by the conjunctiva. A corneal ulcer may be 
produced, and the operator is forced to remove the sutures at once, 
sacrificing the entire success of the advancement. Preference 
should be given therefore to the direct suturing to the sclera. The 
only contraindication to this would be a pathologically thinned 
sclera (ectasia). 
In general, operations performed for manifest deviations of the 
eyes have only a cosmetic value. It is only when the squinting eye 
has good sight that a restoration of binocular vision is possible. 
Stereoscopic exercises should be instituted to support the effect of 
the operation by stimulating the fusion faculty and thus promote 
binocular fixation. 
Preliminary Measures.—In the majority of cases of strabismus, 
particularly of the convergent variety, a high degree of refractive 
error exists, and this should be estimated after full relaxation of the 
accommodation under atropin, and glasses ordered to be worn con- 
stantly. The wearing of the glasses should be begun at as early an 
age as possible, as by their use the squint is often corrected or favor- 138 
OPERATIONS ON THE OCULAR MUSCLES 
ably modified. Operation is never indicated in young children until 
an accurate correction of the refraction has been made, glasses worn 
constantly for a considerable time, and the fusion faculty stimulated 
by stereoscopic exercises. In extremely young children, in whom 
the wearing of glasses is not feasible, the fixing eye is kept under the 
influence of atropin to prevent if possible amblyopia of the eye that 
deviates. In older children, in whom the squint is not fully cor- 
rected by glasses, systematic bandaging of the fixing eye is advisable. 
Before performing a strabismus operation, two conditions should 
be investigated—the degree of deviation of the affected eye and the 
mobility of the eyes. 
Anesthesia.—The most satisfactory results in strabismus opera- 
tions are secured under local anesthesia, and it is therefore advisable 
to undertake operation only in patients who have reached an age 
when they can co-operate with the surgeon. As there is often a 
change in the squint as the child develops, early operation might lead 
to an over-effect in later years. It is only in isolated instances that 
ether will be required. 
In high degrees of squint an operation may be performed in 
children under general anesthesia in order to diminish the squint, 
partly for cosmetic purposes, and partly to render more successful 
the subsequent treatment with glasses and muscle exercises. 
CONVERGENT STRABISMUS 
The character of the operation to be performed will be influenced 
by the degree of deviation and the visual acuity of the two eyes— 
whether the eyes have nearly equal vision, so that the patient fixes 
alternately with one eye or the other (alternating squint), or one 
eye always fixes and the other squints (monocular squint). The 
general indications for operation may be summarized as follows: 
Indications for Operation.—If the squinting eye is amblyopic, 
and vision less than 0, the operations are preferably performed upon 
this eye, so far as the consideration for its mobility will allow; 
however, an operation upon the other eye is usually allowable. 
In convergent strabismus of slight degree (maximum 15 degrees), 
tenotomy of the rectus internus of the squinting eye may be per- 
formed, if the power of adduction is above normal. An examination 
of the new position of the eye must be made immediately after the 
operation to determine whether it is necessary to change the effect RESULTS OE TENOTOMY 
139 
that the tenotomy has produced. If the tenotomy is succeeded by 
a marked diminution in the motive power of the rectus internus, all 
thought of immediate further interference must be abandoned, even 
though a convergent squint still remains. 
Advancement of the rectus externus of one or both eyes is the 
operation of choice in (i) cases with diminished abducting power and 
(2) if the squinting eye has a vision of more than }{0. In moderate 
degrees of squint, advancement is performed only on one eye. In 
deviations exceeding 15 degrees, the external rectus of both eyes may 
be advanced at the same sitting. The operation on both eyes is 
especially successful in alternating convergent squint, because of the 
weakened adducting power. After the advancement of one externus, 
the amount of shortening of the other externus will depend upon the 
degree of convergent squint that remains. A permanent over-cor- 
rection is not to be feared, even though divergence exists immediately 
after operation. Both eyes must be bandaged for four to five days. 
In high degrees of strabismus, with amblyopia of the squinting 
eye, a combination of advancement and tenotomy may be performed 
on the squinting eye, although, if the patient will consent to two sepa- 
rate operations, the tenotomy should be performed first, with sup- 
porting suture if required. Fully correcting lenses are to be worn, 
and at the end of several weeks the final result of the operation will 
be manifest. The advancement may then be performed, the amount 
of shortening varying with the degree of strabismus still existing. 
Results of Tenotomy.—It is commonly believed that tenotomy 
of the rectus internus of one eye corrects to the extent of 15 degrees, 
but often there is produced decidedly less correction, sometimes even 
much less. And, while at times the final result of a tenotomy after 
the lapse of time shows little change in the degree of squint, in other 
cases the effect is unexpectedly great, so that the commonly given 
figures are far exceeded. This applies only to a correctly-performed 
tenotomy. It would not be surprising to find an enormous change 
in the position of the eye after extensive incisions of the conjunctiva, 
the subconjunctival tissue, and Tenon’s capsule, or to get no result 
at all when some of the muscle-fibers were overlooked. But even in 
performing the operation in the most approved manner, the effect 
may be decidedly influenced, not only by pre-existing physiologic 
variations in the distance of the muscular insertion from the limbus, 
in the strength of the muscle, and in the relations of Tenon’s capsule, OPERATIONS ON THE OCULAR MUSCLES 
140 
but also, and sometimes to a considerable degree, by definite even 
though only slight variations in the degree of separation of the sub- 
conjunctival tissue and capsule resulting from the operation. The 
use of the strabismus hook to pick up the muscle causes considerably 
more tearing and disturbing of the relations of Tenon’s capsule than 
follows seizing the muscle at its insertion with the forceps. It must 
also be remembered that the immediate effect of an operation may 
differ greatly from the more remote, permanent result. 
Regulating the Effect Produced by Tenotomy.—It is, therefore, 
plain that the degree of correction after tenotomy of the rectus inter- 
nus cannot be foretold with certainty. Even if the effect were defi- 
nitely known in advance, there would still remain other perplexing 
problems. It would naturally be uncommon for the degree of a 
strabismus to correspond exactly with the degree of change in position 
produced by severance of the tendon. Therefore, the necessity for 
some means of regulating the effect of the strabismus operation is at 
once recognized. With such means at hand one does not need to 
know accurately in advance how much effect the operation will 
have. Hence, for altering the effect of a tenotomy there are intro- 
duced what are termed supporting and counteracting sutures. 
The Supporting Suture.—A short, moderately curved needle is 
inserted into the conjunctiva close to the external limbus in the hori- 
zontal meridian. In this situation the conjunctiva is firmly attached 
to the coats of the eye. If the suture is placed more externally, only a 
fold of conjunctiva will be pulled forward by it, and it will be impos- 
sible for it to exert an appreciable influence upon the position of the 
eye; if introduced above or below the horizontal meridian, the rotat- 
ing of the eye will occur on other axes, which would produce undesir- 
able results. Firm anchorage of the suture is secured by introducing 
the needle twice, once immediately above and once just below 
the horizontal meridian. If the conjunctiva is easily lacerated, the 
needle should penetrate deeper in order to fasten the suture in 
the episcleral tissue. Both ends of the silk suture are then passed in the 
horizontal meridian through the external canthus out to the skin, 
while the outer angle of the eye is stretched between two fingers. 
The sutures are tied over a small gauze compress, and the operator is 
in a position to rotate the eye outward at will. 
The application of the suture is naturally limited to those cases 
in which convergent strabismus still exists after the tenotomy but in THE SUPPORTING SUTURE 
141 
which at the same time the loosened muscle is not too much limited 
in its efficiency. It is important after every tenotomy to determine at 
once the effect of the operation. This is done by having the patient, 
while still lying on the operating table, first fix with both eyes a point 
on the ceiling of the room, and then the operator’s finger while it is 
moved toward him. The convergence-ability of the eye is thus deter- 
mined, and, by laterally conducted movements, also the adduction- 
power of the severed muscle. 
The suture should not be used if the muscle appears considerably 
weakened, even though there still remains some strabismus. As the 
suture rotates the eye outward, the insertion of the muscle will come 
to lie still further from the limbus than after a simple tenotomy, and 
through this the muscle will lose still more in power. If there is pro- 
nounced weakness of the muscle, a divergent squint will soon develop, 
owing to the marked preponderance in strength of the intact rectus 
externus. 
In accordance with the rule always to be satisfied with a slight 
under-correction in the operation for convergent squint when per- 
forming tenotomy, the eye should not be rotated outward to its 
greatest extent by means of the suture, although it is known that 
upon its removal the eye rolls inward again. At most, therefore, it is 
permissible to pull the suture sufficiently tight to produce a slightly 
divergent position. It is not necessary to allow the suture to remain 
for more than twenty-four hours. The final effect of the suture can- 
not be estimated accurately in degrees, as the eye usually rolls inward 
again to a slight extent. The influence of the supporting suture is 
closely related to the size of the incision into Tenon’s capsule. 
Lateral incisions in the capsule, which are also recommended to in- 
crease the effect of tenotomy, must certainly be made to some extent 
in the performance of every tenotomy. 
A great advantage lies in the possibility of introducing this suture 
one, two, or even three days after tenotomy. It happens occa- 
sionally that the correction produced by a tenotomy is entirely satis- 
factory immediately after the operation, but in the next few days, to 
the great astonishment of the operator, the effect diminishes con- 
siderably and the degree of strabismus is correspondingly increased. 
The suture is, therefore, the most certain means of reproducing the 
original result. After cocainizing and re-opening the conjunctival 
wound, a strabismus hook is employed to separate the fresh adhesions 142 
OPERATIONS ON THE OCULAR MUSCLES 
that have formed since the operation, after which the suture may 
usually be introduced with gratifying results. 
Counteracting Suture.—This is introduced through the con- 
junctiva close to the internal limbus, in the same manner as described 
for the supporting suture at the external limbus. Should the con- 
junctiva tear, the thread is fixed in the superficial layers of the sclera. 
The assistant then raises the inner margin of the wound, and the sur- 
geon introduces a hook forceps along the inner surface up to the 
adherent muscle. The latter is drawn forward slightly and pierced by 
the needle, which is then passed out through the wound-margin of the 
conjunctiva. The other end of the suture is inserted in the same 
way, and the two ends are firmly tied. The eye is thereby rotated 
inward, so that the recently divided muscle with its tendon is again 
brought closer to the limbus, and thus gains in power. 
The counteracting suture must invariably be employed if an over- 
correction has resulted from the tenotomy. If the eye shows a ten- 
dency to become divergent immediately after the division of the 
tendon, and if the powers of adduction and convergence of the eye 
have been greatly interfered with by the operation, the omission of 
this suture would constitute a serious mistake. The highest grades 
of divergent squint may follow such unfortunate tenotomies. As in 
the case of the supporting suture, this counteracting suture may also 
be introduced one to three days after the tenotomy. It is only nec- 
essary first to break any existing adhesions by means of the strabis- 
mus hook. The suture is tied firmly so that it produces a slight 
convergence of the eye. The suture should be allowed to remain 
several days. 
Results of Advancement of the External Rectus.—The degree 
of correction secured by advancement of the external rectus must be 
even less certain than by tenotomy of the internus. So many factors 
are to be considered that variation in the results should occasion no 
surprise, as it is impossible to believe that each millimeter of excised 
muscle will produce exactly the same degree of correction in every 
case, or that a certain degree of strabismus will be overcome by the 
excision of so many millimeters of muscle in accordance with an 
inflexible rule. A change of 30 degrees in the position of the eye is 
the most that can be expected from an advancement of one externus; 
usually it is much less, and may be put down at 15 degrees at an 
average. The results of operation depend not only upon the excision ADVANCEMENT WITH TENOTOMY 
143 
of a piece of muscle, but also the suturing of the tendon in front of 
the original point of attachment. The latter plays a more important 
part than the excision. If the operation is limited merely to the exci- 
sion of part of the muscle, and the muscle again sutured to the original 
point of insertion, the effect of the operation will be slight. Of 
decided importance is the approaching of the new point of insertion 
of the muscle toward the limbus. 
There is no danger of producing a permanent over-correction by 
performance of advancement alone, even in a convergent strabismus 
of no more than 15 degrees. The result immediately after the opera- 
tion is at its maximum, and the effect usually diminished considerably 
in the near future. Therein lies an important contrast with the effect 
of a tenotomy. While an over-correction must be strictly avoided in 
the performance of tenotomy on account of the increasing degree of 
divergent strabismus that is inevitably produced, any over-correction 
that may occur during the performance of an advancement need not 
worry the operator. No increase in the divergence is to be expected; 
on the contrary, a retrogression is certain to follow. 
Advancement of the Rectus Extemus with Tenotomy of the 
Rectus Intemus.—Incalculable and undesirable results may follow 
simultaneous advancement of the rectus externus and tenotomy of 
the rectus internus of one eye. Even though a considerable degree of 
convergent squint with good adduction-power of the eye remains after 
a tenotomy of the internal rectus, an immediate advancement of the 
rectus externus is an unwarranted procedure. The effect is often 
enormous, and a high degree of divergent strabismus may be the 
immediate result. As a result of the preliminary tenotomy, the 
advancement not only produces changes in the region of the external 
rectus, but also weakens the action of the internal rectus. Through 
advancement of the rectus externus the eye is rotated outward, and, 
owing to the lack of resistance on the part of the divided rectus 
internus, this rotation is greater than it would be with a normal 
internal rectus. The result is necessarily the same as that produced 
by a supporting suture. The rectus internus is drawn further away 
from its original point of insertion toward the equator of the eye, and 
loses correspondingly in its influence. 
The simultaneous performance of tenotomy and advancement can 
be recommended only for the highest grades of convergent strabismus. 
Even in these cases the operation has to be limited to a resection of 144 
OPERATIONS ON THE OCULAR MUSCLES 
the muscle, and the suture made through the original point of insertion. 
If an over-correction is produced, it should by no means be allowed 
to remain, as the resulting divergent strabismus will rapidly increase 
in degree. It is necessary to introduce immediately a counteracting 
suture, which must be well buried in the superficial layers of the 
sclera at the internal limbus to prevent the thread from tearing out. 
Bielschowsky employs a method of preventing over-correction 
without the counteracting suture, which is claimed to give satis- 
factory results. The usual advancement of the externus is per- 
formed, but the sutures are not at first tied. The conjunctiva 
above the internus is incised, the tendon and the surrounding fascia 
grasped with forceps, and a fine silk suture passed through the tendon 
and the conjunctiva. The tendon is raised by the thread and severed 
from its attachment without disturbing its relations with Tenon’s 
capsule. The needle is now carried through the edge of the cut con- 
junctiva near the inner limbus and a loose loop made of the two 
threads. The advancement sutures of the externus are now tied. 
The suture controlling the internus is then made sufficiently tight 
to ensure the desired effect. 
Advancement Preferable to Tenotomy.—From a physiologic 
standpoint the operation of advancement without tenotomy must be 
given the preference. Advancement increases the motility of the 
eye, while the operated muscle is always weakened by tenotomy, as 
the tendon must reattach itself a greater distance from the limbus. 
Therefore, two fundamental rules are to be followed in tenotomy: (i) 
A muscle may be tenotomized -only if the motility of the eye in the 
direction controlled by that muscle is abnormally great. Tenot- 
omy is not to be performed if the muscle is of normal power, and 
particularly if its function is weakened. The motility of the eye must 
therefore be determined before any tenotomy is performed. Under 
normal conditions the internus should be able to adduct the vertical 
axis of the cornea to a line connecting the two puncta, and the maxi- 
mum abduction to reach the commissure of the lids. If the adduction 
of the squinting eye is increased to the same degree as the abduction 
power is decreased, the squinting eye is presumed to have normal 
motility. A weakening of the internus from tenotomy is then 
contraindicated. If an excess of adduction is present in convergent 
strabismus, tenotomy may be performed provided the operation 
does not decrease the power of the muscle and bring it below the DIVERGENT STRABISMUS 
145 
normal minimum. (2) Over-correction in tenotomy must never 
occur. This means not only manifest divergence, but particularly 
weakening the normal power of the muscle. Should the squint not 
be corrected by the tenotomy, no attempt should be made to increase 
the effect of the operation if the motility is lessened. 
In convergent strabismus, if the defect in abduction is greater 
than the increase in adduction advancement is indicated. 
It is evident, therefore, that in cases of divergent squint which are 
the result of an over-correcting tenotomy of the internal rectus for 
convergent squint, advancement of this muscle is all that is required 
—not a tenotomy of the external rectus. The weakening of the 
one muscle does not increase the power of its antagonist. Tenot- 
omy of an internal rectus is, therefore, not to be repeated, except 
in rare instances. 
Although particular emphasis is laid upon the superior value of 
advancement, this does not mean that an advancement must be per- 
formed under all circumstances; in fact, it cannot be denied that in 
many cases tenotomy is an indispensable operation. 
DIVERGENT STRABISMUS 
The rule in operations for divergent strabismus is to produce an 
over-correction; but this result is not so easily attained. Advance- 
ment of the rectus internus is the only procedure which has any mater- 
ial influence on a divergent strabismus, but in itself an advancement 
of the rectus internus has not as much influence on the position of the 
eye as an advancement of the rectus externus. 
This is due to two causes: (i) It is not possible to prepare and free 
as large a part of this muscle as in the case of the external rectus, and 
consequently the suture cannot be introduced as far back. (2) There 
is less room to advance the muscle, as the insertion of the tendon is 
normally near the limbus and cannot be brought much closer to it. 
Similarly, a division of the external rectus has much less influence 
on the position of the eye than a tenotomy of the internal rectus. As 
the tendon insertion of the rectus externus is already further removed 
from the limbus, its shifting by means of a tenotomy will cause 
relatively much less loss in the influence of the muscle on the motility 
of the eye than is the case with the rectus internus. The value of 
the point of insertion grows in a rapidly increasing ratio as this point 
approaches the limbus. 146 
OPERATIONS ON THE OCULAR MUSCLES 
Advancement of the Rectus Internus with Tenotomy of Rec- 
tus Externus.—In slight grades of divergent squint, both operations 
are usually performed simultaneously in order to obtain immediately 
after the operation an over-correction—a slight degree of convergent 
strabismus—as experience has shown that there is always a tendency 
toward a return to the divergent position. A tenotomy alone of the 
rectus externus has hardly any influence. In higher grades of diver- 
gent strabismus even the simultaneous performance of both opera- 
tions is not sufficient. 
If combined advancement and tenotomy has not corrected the 
deviation, a supporting suture may be inserted at the internal canthus 
similar to that described in tenotomy; or a suture may be passed 
through the bulbar conjunctiva, not too close to the external limbus, 
carrying both ends out through the palpebral fissure toward the 
median line. By drawing firmly on the two threads, the eye is 
brought into a pronounced convergent position, one thread being 
drawn upward to the median line of the forehead, and the other over 
the bridge of the nose to the other side of that organ, in which posi- 
tions both threads are fastened with several strips of plaster. A 
small piece of absorbent cotton is placed beneath the lower thread, 
so that it does not cut into the bridge of the nose. As the eye cannot 
be completely closed, it should be covered with a piece of oiled paper. 
The suture may be removed on the following day. The cornea will 
not be injured by the suture, especially if it has been introduced a 
short distance externally to the limbus, so that it raises a small fold 
of the conjunctiva. If the divergent position is not yet corrected, 
operation on the muscles of the other eye is indicated. 
Divergent Strabismus Caused by Tenotomy of the Rectus 
Internus.—If the divergent strabismus is the result of a tenotomy of 
the rectus internus that has been performed for convergent strabismus, 
an advancement of the rectus internus usually produces an excellent 
result. The preparation of the muscle, however, is somewhat diffi- 
cult, as it is often attached far back from the limbus. It is scarcely 
possible to excise a part of the muscle, as there is only sufficient room 
to introduce the sutures. Nevertheless, the result is good, as the 
point of insertion can be brought forward a considerable distance. 
After an over-correction of convergent strabismus by tenotomy 
of the rectus internus, the operator must be warned against under- 
taking an advancement of this muscle within a few days after the PARALYTIC SQUINT 
147 
tenotomy. The only course that can be pursued is to introduce the 
counteracting suture. As the muscle can often be scarcely found in 
the congested and somewhat swollen tissue, an advancement accord- 
ing to exact rules is extraordinarily difficult, and the procedure in 
addition is painful to the patient in spite of the cocain-injection. 
Under these circumstances, if the suture has not had the desired 
effect, it is much better to wait until the eye has recovered, and 
several weeks later undertake the advancement. An unsuccessful 
attempt at advancement may render the condition even worse. 
Latent Outward Deviation (Exophoria).—Although the principal 
indication for advancement of the rectus internus is manifest diver- 
gent squint, the operation must also be performed in exophoria, in 
which asthenopic symptoms, such as fatigue and variable diplopia, 
arise even during use of the eyes at distance, provided, of course, that 
these symptoms cannot be remedied by use of prisms. As the 
extreme correction possible from an advancement of the rectus internus 
of one eye is about 15 degrees, the operator must be governed in doing 
this operation by the degree of exophoria. If the heterophoria is 
slight, the operation should be confined to a simple advancement 
without excision, or with excision of a short piece of the muscle. It is 
desirable that the patient should show immediately after the opera- 
tion a slight convergence when looking into the distance. If binocu- 
lar vision existed before the operation, the convergence will soon 
disappear under the influence of the fusion-tendency. When a 
carefully-performed advancement of one internus does not relieve 
the patient of the exophoria and its accompanying symptoms, a 
similar advancement of the rectus internus of the other eye may be 
undertaken after the lapse of a few weeks. 
The greater proportion of cases of exophoria are due to conver- 
gence weakness, but in some instances the defect is the result of 
excess of divergence power, in which tenotomy of the externus would 
be the procedure indicated. 
Paralytic Squint.—Operative interference is only indicated if it is 
decided that the paralysis is permanent and has been present for at 
least nine to twelve months. An effect upon the motility of the eye 
can be promised from the advancement only in cases of partial 
paralysis of the muscle. In total paralysis no influence can be 
exerted on the motility, and the operation is performed rather with 
the idea of returning the paralyzed eye to its normal position. CHAPTER IX 
ENUCLEATION OF THE EYEBALL AND THE SUBSTITUTE 
OPERATIONS. OPERATIONS ON THE ORBIT 
ENUCLEATION 
Indications.—Enucleation is to be performed: 
1. When the vision of the eye is irretrievably lost, and the eye is 
painful. 
2. When the sound eye is seriously endangered by a sympathetic 
affection. 
3. When the eye contains a malignant growth. 
The presence of an intraocular tumor is an indication for enuclea- 
tion, although the eye may still be functionating. 
If after an injury iridocyclitis develops, enucleation is not per- 
formed until both light-perception and light-projection have become 
greatly reduced, and sympathetic inflammation is feared. 
Extensive ruptures of the cornea and sclera, with prolapse of the 
iris and vitreous, justify immediate removal of the globe. Prompt 
action spares the patient weeks and months of suffering. After 
extensive injuries the gaping wound may be sutured before the 
enucleation, to prevent involuntary expulsion of the ocular contents. 
Ruptures of the sclera require enucleation much less frequently. 
Even though the visual power is usually either entirely ruined or 
returns only partly, such eyes can later become absolutely quiescent, 
and often do not become disfigured. Not until the globe begins to 
shrink and becomes painful and injected should enucleation be per- 
formed, but then, however, without delay. Enucleation is not 
justified simply because the light-perception of the eye is completely 
destroyed by an injury that does not rupture the globe. Not 
infrequently, immediately after a contusion, the light-perception is 
completely lost, but both perception and projection return gradually 
and may even reach normal. We have seen such eyes which, from a 
condition of absolute amaurosis, have regained partial visual acuity. 
Enucleation is indicated in high degrees of ectasia (total staphy- 
loma of the cornea and staphyloma of the sclera) which are disfiguring 
148 SIEGRIST LOCAL ANESTHESIA 
149 
because of their size, and are in danger of rupture, resulting in serious 
hemorrhage. 
Enucleation is indicated when panophthalmitis is developing. 
For example, if, after an injury which in itself was not considered 
sufficient indication to perform an enucleation, the eyeball becomes 
infected, and this infection is rapidly progressive and makes a pan- 
ophthalmitis probable, we check the process by enucleation of the 
eyeball. 
Enucleation is also demanded if the eye becomes seriously infected 
after operative interference, as, for instance, a cataract operation. 
If, however, the panophthalmitis has already developed, as evidenced 
by exophthalmos, marked edema of the lids, limitations of the move- 
ments of the eyeball, and chemosis, enucleation is contraindicated, 
as experience has shown repeatedly that meningitis may follow re- 
moval of the eyeball. The proper procedure is to open the anterior 
portion of the eyeball to permit the free drainage of the pus and thus 
furnish the patient relief, or to perform evisceration. If there is no 
opening in the eyeball through which pus may enter the tissues of 
the orbit, enucleation may be performed in a fully-developed pan- 
ophthalmitis. 
Anesthesia.—In the majority of instances the removal of the eye- 
ball is performed under local anesthesia. Only difficult enuclea- 
tions of crushed or inflamed eyes, especially if the orbital tissues are 
implicated in the injury, remain for general anesthesia. In children 
and nervous individuals general anesthesia is required. 
Siegrist Local Anesthesia.-—The conjunctiva is rendered insensi- 
tive by several instillations of a 3 per cent, solution of cocain. A 
few drops of a 2 per cent, novocain-adrenalin solution are then injected 
beneath the conjunctiva at the insertion of each of the recti muscles. 
After a few minutes the conjunctiva at the lower border of the inter- 
nal rectus muscle with the underlying capsule is picked up with 
forceps and an injection of a 2 per cent, novocain-adrenalin solution 
made into the tissues around the posterior pole of the eyeball. A 
similar injection may be made along the border of the other three 
recti muscles, although many operators inject the entire solution 
at the one point. The usual Pravaz syringe,with a somewhat curved 
needle (Fig. 98), may be used. The needle, with its concavity toward 
the eyeball, is pushed in and carried back along the surface of the eye 
to the point where the optic nerve and ciliary nerves enter the ball. 150 
ENUCLEATION OF THE EYEBALL 
The needle should not be passed through the eye muscles, as the 
dragging on the tissues causes considerable pain. A total of about 
3 cm. of the solution is injected. Following the injection there is a 
moderate degree of exophthalmos, and anesthesia soon follows. 
Fig. 98.—Curved needle (natural size) for injections behind the eye (method of 
Siegrist). 
Even in inflamed and painful eyes the operation may be started in a 
few minutes and is finished with almost complete absence of pain. 
The exophthalmos facilitates the enucleation. 
Ganglion Anesthesia (Lowenstein).—The ciliary ganglion is 
situated posteriorly in the orbit in the angle between the optic nerve 
and the external rectus muscle. An injection made in the vicinity 
of the ganglion influences the sensibility of all the nerves of the globe. 
A i per cent, solution of cocain is employed, and is injected with the 
ordinary Pravaz syringe, which is supplied with a sharp needle 
5 cm. long and correspondingly thick (Fig. 99). The conjunctival 
culdesac is first rendered anesthetic with several instillations of a 3 
Fig. 99.—Straight needle for ganglion anesthesia. 
per cent, cocain solution, the commissure stretched outwards, and 
the needle of the syringe entered close to the external orbital margin, 
slightly below the center, along the inferior margin of the external 
rectus, and pushed obliquely inward toward the median line until 
not more than cm. remains visible (Fig. ioo). The barrel of the 
syringe is now turned slightly outward, so that the needle point is 
raised away from the external orbital wall, and one-half of the con- 
tents of the syringe injected. If the needle has reached the proper 
situation, there is some sensitiveness on pressing the globe with the 
forceps in tender and inflamed eyes, but the pain gradually disappears. 
At the expiration of a few seconds the remainder of the contents of 
the syringe is injected at the same place. GANGLION ANESTHESIA 
151 
Since the external orbital wall runs obliquely inward, care must 
be exercised in thrusting the needle forward to direct the point toward 
the median line and thereby escape the bone. The needle must not 
be pushed too near the apex, or the optic nerve will be penetrated. 
By a lateral movement of the syringe it is readily determined if the 
needle point is free or caught in the optic nerve or a large vessel. 
Fig. ioo.—Horizontal section through the orbit, showing position of the needle; 
o., optic nerve; g., ciliary ganglion. 
If the eye has been inflamed for a long time, it is advisable to make 
a subconjunctival injection of another half-syringeful of the solution 
around the globe before beginning operation. 
If the sensibility of the eye has not been affected by the injection 
of the first half of the contents of the syringe, the needle is drawn out 
for a short distance and pushed forward in a slightly altered position 
to reach the ganglion. 
In timid and excitable patients a preliminary subcutaneous injec- 
tion of scopolamin and morphin is of value. 
Rapid protrusion of the eye, with severe pain immediately after 
injection, probably caused by hemorrhage, is a rare complication. 
The danger of hemorrhage and of injury to the optic nerve necessi- 
tates the limitation of this method of anesthesia to enucleation. It 
cannot be applied to intraocular operations even in blind eyes. 
Ganglion anesthesia may be performed by passing the needle 
through the skin, immediately below the external canthus. The 
skin, after thorough cleansing, is painted with 3 per cent, tincture 152 
ENUCLEATION OF THE EYEBALL 
of iodin, and a small quantity of the anesthetic solution injected 
under the skin of the area by a fine hypodermic needle. This renders 
painless the introduction of the heavy needle. As the conjunctival 
sac is not touched with the needle, the method is indicated where 
infectious material in the conjunctival sac might lead to the implant- 
ing of germs into the orbital tissue if the needle is carried through the 
conjunctiva. 
In exceptional instances the injection into the orbit fails to reach 
the ganglion, and anesthesia is absent or incomplete. In such an 
event, Lieberman advises that twro additional injections be made, 
one through the skin of the upper lid, below the orbital margin, and 
about i cm. above the internal canthus, and the other through the 
skin of the lower lid, at a point about i cm. to the inner side of 
the center of the lower orbital margin. In the upper injection the 
needle is first carried backward 2 cm. in the sagittal direction, then 
turned slightly downward and outward, and pushed into the orbit a 
depth of 4 cm. The injection through the lower lid is made in a 
direction slightly upward and outward for a distance of about 6 
cm. By using 2 cm. of the novocain-adrenalin solution for each of 
the three injections, a conical area of orbital tissue is sufficiently 
infiltrated to reach all of the nerves affected by the enucleation 
operation. 
Seidel Posterior Orbital Injection.—If the anterior entrance into 
the orbit is blocked by tumors, or the tissues around the eyeball are 
deeply inflamed, and the existing conditions require immediate 
enucleation without waiting until the inflammatory symptoms have 
subsided, the method of Seidel may be adopted. He recommends 
that the injection be made with a needle 8 cm. in length through the 
cheek, 2 cm. beneath the anterior portion of the lower margin of the 
zygomatic bone, and carried behind this bone upward and slightly 
inward. According to Seidel, the point toward which the needle 
has to be directed is situated on the sutura coronaria, one thumb's 
breadth laterally to the outer side from its junction with the sagittal 
suture, that is, to the right of the median line if the left orbit is to be 
injected. On this point the index finger of the free hand is fixed 
(Fig. 101). In order to find the point on the patient, a band is placed 
from the anterior margin of the mastoid process of the one side close 
behind the auditory meatus perpendicularly over the skull to the 
mastoid process on the opposite side. The direction of the needle POSTERIOR ORBITAL INJECTION 
153 
lies one thumb’s breadth laterally from the point where the median 
line cuts the line of the band. In this way the needle enters the 
posterior portion of the orbit through the inferior orbital fissure. 
After slowly injecting 1 cm. of the 2 per cent, novocain-adrenalin 
solution, the needle is gradually pushed forward, injecting an addi- 
Fig. 1 oi.-—Posterior orbital injection (Seidel). Index finger of the free hand put on 
the aim-point. The needle has reached the roof of the orbit, closely in front of the 
optic foramen. 
tional i cm. of the solution until the roof of the orbit is reached, 
closely in front of the optic foramen. As the needle is slowly drawn 
back 4 cm. of solution are injected into the orbital tissues, a total of 
6 cm. in all. Prior to the orbital injection, the skin and tissues of the 
pterygo-palatine fossa through which the needle has to be pushed 
must be rendered insensitive by first superficial infiltration of the 
skin, and later injections with a fine needle, 4 cm. in length, of 6 cm. 
of the solution into the pterygo-palatine fossa to the posterior surface 
of the maxillary bone. At the end of twenty minutes the eyeball 
may be enucleated, and even the orbital contents eviscerated, with- 
out pain. 
Enucleation.—The first step of the operation is to separate the 
conjunctiva from the eyeball. A fold of the bulbar conjunctiva is 154 
ENUCLEATION OF THE EYEBALL 
picked up with a pair of toothed forceps in the horizontal meridian 
near the limbus, and a small incision is made into it close to its attach- 
ment. Not a particle of conjunctiva should remain on the bulb, 
as every millimeter is of the greatest importance for the wearing of 
a prothesis. 
Separation of the Conjunctiva (Fig. 102).—The blunt blade of 
the small, slightly curved scissors is inserted into the opening made at 
Fig. 102.—Enucleation of the right eye. Division of the conjunctiva has advanced 
to the vertical meridian. Note the position of the scissors: one of the blades is pushed 
forward beneath the conjunctiva, the forceps at the same time lifting the margin of the 
conjunctival wound somewhat; the other blade of the opened scissors is placed in front of 
the cornea in such a manner that by shutting the instrument the conjunctiva is separated 
close to the limbus. 
the limbus, and pushed forward beneath the neighboring conjunc- 
tiva, while the other blade remains in front of the cornea. The 
blades must be held parallel to the limbus. The scissors are then 
closed, thus separating the conjunctiva from its attachment at the 
limbus. This is continued, the conjunctiva being picked up with 
forceps at the end of the incision, and the scissors being pushed for- 
ward until the conjunctiva is loosened completely at the limbus. As 
a right-handed operator always cuts from right to left, the detach- 
ment of the conjunctiva in the case of the right eye should begin on 
the inner side; in the case of the left eye, on the outer side of the 
corneal limbus. The lower periphery is separated first, and then the DIVIDING THE MUSCLES 
155 
upper, so as not to be disturbed by the blood. After the conjunctiva 
has been cut all the way around, it is undermined with closed scissors 
on all sides, in order to completely detach it from the eyeball. 
Dividing the Muscles.—The tendon of the internal rectus is 
the first to be divided on the right eye; the tendon of the external rec- 
tus, on the left eye. The tendon is picked up with the toothed 
forceps as in tenotomy (p. 129), and, while the assistant slightly lifts 
the conjunctiva in front of the muscle, the operator, having scissors 
ready in his right hand, pushes the shut forceps held in his left hand 
Fig. 103.—The forceps have grasped the internal rectus at its attachment, and have 
turned the eye outward; one blade of the scissors is pushed under the muscle to the inner 
side of the forceps to cut through it vertically to the direction of its fibers. 
back along the sclera close to the attachment of the muscle, where he 
opens them and grasps the muscle by pressing the forceps against the 
sclera. The final detachment of the tendon from the sclera is not 
completed as in tenotomy, but the muscle is cut through at the side 
of the forceps, away from the eyeball, by pushing the blunt blade of 
the scissors under the muscle-tendon from beneath and cutting 
through it obliquely, so that a short piece remains attached to the eye, 
by which the globe is held during the subsequent stages of the opera- 156 
ENUCLEATION OF THE EYEBALL 
tion (Fig. 103). The tenotomy opens Tenon’s capsule and exposes 
the sclera. The small, slightly curved scissors, employed for the 
division of the conjunctiva and the tendon, are now replaced by 
a somewhat larger and stronger pair, which may be either straight or 
slightly curved, the enucleation-scissors. 
The eyeball, which is held throughout by the stump of the muscle- 
tendon, is rotated in a horizontal direction toward the side opposite 
the cut muscle (i.e., the right eye outward, and the left eye inward), 
and the scissors inserted into the opening in Tenon’s capsule, which is 
found by pressing the blunt blade of the opened scissors against the 
Fig. 104.—The forceps pull the eye downward with the tendinous stump of the 
rectus internus, while the blunt blade of the enucleation-scissors is pushed from the inner 
side under Tenon’s capsule, until it reaches the superior rectus, which it now cut off close 
to its insertion. 
bared sclera and pushing it from here upward under the capsule. 
In this way the blade glides under the tendon of the superior rectus 
(Fig. 104). The muscle is recognized by the marked resistance 
which it offers the scissors. The eyeball is next pressed forward with 
the aid of the scissors, so that the tendon of the muscle is exposed, 
when it is cut off close to its insertion with one snip of the scissors. 
The tendon of the inferior rectus is next severed by similar fixation 
and position of the eyeball, excepting that the operating hand must 
be held perpendicularly. In the same manner, the blunt blade of the 
scissors glides beneath the capsule of Tenon, lifts up the tendon of the 
inferior rectus, so it can be seen on the scissors, and cuts it. 
Cutting the Optic Nerve.—The tendon of the fourth straight eye- 
muscle is not divided until after the severance of the optic nerve. CUTTING THE OPTIC NERVE 
157 
While the eyeball is held rotated to the right, the closed enucleation- 
scissors are pushed along the sclera slowly to the posterior pole of the 
eye. Inasmuch as the optic nerve of the right eye is approached from 
the inner side, it is more easily reached than the optic nerve of the 
left eye, where the advance is made from the outer side, and conse- 
quently the posterior pole must be passed before the nasal side of the 
bulb is reached. The beginner often has difficulty in locating the 
optic nerve. This is the result of a wrong position of the scissors, 
which must not be directed backward toward the depth of the orbit, 
Fig. 105.—-The eye, which is still held fast at the same point, is strongly turned out- 
ward exactly around its vertical meridian. The opened enucleation-scissors have the 
optic nerve between their blades ready to cut through it. 
but introduced close to the sclera in an approximately frontal direc- 
tion, about vertically to the course of the optic nerve. If the eye- 
ball is rotated about its vertical axis to the right, and the closed 
scissors held in the horizontal meridian against the sclera, and moved 
from above downward, the optic nerve can be made out as a tightly 
stretched cord. The finding of the optic nerve may be facilitated 
by drawing the eye slightly out of the orbit in order to stretch the 
nerve. Ordinarily the nerve should be severed close to the bulb. 
After having ascertained its position, the scissors are opened, the 
operator feels around once more to make sure that the nerve is 
between the two blades (Fig. 105), and then divides it with one cut. 
The loosened bulb is immediately pressed forward with the closed 
scissors, and turned out from the orbit, so that the assistant may check 
the bleeding with a tampon of dry gauze firmly packed in the bottom 
of the opening, and prevent any suffusion into the orbit. 158 
ENUCLEATION OF THE EYEBALL 
Removing the Eyeball.—Nothing remains now except to free the 
bulb from its remaining attachments, which consist of the tendons of 
both oblique muscles and of the fourth rectus, and these are cut 
through with the scissors close to the bulb. If the enucleation has 
been properly performed, no large tissue-remnants should remain 
on the eyeball with the exception of the muscle stump, by which the 
bulb is held. 
Closing the Conjunctival Wound/—The wound in the conjunctiva 
may be closed either with a purse-string suture or with several verti- 
cal sutures. If the latter are employed, it is important to draw both 
threads through near the border of the wound, so that no shortening 
of the conjunctival sac may be produced by the central margin of the 
conjunctiva projecting inward in the form of a roll. 
Many operators believe that a more movable stump for the prothe- 
sis is secured by suturing the four straight muscles to the conjunctiva 
and by bringing the edges of the wound in the conjunctiva and 
Tenon’s capsule together with interrupted silk sutures. Moderate 
compression should be employed in the dressing in order to prevent 
secondary hemorrhage. On the day after the operation the bandage 
is changed and a light pad worn for several days. The conjunctival 
sac is cleansed with a weak bichlorid solution. 
Complications.—If the eye has been inflamed for a long time, 
adhesions frequently exist between the conjunctiva and the sclera, 
particularly if subconjunctival injections of solutions of mercuric 
chlorid or sodium chlorid have been repeatedly made, or, after 
injuries, destructive processes have led to cicatricial fusion between 
conjunctiva and sclera. The loosening of the conjunctiva may 
become impossible after the action of corrosives, when, in place of 
the conjunctiva, only a small layer of scar-tissue remains, thin and 
easily perforated. The conjunctiva must be preserved as much as 
possible, and not torn by unnecessary handling of the toothed for- 
ceps. The severing of the muscles is made easier for the beginner if 
he searches for them with the strabismus hook. The operator, 
however, who pushes the scissors beneath Tenon’s capsule, after the 
manner described, finds that this method has the advantage of greater 
rapidity, but he must be careful while cutting the tendons of the 
superior and inferior recti not to injure the lid by a snip of the scissors. 
During the entire operation the lids must be held apart by a lid- 
speculum. ORBITAL HEMORRHAGE 
159 
Tearing Off of the Muscle Stump.—Should the muscle stump, by 
means of which the eyeball is handled, break or tear off from repeated 
seizures with forceps, the tendon of another muscle must be grasped, 
or, if the eye is soft, a fold of the sclera may be picked up. If all the 
tendons have been cut close off, the index and middle fingers of the 
left hand must be used to hold the ball in the desired position in 
order to cut through the nerve, or the ball held by a suture through 
the sclera. The closer to the eyeball the tendon is grasped, and the 
less frequently the forceps are applied, the more firmly will the 
tendon hold. 
Orbital Hemorrhage.—The most difficult part of the operation 
for the beginner is the division of the optic nerve. The nerve may be 
easily found by slow groping about with the closed scissors, but should 
the eye be inclined in an oblique direction, and the operator hastily 
make a cut anywhere backward in the orbit, he will not succeed in 
dividing the nerve. This blind cutting leads to a profuse hemorrhage 
into the orbit, which cannot be stopped by inserting a tampon so long 
as the eyeball remains in place. The infiltration may become so 
extensive that the tissue of the orbit is bulged forward like a tumor, 
and weeks may elapse before the blood will become absorbed. An 
attempt should be made to cut the optic nerve with the first stroke. 
It is rare, however, for the hemorrhage to be profuse (arteriosclerosis, 
haemophily). If energetic compression does not suffice to check 
the bleeding, ligation of the blood-vessels must be resorted to, or 
even the Paquelin cautery used. Secondary hemorrhage is rare, 
and is treated by removing the bandage and packing the orbit. 
Perforation of the Sclera.—After division of the optic nerve the 
eyeball must at once be displaced forward, so that the tampon may 
be inserted. It is unpleasant if the operator, instead of severing the 
nerve, cuts into the posterior part of the ball itself. This may hap- 
pen after severe injuries which have induced a complete collapse of 
the ball, or if the globe has ruptured when the muscles were severed. 
It becomes necessary then to search for the nerve, while still holding 
the stump on the eyeball, and resect it. As the surrounding orbital 
tissue becomes much swollen from effusion of blood, it is difficult to 
dissect and free the optic nerve so as to divide it further back. The 
bearings to its position are lost, and the profuse bleeding prevents a 
clear view. 160 
ENUCLEATION OF THE EYEBALL 
Injury to the levator palpebrae can only occur if the position in 
which the eyeball is held or the direction of the cutting is extremely 
faulty. Cases of total ptosis have been reported after enucleation. 
Resection of the optic nerve must be done if, during enucleation 
because of a malignant growth, the stump of the nerve is found in- 
volved by the tumor. The nerve should be cut as far back of the 
eyeball as possible; but if it is assuredly affected, exenteration of the 
orbit (p. 164) is a safer procedure than resection of the nerve. In 
iridocyclitis following injuries, in which sympathetic inflammation 
threatens, as much of the nerve as possible should be resected. 
Substitute Operations.—The following operations may be em- 
ployed as substitutes for enucleation: 
1. Abscission of the cornea. 
2. Evisceration. 
3. Evisceration, with the insertion of a glass or metal sphere in 
the scleral cavity (Mules’ operation). 
4. Implantation of a glass or metal sphere in Tenon’s capsule after 
removal of the eyeball (Frost-Lang operation). A mass of fat has 
been employed instead of the glass or metal sphere (Barraquer); 
also cartilage (Magitot). 
5. Optico-ciliary neurotomy and neurectomy. 
Abscission (Complete Keratectomy).—Excision of the entire 
cornea, and closure of the edges of the scleral opening with sutures, is 
performed in non-inflamed staphylomatous eyes, especially in 
children. The operation, however, is not free from the dangers of 
sympathetic inflammation. (See page 302.) 
Evisceration.—Evacuation of the contents of the eyeball, without 
removing the sclera and its attachments, is indicated in panophthal- 
mitis. The operation consists of excision of the entire cornea, the 
evacuation of the contents of the scleral cavity, and swabbing the 
interior with antiseptic solution or, as some advise, carbolic acid. 
Evisceration, with Insertion of a Globe in the Sclera (Mules’ 
Operation).—Although Mules’ operation has many advocates 
who regard it as of especial value from a cosmetic standpoint in (1) 
recently injured eyeballs, (2) in eyes painful and blind from glau- 
coma, and (3) when only the cornea is diseased, this operation is not 
performed in our clinic. Cases of sympathetic inflammation have 
repeatedly been observed. The expulsion of the sewed-in balls 
occurs frequently, sometimes even after years have passed. This IMPLANTATION OPERATION 
161 
may be accompanied by symptoms of inflammation, which may 
require operative interference, such as the shelling out of the ball; 
in fact, subsequent enucleation of the stump may be necessary. 
Enucleation, with Implantation of a Globe in Tenon’s Capsule 
(Frost-Lang Operation).—It is claimed for this operation that it 
gives a more movable stump for the prothesis, lessens the tendency 
to sinking of the upper eyelid, and is free from the risks of sympa- 
thetic disease. The artificial sphere, either glass or gold, is inserted 
into Tenon’s capsule after the eyeball has been removed and hem- 
orrhage stopped. The edges of the capsule are brought together 
horizontally over the ball by a number of fine silk or chromicized 
catgut sutures, and the conjunctival wound is then sutured with silk, 
also in the horizontal direction, and the usual bandage applied. The 
reaction after operation is usually no greater than follows enucleation. 
Operators of large experience with the operation extending over 
many years report that when properly implanted the gold ball 
remains in fixed position and is not extruded. 
Enucleation, with Implantation of Fat in Tenon’s Capsule (Bar- 
raquer Operation).—The operation differs from ordinary enuclea- 
tion in the passing of a double-armed catgut suture through the 
divided ends of the four recti muscles. A piece of fat sufficiently 
large to fill the cavity of Tenon’s capsule is removed from the abdom- 
inal wall, inserted into the capsular cavity, and the recti united 
crosswise over it. The edges of the capsule are then sutured with 
catgut and the conjunctiva with silk. Protruding pieces of fat must 
be carefully cut away before the conjunctival wound is closed. 
Lauber recommends that the skin incision of the abdomen be rec- 
tangular, with one side in the linea alba. In from eight to ten days the 
conjunctival sutures are removed, and the prothesis worn at the end 
of about three weeks. It is claimed that the implanted fat forms an 
excellent support for the artificial eye, although in time it gradually 
decreases in volume. 
Enucleation with Implantation of Cartilage in Tenon’s Capsule. 
Magitot advises sterilized cartilage for implantation, after enucleation 
of the ball, and claims that it is superior to unorganized tissues, 
such as gold or glass, since the latter are foreign bodies tolerated and 
encysted, whereas the cartilage is at once covered by a network of 
connective tissue and becomes permanent. Bone may be used/but 
Magitot prefers cartilage because it can be cut readily to the [size 162 
ENUCLEATION OF THE EYEBALL 
desired. A sternal piece of a large-sized calf is selected, which is of 
sufficient size to allow the cutting of fragments 20 to 25 mm. in thick- 
ness and of the length required. Care is taken that the perichondrium 
of the cartilage is not removed, as this membrane becomes the union 
between the transplant and the living tissues of the orbit. The fresh 
cartilage is fixed for eight to ten days in a solution of formalin, 20 per 
cent. The formalin is then poured off and replaced by sterile water. 
The cartilage is ready for use two weeks later. The formalin from 
the cartilage gradually permeates the water, and in this weak anti- 
septic solution the fragments will keep indefinitely. 
The fragment of cartilage is inserted in the muscle funnel as soon 
as the eye is removed and all hemorrhage stopped, and the recti 
muscles brought together and sutured with catgut. Over the 
muscle layer the conjunctiva is closed with sutures. A binocular 
bandage is applied for three days. 
The implantation may be made at the time of the enucleation, 
or may be done at a remote period if the removal of the eyeball was 
properly done. In these cases it is necessary to create a pocket in the 
middle of what remains of the muscles, in which is inserted the 
fragment of cartilage. The first step is the freeing of the con- 
junctiva at the bottom of the orbit from its deep attachments, incis- 
ing the fibromuscular mass and making an opening, which is sub- 
sequently enlarged with forceps. After the implant is pushed in the 
cavity, the muscle mass is sutured with catgut, and the conjunctiva 
with silk. 
Optico-Ciliary Neurotomy.—An eye blinded by glaucoma, which 
has become painful, furnishes a suitable indication for optico-ciliary 
neurotomy. As the eye is not disfiguring, it is more desirable that 
the owner retain it than replace it with an artificial eye, the use of 
which is associated with many inconveniences. The operation is 
rarely indicated if the eye has become blind through a spontaneous 
iridocyclitis—one not induced by injury—and causes the patient 
pain. These eyes are generally shrunken and disfiguring, so that 
enucleation must be recommended. An optico-ciliary neurotomy in 
such eyes could only serve to render the cornea anesthetic and permit 
the wearing of an artificial eye over the shrunken globe. The motil- 
ity of the prothesis is then excellent, as reported by Axenfeld. If an 
injury has preceded, enucleation must of necessity be performed, as 
an optico-ciliary neurotomy would not prevent a sympathetic inflam- OPTICO-CILIARY NEUROTOMY 
163 
mation. When an intraocular tumor is suspected, enucleation is 
peremptory. 
Anesthesia.—The operation is usually done under general anesthe- 
sia, especially if the ball is sensitive, although scopolamin-morphia 
narcosis may suffice, if efficient local anesthesia is secured by deep 
injections of novocain-adrenalin solution in the region of the ciliary 
ganglion, as described under enucleation. These injections have the 
advantage of making the field of operation anemic, although they 
may be followed by a rapidly increasing exophthalmos. 
Operation.—The rectus internus is freed as in an operation for 
advancement, and a suture is passed through the muscle at a distance 
of about % cm. from its attachment, then tied, and given to the 
assistant to hold, after which the muscle is divided between its 
insertion and the knot. The assistant pulls the muscle away from 
the eye by means of the suture, the operator using the stump, 
which remains attached to the eye, to fix the ball. As in enuclea- 
tion, the scissors are passed slowly backward along the sclera, and 
the optic nerve divided. The scissors are withdrawn and strong pres- 
sure maintained on the bulb through the closed lids for five minutes to 
prevent a hemorrhage into the orbit. Without this compression the 
bleeding may push the loose eye through the palpebral fissure at 
once, or it may be found out of the orbit on the next day. As a 
reposition is impossible, nothing remains but enucleation. Exten- 
sive hemorrhage may occur in the aged from arteriosclerosis, in spite 
of firm compression. 
As the ciliary nerves were not divided at the severing of the optic 
nerve, the eye is turned on its vertical axis so that the posterior sur- 
face of the eyeball lies free in the palpebral fissure, and the ciliary 
nerves cut that pass through the sclera in the neighborhood of the 
optic nerve, the greater number of which have already been torn 
during the turning of the eyeball. 
Axenfeld recommends that, in addition, the openings where the 
ciliary nerves enter the eyeball in the area of the sclera be touched 
with the galvano-cautery, as many nerve-fibers of the central nerve 
stump regenerate and find their way into the interior of the eye 
jthrough these openings, so that the eye may again become sensitive 
and painful. 
If a long piece of the optic nerve remains attached on the eyeball, 
a part of it may be resected (neurectomy). The eyeball is then re- 164 
ENUCLEATION OF THE EYEBALL 
placed in its normal position, the muscle carefully sutured to the 
stump to insure its normal motility, the conjunctival opening closed 
with sutures, and a firm pressure-bandage applied over the closed 
lids. Usually, healing progresses without incident. The slight 
amount of exophthalmos after the operation, because of the hemor- 
rhage, disappears within a short time. 
If the operation has been successful, the cornea is perfectly anes- 
thetic and the eyeball free from pain. The sensitiveness of the cor- 
nea returns very slowly. A neuroparalytic keratitis is not to be 
feared. Over the fundus the blood-vessels are seen to be absolutely 
empty, appearing as white lines, and the papilla is a pure white. 
The tension of the bulb remains normal, sometimes even greater than 
normal. Atrophy of the eyeball does not develop. 
Exenteration of the Orbital Cavity.-—The removal of all the 
contents of the orbit for the extirpation of malignant neoplasms, 
whether of the orbit itself or of the eyeball after they have broken 
through the sclera, is performed as follows: 
If the lids are to be preserved, the palpebral fissure must first be 
widened by canthotomy; this exposes the outer border of the orbit. 
Next, the conjunctiva of the lower fornix is cut through with a sharp 
scalpel to the bony lower border of the orbit, which is thus completely 
bared. The assistant draws the lid away with a dull tenaculum. 
The upper conjunctival fornix is then cut through in the same man- 
ner, along the upper orbital margin. To the inner side both incisions 
meet at the front part of the lachrymal bone. If the conjunctiva is 
normal in its entire extent, it may be saved by severing it from the 
eyeball at the limbus as in enucleation. The exenteration may then 
be performed behind the conjunctiva. (Subconjunctival method of 
Axenfeld.) Both lids can now be easily drawn away from each 
other with tenacula, so that the entire orbital border is exposed. 
The periosteum is incised along the bony margin of the orbit, and, by 
means of a periosteal elevator or closed, somewhat curved, scissors, 
pushed between bone and periosteum, the entire contents of the 
orbit are shelled out with great rapidity on all sides as far as the 
posterior end of the orbit. Only at the inferior orbital fissure and at 
the posterior crest need we make use of the scissors to divide the 
fascial strands. With proper care we can easily avoid injuring 
the thin bones of the orbit. Finally, the entire mass is divided as far 
back as possible by several snips of the scissors. Energetic tampon- OPERATIONS ON THE ORBIT 
165 
ing prevents serious hemorrhage, and we are rarely forced to use the 
cautery. The orbital cavity is now tightly packed, gauze is pushed 
beneath the lids so that they will not fall into the orbit, and a pres- 
sure-dressing applied. A long time ensues before the wound of the 
orbit begins to be covered with granulations, and several weeks pass 
before the entire cavity has become filled. During this time it must 
be kept loosely packed. 
In the end, however, the lid is always drawn far back by scar- 
tissue, and the use of an artificial eye is not possible. The palpebral 
conjunctiva may even become a burden to the patient on account of 
its secretion and, therefore, nothing is lost if in the exenteration of 
the orbit the lids are also removed. Such an operation is easier, and 
the large wound in the skin can be so diminished by a few vertical 
sutures that only the normal width of the palpebral fissure remains. 
After cicatrization is completed, the area of the orbit forms a fossa 
covered with epithelium. The appearance is not much improved 
by transplanting skin-flaps for covering the raw surface. Much of 
the disfigurement is removed by the prothesis of Henning. 
OPERATIONS ON THE ORBIT 
Indications.—Acute or chronic inflammation, foreign bodies, 
and tumors. 
If operation is required to reach the anterior portion of the orbit, 
access may be obtained through an incision in the lids at the margin 
of the bony orbit; through an opening made in the transitional fold 
of the conjunctiva; or by a cut through the skin and underlying tis- 
sues along the upper orbital margin. 
Operation through the upper transitional fold is preferable to an 
incision in the eyelid, since external scars are avoided and there is 
no danger of injury to the branches of the facial nerve which supply 
the orbicularis muscle, but the space secured is limited, even when 
combined with temporary detachment of the muscles. If operative 
interference is to extend to the upper orbital region, this method is 
not suitable, owing to injury of the levator muscle. The operation 
is therefore only indicated for those portions of the orbit toward 
the median line between the superior and internal recti muscles. 
In the lower portion of the orbit, the opening may be made through 
the whole transitional fold, and the space created considerably en- 
larged by an external canthotomy, with turning back of the eyelid. 166 
OPERATIONS ON THE ORBIT 
If the anterior portion of the orbit above the eyeball is to be 
explored, the incision is made along the upper orbital margin, through 
the skin, underlying tissues, and the periosteum. By this method no 
injury is done to the levator muscle. If possible the cut is not carried 
so far toward the median line that the supraorbital and frontal 
nerves are injured, but if these structures cannot be avoided, the 
nerves are exposed and drawn to one side by blunt hooks. The 
insertion of the trochlea is dissected off in connection with a small 
plate of bone, and its union with the periosteum preserved so that 
the superior oblique muscle is not permanently weakened. 
If the incision is made at the lower orbital rim, the infraorbital 
nerve and the insertion of the inferior oblique muscle are carefully 
protected. The bony canal of the nerve is exposed by chiseling and 
the nerve pulled aside. 
The region towards the nasal side of the median line seems to be 
the best entrance to the orbit. If circumstances demand, the 
internal canthal ligament may be detached from its insertion and 
separated with the lid-flap from the orbital wall together with the 
tear-sac, which is freed from its fossa. If the flap is carefully brought 
back in its proper position and fastened with sutures, the normal 
function of the structures is restored and there is no displacement of 
the internal canthus. It is only in cases where the greater portion of 
the ligament is excised that disfigurement at the canthus occurs. 
Among the operations for the purpose of exposing the depth of 
the orbit, the most important is the temporary resection of the ex- 
ternal orbital wall (Kronlein’s operation). 
Resection of the Outer Orbital Wall (Kronlein).—The operation 
permits free access to the orbit back of the eyeball for: (i) Removal 
of tumors, cysts, or large foreign bodies; (2) to facilitate operation 
upon the posterior segment of the eyeball, for instance, the extraction 
of a cysticercus from the interior of the eye, or for resection of the 
sheath of the optic nerve in choked disc (Muller); (3) as a means of 
exploration for purposes of diagnosis. 
Tumors of the orbit may originate from the periosteum, from the 
sheath of the optic nerve, or from other portions of the orbital tissue. 
Resection of the orbital wall serves to indicate whether the removal 
of a tumor can be done with preservation of the other contents of the 
orbit and especially the eyeball. If there is malignant infiltration of 
the orbital tissues, exenteration of the orbit will be required. A bony RESECTION OF THE OUTER ORBITAL WALL 
167 
growth, cyst, or tumor of the optic nerve sheath may often be 
removed with preservation of the eye. 
Anesthesia.—General narcosis is recommended for most of the 
cases, although the operation may be done under local anesthesia 
after the method of Seidel. At the beginning the whole operative 
skin area is infiltrated by an injection of 6 c.c. of i per cent, novocain- 
adrenalin solution, and then the piece of bone to be excised is sur- 
Fig. 106.—The three arrows at the outer orbital wall indicate the directions in 
which, one after the other, the needle has to be pushed towards the lower orbital fissure. 
It is carried in from the outer upper margin of the orbit. The vertical arrow laterally 
from the orbit indicates the position and the direction of the needle for injecting the 
solution at the outer surface of the bone which has to be excised. The needle in the 
drawing is situated along the lower orbital fissure and pushed forward in the direction of 
the foramen rotundum. 
rounded by injection of the same solution. The needle of the syringe 
is inserted at the outer upper angle of the orbit and carried forward 
obliquely inward and downward, and successively toward the 
anterior, the middle, and the posterior third of the lower orbital 
fissure (Fig. 106), and 5 c.c. of 4 per cent, novocain-adrenalin solution 
used for this purpose. In order that the liquid may reach the 
external surface of the bone, the operator with the finger finds the 
posterior margin of the perpendicular frontal process of the zygoma, 
and one finger’s breadth outward from the outer upper orbital angle 168 
OPERATIONS ON THE ORBIT 
the needle is pushed perpendicularly down into the pterygo-palatine 
fossa, and arrives at the posterior surface of the fronto-sphenoidal 
process of the zygoma. In this situation 6 c.c. of the 1 per cent, novo- 
cain-adrenalin solution are injected. Finally, 3 c.c. of the 2 percent, 
novocain-adrenalin solution are injected along the lower orbital fis- 
sure, the needle being pushed into the orbit at its lower outer angle 
and carried in for a depth of about 3 to 4 cm. 
In about ten minutes after the injection has been made the 
operation may be started. After the bone is resected and turned 
Fig. 107.—Incision through the soft tissues for the resection of the outer orbital wall 
after Kronlein. 
out, 2 c.c. of the 2 per cent, novocain-adrenalin solution are injected 
around the nerve at the apex of the orbit to anesthetize the tissues 
within the muscle cone. After ten minutes the operation may be 
continued. Complete anemia of the operative field recompenses 
the operator for the somewhat wearisome preparation. 
Dissection of the Soft Tissues.—The incision in the skin starts 
i cm. above and 2 cm. outward from the external limit of the eyebrow, 
and extends in a flat arch, its convexity forward, in a direction 
downward towards the outer orbital margin, and bends in an arch 
backward horizontally toward the zygomatic arch, where it ends 
perpendicularly below the starting point, about midway between 
the external can thus and the tragus (Fig. 107). The incision divides 
the skin and soft parts down to the deep fascia, and at the orbital 
margin is carried down to the bone. The skin and soft parts are 
dissected loose from their fascial base and the flap is turned outward. RESECTION OF THE OUTER ORBITAL WALL 
169 
Opening the Periosteum.—The knife now incises the periosteum 
along the outer orbital margin, the frontal process of the zygoma, 
and about 1 cm. further backward along the zygomatic arch. The 
periosteum of the entire external orbital border is now loosened 
upward to the base of the zygomatic process of the frontal bone 
and downward to the bottom of the orbit until the inferior orbital 
fissure is reached. The fissure is readily recognized by the elastic 
Fig. 108.—Orbital spatula for retaining the orbital tissue. (Natural size.) 
resistance of the fascia which fills it. The tissues are now drawn 
inward with a broad orbital spatula (Fig. 108), so that there is 
exposed the region of the bone to be excised (Fig. 109). 
Fig. 109.—The skin-muscle flap tilted back. The periosteum of the external orbital 
wall shifted off by elevator. The frontal process of the zygomatic bone and the 
beginning of the zygomatic arch are glistening through the fascia. 
Section through the Bone.—The flap of bone to be resected is 
outlined as follows: 
Below, the incision passes through the origin of the frontal process 
of the zygoma, and runs into the anterior end of the lower orbital 
fissure. Above the zygomatic process the frontal bone is chiseled 170 
OPERATIONS ON THE ORBIT 
through slightly above the zygomatic-frontalis suture, and the 
incision continued through the external orbital wall to i cm. behind 
the anterior end of the lower orbital fissure (Fig. i io). 
As these bones are hard, the mallet and chisel are not to be used, 
because of the danger of splintering the bone and causing permanent 
disfigurement. The circular saw severs the frontal process quickly 
Fig. no.—The incisions through the bone are indicated by the full black lines. 
O.F. = Os frontale, S.z.f. = Sutura zygomatico-frontalis, P.f. = Processus frontalis of 
the Os zygomaticum, F.i. = Fissura orbitalis inferior, O.z. = Os zygomaticum. 
and smoothly, but if not available, a wire-saw, as proposed by 
Magitot, may be introduced from the temporal fossa through the 
lower orbital fissure and carried out through the orbit. The section 
is then made in the direction from the fissure to the surface (Fig. in). 
The best means of determining the proper channel for the saw is 
to push aside the muscles of the fossa, insert a hollow sound at the 
angle of the body and the frontal process of the zygoma, and push 
it forward along the outer surface of the process in a horizontal direc- 
tion, deviating slightly backward. The usual mistake is to seek the 
opening above the direction indicated. The periosteum of the fossa 
must not be disturbed, as it supplies the nourishment of the bone. 
After the probe has been properly passed, the wire-saw is easily drawn 
through with forceps. The saw allows a smooth section of the bone RESECTION OF THE OUTER ORBITAL WALL 
171 
without splintering. The frontal process of the zygomatic bone is 
thereby cut through at its origin, starting from the lower orbital 
fissure. The upper section of the bone starts slightly above the 
zygomatic-frontal suture and continues to a depth of about 5 mm. 
A fine saw is used. The inner end of the incision is inclined a little 
Fig. hi.—The orbital tissue pushed back by the spatula. Wire-saw introduced 
from the temporal fossa through the lower orbital fissure into the orbit. Above 
beginning of the incision through the bone with the saw. 
downward, otherwise the section falls too far into the upper orbital 
margin. The remainder of the section is made with mallet and 
delicate chisel, the cutting edge of which forms an oblique angle with 
Fig. 112.—Delicate chisel with oblique cutting edge. (Natural size.) 
the long axis (Fig. 112). The incision ends about 1 cm. behind the 
anterior end of the lower orbital fissure. Delicate splinters of the 
bone are carefully removed. Recently an electric saw, which con- 
sists of a small electric motor held in the hand, with saw attached, 
has been employd with success for making the osteoplastic resection 
of the outer orbital wall. 
Tilting of the Flap.—The piece of bone, triangular in shape, is 
now freed, leaving it connected only with the soft tissues of the 172 
OPERATIONS ON THE ORBIT 
temporal fossa. It is pulled forward slightly, swung outward and 
backward, and fixed in this position with hooks (Fig. 113). 
The orbital tissues are now freely accessible, and, after the 
periosteum has been opened, tumors situated beyond the muscle 
cone in the external portion of the orbit are readily reached. The 
incision through the periosteum is best made in the sagittal direction 
from before backward. 
If an operation is required within the cone of muscles, blunt 
hooks are used to separate the muscles. If sufficient space is not 
Fig. i 13.—-The excised piece of bone tilted outward and fixed by a hook. The access 
to the orbit exposed. 
secured by this means, the external rectus must be cut through, the 
two divided ends being caught with threads, so that the muscle 
may be brought together afterwards. 
Replacing the Bone-Flap.—After completion of the orbital opera- 
tion, the flap of bone is turned inward, pulled slightly forward, and 
fitted into the gap. If the cut through the orbital margin has been 
made without splintering of the bone, the bone joins faultlessly 
without any unevenness. The incision in the periosteum is closed 
with catgut sutures. If a large tumor or foreign body of considerable 
size has been removed, a small drainage tube or strip of gauze is 
inserted for a few days. The skin-wound is closed with silk sutures. 
In applying the bandage care is taken that the cornea is not injured, 
if the case is one of an exophthalmos that is not covered by the lid. 
A thick layer of boric acid ointment is inserted into the conjunctival 
sac, and the lids covered with gutta-percha tissue. If required, a INCISION OF OPTIC NERVE SHEATH 
173 
moist chamber bandage may be applied or a temporary tarsorrhaphy 
performed. The skin sutures are removed in from five to six 
days. 
Results;—Numerous complications may occur after the operation, 
including infection, permanent palsy of the external rectus, with 
internal strabismus and diplopia, and enophthalmos. Disfigure- 
ment may be avoided, as previously mentioned, provided infection 
does not occur with death of the bone-flap. Corneal complications 
are uncommon under proper care. 
Incision of Optic Nerve Sheath for Choked Disc (Muller).—The 
opening of the optic nerve sheath, with excision of a portion of the 
sheath, has been done by Muller, in connection with the Kronlein 
procedure. 
Indications.—The operation is recommended for choked disc in 
which internal treatment has been without result, and where a 
diagnosis of a tumor of the brain can be excluded or is doubtful. 
It may be employed in cases of tumor of the brain in which the 
exact location cannot be made or the growth cannot be removed. 
The operation is suggested as a substitute for opening of the skull 
for the relief of intracranial pressure, but it is a question whether 
it is as safe and as satisfactory a method as decompression-trephining. 
Operation.—After resection of the external orbital wall by the 
Kronlein method, a fixation-suture is fastened through the conjunc- 
tiva at the insertion of the external rectus muscle, and the eyeball 
drawn forward, which stretches the muscle and the optic nerve. 
i\bove the upper border of the muscle the orbital fascia is incised 
and the optic nerve exposed. Immediately behind the eyeball a 
rectangular piece of the sheath of the optic nerve is excised with 
scissors and forceps, measuring 3 to 4 mm. wide and about 6 mm. 
long. An ampulla of the sheath is only exceptionally found. The 
bone-flap is replaced, and the dressings and after-treatment are the 
same as outlined for the Kronlein operation. 
Results.—In a certain number of cases the choked disc becomes 
regressive on the side of the operation and occasionally on the other 
side, and there is also a favorable influence on the other symptoms, 
such as headache and dizziness, which accompany the intracranial 
pressure; in other instances no effect is noticed. The operation is 
not without danger to the optic nerve. Sometimes immediately 
after the operation the sight is seriously reduced, either from hemor- 174 
OPERATIONS ON THE ORBIT 
rhage into the substance of the nerve, injury from the contact of the 
instruments, or by excision of a piece of the pial sheath, although the 
latter could only occur from tearing the fibers of the nerve. 
As the purpose of the operation is to save the sight by relieving 
the pressure on the optic nerve, it must be performed before exten- 
sive degenerative changes have developed that lead to ultimate 
atrophy of the fibers of the nerve. 
Whether the results secured by the operation show it to be a justi- 
fiable and valuable procedure in the cases in which it is indicated 
must be later determined with more extended experience. CHAPTER X 
EXTRACTION OF SENILE CATARACT 
General Considerations.—If a patient is enjoying usual health, 
extreme old age and the senile changes associated with advanced 
years are not contraindications to the removal of a cataractous lens. 
In fact, the restoration of sight of old people exerts a beneficial influ- 
ence on the preservation of their mental powers. Even disease, if 
not likely to lead to death in a short time, is no contraindication to 
extraction of cataract. As a routine practice a general systemic 
examination is made to enable the operator to correct any ailment 
that may exist and which might influence the success of the opera- 
tion, and to prepare him to meet any complication that might arise 
during the after-treatment. By suitable treatment the patient is 
brought into the best possible physical condition before operation. 
A complete examination of the urine is never neglected, and, should 
a high percentage of sugar be found, operation is postponed until 
the sugar excretion is corrected. During the after-treatment large 
doses of sodium bicarbonate assist to prevent the development of 
diabetic coma. If the patient has not been under observation during 
the incipiency of the cataract, and the condition of the interior of the 
eye is not known, a test is made with two lighted candles to determine 
if there is light-projection in all portions of the field. 
The accompanying illustrations have all been made from photographic views, and are 
intended, primarily, to reproduce faithfully the position of the hands of the operator as 
well as those of his assistant during the different operative procedures. This can be 
accomplished better by a photograph than by the most extensive description. In so far 
as possible, the operative procedure on the eye itself is also delineated sufficiently well in 
the same illustration. However, when it seemed necessary, the operation on the eye has 
been represented by itself in accompanying diagrams. The photographs were taken 
from the operator’s side (that is, from the right side of the patient as he lies upon the 
table). In order to render recognition easier, the hands of the operator are indicated by 
the letter o; those of the assitant, by the letter a. In all instances the operator sits to the 
right of the patient, while the assistant stands to the left. The relative positions assumed 
by the hands and the fingers of the operator and assistant should be observed. The 
figures show clearly how the hands are supported, how the instruments are held, etc. 176 
EXTRACTION OF SENILE CATARACT 
In order that there be no complication during the course of heal- 
ing, two conditions must be fulfilled—thorough cleanness of the 
conjunctival sac and careful asepsis during the operation. 
The conjunctival culdesac cannot be made absolutely sterile, but 
an aseptically conducted operation with a clinically normal con- 
junctiva almost always takes a course without infection. It is not 
possible in a large clinic to establish in every case the absence of 
pathogenic germs by bacteriologic examination and by cultures, but 
these tests should be made in all instances when the conjunctiva is 
hyperemic or slightly thickened or in the presence of secretion, 
however trifling. 
Especial attention is to be directed to the lachrymal sac, and 
should the slightest amount of fluid be pressed out of the puncta, 
extirpation of the sac must be performed before operation upon the 
cataract. In cases which show only slight symptoms of an affection 
of the lachrymal sac, such as epiphora or unilateral conjunctival 
congestion, the lower punctum is to be dilated with the conical 
probe, and a sterile fluid injected through the canaliculus. If the 
duct is normal the fluid will pass quickly into the nose, but should 
stenosis exist the injection will come through drop by drop. Passage 
of a probe will indicate when the mucous membrane of the sac 
is thickened. Any affection of the sac is an indication for its total 
extirpation and cauterization of the puncta to destroy all connection 
with the conjunctiva. Systematic bacteriologic examination at 
intervals of eight days is to be made until the conjunctiva is free from 
the presence of streptococci or pneumococci. The presence of xerosis 
bacilli or a few staphylococci are no contraindication to the cataract 
operation. During the time that the patient is under observation a 
solution of sulphate of zinc (3dj to i per cent.) is dropped into the con- 
junctival sac three times daily, and, if the secretion is excessive, this 
is supplemented by applications to the conjunctiva of a 2 per cent, 
solution of silver nitrate. If these precautions are taken, other 
measures are superfluous and are not recommended, such as occlusion 
bandage before operation, extraction of the lashes, etc. 
Time of Operation.—When a cataract develops in each eye, the 
eye with the more advanced lenticular opacity is operated upon as 
soon as disturbance of vision has progressed to a point where the 
patient can no longer pursue his occupation, irrespective of whether 
the cataract is completely mature or not. The extraction of an MONOCULAR SENILE CATARACT 
177 
immature cataract offers as favorable conditions for good results as 
the extraction of a fully ripe one. 
The probability of the retention of unclouded lens remnants, 
when operating on an immature cataract, is usually not much greater 
than in the stage of ripeness. The clinical diagnosis of maturity 
refers only to the anterior cortex of the lens. The posterior cortical 
portion may be transparent and therefore remain unobserved during 
the extraction, especially as it is not massaged out of the eye at once 
owing to its adhesion to the posterior lens capsule. If the.posterior 
cortex is farther advanced in opacity than the anterior, the lens 
substance separates from the capsule and is readily expressed by 
massage, while the use of the capsule-forceps to tear a large central 
piece of the capsule secures the same results for the anterior lens 
fibers. Even when greater masses of lens particles remain in the 
eye, they are quickly absorbed if the lens sac remains permanently 
opened by the removal of a large piece of its anterior portion by the 
forceps. Any procedure for artificial ripening of the immature lens 
should be avoided, and the performance of the so-called preliminary 
iridectomy is of no special advantage, and is only indicated in central 
opacity of the lens in which dilatation of the pupil consequent on 
the iridectomy sufficiently improves vision. (See optical iridectomy, 
page 283.) 
Monocular Senile Cataract.—If opacities develop in the lens of 
one eye, while the other eye has good vision, no operation is indicated 
until the cataract has become completely mature. When this point 
is reached, even though the other eye continues to have normal sight, 
extraction of the cataract is advisable. 
Serious consequences occasionally arise if the cataract becomes 
hypermature, such as secondary glaucoma and luxation of the lens, 
which endanger the integrity of the eye. In any event the degenera- 
tion of the lens, with thickening of the capsule, deposit of chalk in the 
capsular sac, atrophy of the zonula, and liquefaction of the vitreous 
body is likely to complicate the operation and make the prognosis 
less favorable. The unequal vision of the two eyes, which is alleged 
as an objection to unilateral extraction, causes discomfort only in a 
few, usually nervous people, and is of short duration. It is more 
than balanced by the increase in the field of vision and the conscious- 
ness of a reserve eye in the event of injury or failure of the 
other. 178 
EXTRACTION OF SENILE CATARACT 
Preparation of the Patient.—On the day before operation the 
patient is trained to look up and down, as directed, without move- 
ment of the head, and instructed as to his behavior during and after 
operation. Sneezing may be suppressed by firmly pressing the tip 
of the thumb toward the palate at the point of the foramen incisi- 
vum. Bromids may be administered in nervous patients, and 
codein in those that are inclined to cough. The bowels are to be 
emptied previously, and no constipation is to be allowed during the 
after-treatment. A simple, easily digested diet is ordered. 
Preparation of the Eye.—One or two drops of a 3 per cent, solu- 
tion of cocain are dropped into the conjunctival sac frequently for 
ten minutes. The beginning dilatation of the pupil is an indication 
that the cocain has exerted its action on the iris. The skin of the 
closed lids and the surrounding parts is wiped with benzin to remove 
all fatty material, and then carefully cleaned with a liquid neutral 
eye soap. The skin is then washed with a 1-2000 bichlorid solution, 
but this is omitted in persons inclined to eczema. The conjunctival 
sac is now thoroughly douched with physiologic salt-solution, par- 
ticularly the upper and lower culdesacs and the recesses in the region 
of the inner canthus, and the conjunctival surface of the everted lids 
gently rubbed with pledgets of cotton dipped in the solution. The 
entire region of the eye is then covered with a sterile, moist gauze 
dressing. During operation the other eye is kept closed by a gauze 
pad, unless the patient cannot turn the eye to be operated on in the 
desired direction without having the seeing eye uncovered. 
Cocain usually suffices to give perfect anesthesia. In nervous 
and unruly patients an injection of morphia-scopolamin may be 
required to ensure perfect quietness. No mydriatic is employed 
before the operation, and none after unless special indications point 
to its use. 
Akineses.—In order to remove the twitching of the lids during 
operation, which may be a troublesome and even dangerous complica- 
tion, the orbicularis muscle may be temporarily paralyzed by the 
method of Van Lint-Rochat. This consists of injections of 2 to 4 c.c. of 
a 2 per cent, novocain-adrenalin solution about ten to fifteen minutes 
before operation. The needle of the syringe is inserted in the skin of 
temple 1 cm. posterior to the outer canthus, and pushed through 
the muscle to the bone. It is first carried perpendicularly upward 
along the upper orbital margin, and one-half of the solution injecte d STERILIZATION OF HANDS AND INSTRUMENTS 
179 
as the needle is slowly withdrawn. The needle is then pushed forward 
along the lower orbital margin, and the second half of the solution 
injected in this area. The lids soon become lax, and in about fif- 
teen minutes the orbicularis muscle is either paralyzed or sufficiently 
weakened that its contraction cannot disturb the operation. In 
about an hour the lagophthalmos entirely disappears. This temp- 
orary palsy has no effect on the healing of the wound, as the relaxed 
lids are closed by the dressing, which may be applied moist. If the 
needle is introduced beneath the skin, and the injection made in this 
situation instead of deep into the muscle, there will be no effect. 
Fig. 114.—Fixation forceps. 
The superior rectus muscle may be temporarily paralyzed by the 
injection of 0.5 c.c. of the novocain-adrenalin solution well back 
beneath the tendon. The tendon is grasped with forceps as far back 
as possible, and the needle carried under the muscle a distance of 
about 2 cm. before the solution is injected. This insures that there is 
no accumulation of the injected fluid beneath the conjunctiva at the 
limbus where the incision is to be made. The weakening of the mus- 
cle is soon apparent, the upward rotation of the eye is lost, and there 
is no resistance to drawing the globe down with the forceps. The 
inferior oblique allows the patient to turn the eyeball up if he is 
directed to do so. 
Sterilization of the Hands and Instruments—Both surgeon and 
assistant thoroughly scrub the hands with soap and water and bichlo- 
rid solution and dry them with sterile towels, cover the head with a 
sterile cap, and wear a sterilized mouth mask to guard against possible 
infection of the wound while giving necessary directions. Sterile 
dressings are placed around the patient’s head and neck, with light 
gauze over the nose and mouth. 
All instruments are boiled for three minutes in a 1 per cent, 
solution of carbonate of soda. It is exceptional for the blade of the 
knife, if of the proper hardness, to suffer any damage, and we have 
repeatedly performed a number of extractions with the same knife 
which showed no dullness from the frequent boiling. The instruments 
are lifted from the boiling water to a large flat tray filled with sterile 180 
EXTRACTION OF SENILE CATARACT 
physiologic salt-solution of body temperature. The sterilizer is 
close beside the operator, and no instrument touches the eye a second 
time until it has been re-sterilized by boiling. Duplicates of instru- 
ments frequently required, such as Daviel’s spoon and spatula, should 
be ready. 
During the operation, any secretion or blood is removed by small 
pledgets of absorbent cotton, which are kept soaked in a sterile 
physiologic salt-solution. 
EXTRACTION WITH IRIDECTOMY 
The technic of the various steps of the operation will first be con- 
sidered, and then the complications which may occur in each. 
Fig. 1x5.—Beginning of the cataract-incision in the left eye. While the assistant 
holds the eye open according to the rules given on page 341, the forceps held in the left 
hand grasp the eye below, close to the limbus and exactly in the vertical meridian. The 
patient during this procedure looks well downward. The knife held in the right hand 
with its edge directed upward is applied exactly at the limbus and is held horizontal and 
parallel to the plane of the iris. 
Fixation of the Eye (Figs. 115 and 116).—It is the custom in our 
clinic to sit at the right of the patient who is lying upon the operat- EXTRACTION WITH IRIDECTOMY 
181 
ing table. The incision is made from the outer side, on the right eye 
with the left hand, and on the left eye with the right hand, the other 
hand fixing the eyeball. An ordinary pair of toothed fixation forceps 
(Fig. 114), with three dentations, held between the thumb and fore- 
finger, is applied perpendicularly to the sclera near the lower part of 
Fig. 116.—Beginning of the cataract-incision in the right eye, the operator and, the 
assistant occupying the same positions. The eye is fixed with the right hand, the knife 
is held in the left. 
the limbus, and grasps tightly a fold of the conjunctiva exactly in the 
vertical meridian. If the conjunctiva is seized at even a slight dis- 
tance from the limbus, fixation will not be firm. The forceps may 
be moderately pressed toward the eye in order to pick up also the 
connective tissue beneath the conjunctiva to avoid tearing out of 
a fold of conjunctiva. After the forceps are closed, traction is made, 
which causes the eye to be brought slightly forward from the orbit. 
The operator at the right of the patient finds no difficulty in fixa- 
tion of the right eye, as the forceps held in the right hand are placed 182 
EXTRACTION OF SENILE CATARACT 
directly opposite to the right eye, but it is not so easy, especially for 
the beginner, to fix the left eye from the position mentioned. To 
this end, the left upper arm, with the elbow in a strongly flexed 
position, is pressed firmly against the chest, while the hand, itself 
bent dorsally, guides the forceps, held between thumb and first and 
second fingers, vertically to the lower portion of the limbus, where the 
fold is raised. Through this unaccustomed position of the arm, the 
beginner easily falls into the error of pressing upon the eye instead of 
pulling forward, a mistake that is frequently the cause of unpleasant 
complications. 
The fold of the conjunctiva must be raised exactly in the vertical 
meridian. If the operation is performed with an iridectomy, it is 
essential that the incision be made accurately above, so that the colo- 
boma, which corresponds to the central portion of the cut, will also 
be directed upward, and be completely covered by the upper lid. 
If the eyeball is grasped sideways, for example, at the end of 
the horizontal meridian, rotation of the globe is unavoidable, as the 
eye must be drawn continually downward during the incision in order 
to expose the upper corneal margin. This rotation places the incision 
in an oblique and undesirable position, and with it also the coloboma. 
In inserting the knife, the eye may rotate slightly out of its position, 
but this cannot further displace the incision. By means of the ele- 
vated fold the eye is drawn not merely downward but also slightly 
forward. During the incision the patient is directed to look well 
downward. 
The incision (Figs. 115 to 120) is probably the most difficult part 
of the operation. It is made upward with the narrow Graefe cata- 
ract-knife and includes about one-third of the corneal periphery, 
and in its entire length is in the limbus or close behind it. 
The knife, with the edge upward and the blade parallel with the 
iris, is held horizontally between the thumb and first and second 
fingers, and the hand is supported by the little finger placed on the 
patient’s head (Figs. 115 and 116). The point of the knife pierces the 
eye at the limbus, 1 mm. above the end of the horizontal meridian, 
and is pushed without a pause through the anterior chamber in 
order that the counter-opening internally is made in a symmetrical 
position. The chief factor in the success of the incision is the avoid- 
ance of any pause or retrograde movement. THE INCISION 
183 
The beginner finds it difficult to make the counter-puncture in the 
proper position, and to his astonishment the knife emerges in the 
sclera behind the limbus. The reason for this error is clearly under- 
stood from a study of the anatomical relations of the anterior chamber 
(Fig. 167). The limbus extends much further (2 mm.) anteriorly 
than the angle of the anterior chamber. If the knife is brought as far 
as this angle, the inevitable consequence is that the counter-puncture 
Fig. 117.—Diagram showing the point of the knife directed toward a point in the cornea 
about 1 mm. within the limbus, so as to begin the counter-puncture. 
is performed in a faulty place far beyond the limbus. In order that 
it be made either directly at the limbus or close to it, the knife must 
be directed to a point in the cornea about 1 mm. from the limbus 
(Fig. 117), where, as viewed from in front, transparent cornea is still 
present. The impression thus given is that the knife will appear at 
Fig. 118.—Diagram showing the point of the knife thrust just through at the limbus' 
the surface in transparent cornea, but to the beginner’s surprise the 
point emerges in the limbus (Fig. 118). He is, therefore, usually told 
to direct the point of the knife toward a spot in the cornea, situated 
about i mm. distant from the limbus. 
As soon as the counter-puncture is made, the knife, as it is pushed 
across the anterior chamber, is steadily carried upward without 
Fig. 119.—The knife is pushed forward in the same direction in which puncture and 
counter-puncture are made, so that a good part of the incision is made. In this manner 
a considerable part of the blade has been employed for this part of the incision. 
pause, at all sides parallel to the limbus, so that a large part of the 
incision is effected by this one movement (Fig. 119). This brings the 
blade above the pupillary border and prevents premature escape of 
the aqueous and also injury to the iris. After the greater part of the 184 
EXTRACTION OF SENILE CATARACT 
blade has been passed across the anterior chamber, the incision is 
continued and frequently completed as the knife is drawn back, or 
it is at least finished with the next forward movement. With a 
keen-edged knife the incision can be completed in two or three draw- 
Fig. 120.—Incision on left eye. The cornea-sclera is already cut through and the 
knife is beneath the conjunctiva. In order to cut the flap off short, the knife is turned in 
such a manner that the edge looks forward. The knife is now turned up. Note the 
change in the position of the hands of the operator as compared with Fig. 115. The line 
of the incision in the cornea-sclera, as far as it lies behind the base of the conjunctival 
flap, is designated by dots. 
ing movements. The shorter the sawing cuts the more irregular the 
wound. The inexperienced operator fails to carry the blade forward 
sufficiently after making the counter-puncture, and frequently does 
not begin the upward cut until the knife is drawn back. As the thin- IRIDECTOMY 
185 
nest part of the blade near the point is insufficient to properly close 
the wound opening, the aqueous begins to escape, and the surgeon, 
no longer controlling the long part of the blade, is forced to complete 
the section by short sawing movements. It may even happen that 
in drawing back the knife the point is brought again into the anterior 
chamber. 
The reason that the beginner frequently does not advance the knife, 
in spite of many short sawing movements, lies usually in the fact that, 
instead of pushing the edge upward, he presses the blade backward 
toward the sclera. 
During the incision the knife must remain exactly parallel to the 
iris, as any turning of the edge forward or backward would naturally 
Fig. 121.—Iris-forceps. 
result in a deviation of the cut, either into the cornea or into the sclera. 
Only after cutting through the sclera, and the knife is seen under the 
conjunctiva, is it recommended to turn the blade through an arc of 
90 degrees (Fig. 120), so that the edge looks anteriorly. This secures a 
conjunctival flap that is much shorter than if the knife in the previous 
position had been permitted to cut through. A long conjunctival 
flap is an unpleasant impediment to a proper performance of the 
operation. The incision having been completed, the forceps are 
released and the rest of the operation finished without fixation. 
Iridectomy (Figs. 123-126).—The patient looks well downward, 
and the closed iris-forceps (Fig. 121), held in the left hand between 
thumb and forefinger, with the concavity of the blade forward, are 
introduced vertically through the wound in front of the iris to the 
pupillary margin, opened slightly, and a narrow fold of the iris seized, 
drawn forward and quickly cut off with the iris-scissors (de Wecker 
pince-ciseaux, Fig. 122) held in the right hand (Figs. 123 to 126). 
The hand guiding the forceps must take a position of marked flexion, 
Fig. 122.—Iris-scissors (pince-ciseaux, de Wecker). 186 
EXTRACTION OF SENILE CATARACT 
in order to introduce the instrument exactly from above. Should 
the conjunctival flap interfere with the introduction of the forceps, 
it may be turned down over the cornea by aid of the closed scissors, 
while the forceps press the scleral edge of the wound slightly 
backward. 
The arms of the pince-ciseaux should be directed upward during 
the excision (Fig. 123), to secure a narrow coloboma in the form of a 
Fig. 123.—The iridectomy. The eye is no longer fixed. With the thumb of the 
right hand, the assistant holds the upper lid up from the side in such a manner that the 
operator is not hindered in inserting the closed iris-forceps directly from above through 
the wound to a point near to the pupillary margin. The right hand holds the iris- 
scissors already opened close by, ready to quickly cut off the iris as soon as it is drawn 
forward. For the sake of clearness the conjunctival flap is not represented on this and 
the following figures. 
pointed arch. It is, however, no mistake to make the cut with the 
arms of the scissors held parallel to the limbus. 
Opening the Anterior Lens Capsule (Figs. 129 to 131).—This may 
be done with the capsule-forceps or the cystotome, but our preference 
is the capsule-forceps (Figs. 127 and 128). The patient looks well OPENING THE ANTERIOR LENS CAPSULE 
187 
downward, and the operator holds the forceps in the right hand 
between the thumb and forefinger, raises the upper lid with his left 
hand, while the assistant draws the lower lid slightly away from the 
eye. The closed instrument is introduced vertically from above 
Fig. 124. 
Fig. 125. 
Fig. 12.6 
Figs. 124 to 126 show in natural size the maneuvers in seizing and extracting the iris. 
Fig. 124.—The blades of the iris-forceps held close to the pupillary margin have just 
been opened. 
Fig. 125.—The blades have been closed and have seized a fold of the iris. 
Fig. 126.—The portion of the iris, which has been drawn forward, is cut off by the 
scissors brought from below. 
(hence a position of the hand analogous to that in iridectomy), and 
pushed forward into the anterior chamber until the dentated parts 
Fig. 127.—Capsule-forceps open (side view). 
Fig. 128.—Capsule-forceps closed, showing the toothed portions only in contact. 
of the arms lie in the lower half of the pupil, while their posterior 
portion is situated in the coloboma. 
The forceps must be in such a position that both arms, when 
opened, glide along the surface of the anterior capsule (Fig. 130). 188 
EXTRACTION OF SENILE CATARACT 
A common mistake is to hold the forceps obliquely so that only one 
arm lies against the capsule, while the other rests a greater or lesser 
distance away in the chamber. After the forceps has been placed 
properly on the capsule, with the teeth directed inward, the instru- 
ment is opened as widely as the size of the pupil permits. A slight 
Fig. 129.—Opening of the capsule. The eye is not fixed. The operator himself is 
holding the upper lid elevated with his left hand, while with the right he is just beginning 
to introduce parallel to the plane of the capsule the closed capsule-forceps. The assis- 
tant holds the lower lid slightly away from the eye, not only to freely expose the cornea, 
but also to prevent any pressure on the eye by the lid should it be forcibly contracted by 
the patient. The other hand of the assistant holds the spoon directed toward the upper 
lid in such a manner that he can bring it at any time and at once beneath the lid, if the 
patient should begin to wince and there would be danger of his pressing the upper lid into 
the wound. 
degree of pressure is then exerted in the direction of the lens, the 
forceps again closed, and a fold of the capsule seized between the 
teeth (Fig. 131), and torn loose from its surroundings by a slow 
pulling movement. A still greater opening may be obtained by USE OF THE CAPSULE FORCEPS 
189 
permitting the arms to push the pupillary margin of the iris gently 
backward. The separated piece of capsule must be drawn slowly 
from the eyeball in order that it be not detached from the forceps 
and left folded up in the wound. 
After withdrawing the forceps it is desirable to ascertain that the 
piece of capsule is in its grasp and does not by any mischance remain 
Fig. 130.—Diagram showing both blades of the capsule-forceps widely opened glid- 
ing over the anterior capsule. 
Fig. 131.—The blades have been closed and have grasped between them a fold of 
the capsule which is now being pulled out. 
Fig. 130. 
Fig. 131. 
behind in the wound. Ordinarily, there is obtained a round piece of 
the anterior capsule, which is usually the size of the pupil or much 
larger. The degree of pressure needed to raise up a fold of capsule 
is very slight, but if greater than it should be there is no danger of 
Fig. 132.—Sharp hook for incising anterior lens capsule. 
dislocating the lens, as the soft cortical material back of the capsule 
gives way to the pressure and slips aside. To avoid seizing the iris, 
the forceps are so constructed that, when closed, the posterior por- 
tions of the arms remain apart from each other, and besides, in 
raising up the fold of the capsule, the forceps are so held that only the 
toothed edges impinge, while the posterior parts of the arms are free 
in the chamber. In extraction with iridectomy this factor plays 
no role, as the posterior portions of the arms lie within the confines 
of the coloboma, but in extraction without iridectomy, it is impor- 
tant, by these precautionary measures, to prevent pinching the iris. 190 
EXTRACTION OF SENILE CATARACT 
Opening of the anterior capsule by means of the pointed tenacu- 
lum (Fig. 132) or the cystotome (Fig. 133) is relatively easier. The 
tenaculum should be made to slide down close to the posterior surface 
of the cornea and parallel to it, so as not to become entangled. When 
it reaches the pupillary area, it turns through an arc of 90 degrees 
until the point is directed backward. It is then brought into contact 
with the anterior lens capsule, and several superficial cuts are made 
in various directions. During this procedure, no degree of force is 
Fig. 133.—Cystotome. 
either necessary or permissible. The instrument is withdrawn from 
the eye in the same manner as it was introduced, that is, parallel to 
the corneal surface and inverted. 
The great advantage of the capsule-forceps, which outweighs the 
disadvantage of its somewhat more difficult manipulation, lies in the 
fact that a large opening is made in the anterior capsule directly in 
the pupillary area. The result of this loss of tissue is that the cap- 
sule cannot produce optical disturbances later on. Again, the 
remnants of the cataract left behind in the capsule-sac are exposed to 
the action of the aqueous humor, with the result that, even in the 
operation for unripe cataract or when a large number of cataract 
remnants are present, they usually undergo spontaneous absorp- 
tion soon after the operation. We therefore do not employ irri- 
gation of the anterior chamber to remove particles of lens, and 
believe the procedure is calculated to do more injury than good, sub- 
jecting the eye to the danger of infection, to iritic irritation, and to 
injury of the corneal endothelium, with subsequent cloudiness of 
the cornea. 
Expression of the Cataract (Figs. 134 and 135).—The patient 
looks downward; the eye is not fixed. While the upper lid is raised 
by the thumb of the left hand, the forefinger of the right hand begins 
to exert pressure through the lower lid in an anterior-posterior direc- 
tion against the region of the lower corneal margin (Fig. 134). The 
immediate result is that the lens rotates upon its horizontal frontal 
axis and its upper edge turns anteriorly and presents in the wound, 
which now begins to gape. EXPRESSION OF THE CATARACT 
191 
From the moment the edge of the lens presents in the wound, the 
direction of the pressure is to be made from below upward, as a fur- 
ther continuance of the backward pressure would cause the vitreous 
to appear. The lens is now pushed up and out of the wound by a 
Fig. 134.—Expression of the lens. The manner in which the operator holds his 
hands should be observed. With the thumb ot his left hand, he raises the upper lid and 
at the same time pulls it slightly away from the eyeball. The forefinger of the right 
hand exerts pressure on the lower half of the cornea through the lower lid; this causes 
gaping of the wound and the edge of the lens presents in the wound. The assistant holds 
the spoon ready, on the one hand, to care for the upper lid and, on the other, to roll the 
lens completely out of the eye after it has protruded half way. 
stroking movement exerted on the eye through the lower lid. It is 
not permissible, however, to stroke upward above the middle of the 
cornea, as this would compress the wound and cause the lens to 192 
EXTRACTION OF SENILE CATARACT 
retreat into the eye. As soon as the upper half of the lens has passed 
the wound, the assistant applies the spatula to its margin and 
removes the cataract from the eye (Fig. 135). At the same time the 
operator ceases pressure. The presentation of the lens-border in the 
wound can be facilitated by a slight depression of the scleral edge of 
the wound through the aid of Daviel’s spoon. In the average case, 
however, this is not necessary, and depression is employed only 
when the delivery of the lens is difficult. 
After the exit of the lens, the upper lid is guided carefully down 
over the eye, so as to prevent the wound from gaping. Through 
Fig. 135.—Diagram showing the spoon just about to be applied to the lateral margin of 
the half-delivered lens so as to roll it completely out. 
similar stroking and kneading motions, any retained cortical rem- 
nants are brought out through the wound. The more thoroughly 
this is done, the less likelihood there will be of secondary cataract. 
Sometimes lens remnants are brought up from behind the iris by this 
massage, and the pupil, which at the outset appeared black, turns 
gray again until the lens particles have passed into the wound. 
Occasionally their removal is facilitated by inserting Daviel’s spoon 
into the anterior chamber, but long-continued manipulation is not 
advisable in the endeavor to get the pupil clear. 
As soon as it is seen that the wound shows an inclination to gape, 
and the vitreous is bulging forward and is in danger of prolapse, it 
is better to desist from attempts at removal of the remnants, and to 
end the operation. It may happen that, although the pupil is 
thought to be free of cortical substance, on the day after the extrac- 
tion it is found to be full of swollen masses of lens material. At the 
time of the operation this material was transparent, and, of course, 
could not be detected. 
Toilet of the Eye (Figs. 136 to 139).—This represents the final 
stage of the operation, and its most important part is the reposition of TOILET OF THE EYE 
193 
the iris. This is accomplished by the spatula, which is held parallel 
to the plane of the iris and pushed carefully through the lips of the 
wound into its angle (Fig. 138). When the anterior chamber is 
reached, gentle pressure is exerted on the iris, one edge of the spatula 
being’turned slightly posteriorly at the same time (Fig. 139). By 
Fig. 136.—Reposition of the inner margin of the coloboma. The eye is not fixed. 
The operator himself holds the upper lid in the same manner as above. His right hand 
introduces the spatula obliquely into the inner angle of the wound, in order to smooth 
the iris down from this point. The lower lid is drawn slightly away by the assistant. 
moving the spatula toward the center of the pupil, the iris is stroked 
into its proper position. Care must be taken not to turn the end of 
the spatula backward, as injury of the hyaloid will occur, with pro- 
lapse of the vitreous. It is of no importance which hand is used in 
this manipulation. We employ alternately, as a rule, the right and 
left hand for the right and left angles of the wound, respectively 
(Figs. 136 and 137). In many cases one can smooth the iris out 
directly from above downward, by holding the spatula vertically. 194 
EXTRACTION OF SENILE CATARACT 
It may happen that the iris does not return to its normal position 
with the entrance of the spatula, because its tissue is relaxed or the 
eye is soft, and the iris, with no posterior support, gives way to the 
pressure of the spatula. Under such circumstances the operator of 
experience carries the spatula behind the iris and presses it towards 
the posterior surface of the cornea, along which the iris can be 
replaced in its normal position. 
Fig. 137.—Reposition of the outer margin of the coloboma.—The operator holds the 
upper and lower lids by means of the thumb and forefinger of the right hand, while the 
spatula is introduced with the left hand from the inner side obliquely into the outer angle 
of the wound and the iris smoothed back. 
The conjunctival flap is now carefully stroked into its intended 
position by aid of the spatula. Occasionally the conjunctival flap is 
caught in the wound, and naturally causes a material delay in its 
closure. 
After the conjunctival sac has been freed of blood and lens 
remnants, the eye is closed and a binocular bandage applied. 
Dressing and After-treatment.—After completion of the cataract 
operation, the conjunctival sac is washed out with sterile salt-solu- 
tion, a pad of gauze and cotton placed over each eye, and a binocular 
bandage applied. The Snellen cup of perforated aluminum (Fig. 140) DRESSING AND AFTER-TREATMENT 
covers the operated eye to guard against mechanical injury, and is 
held in place with strips of adhesive. As the plaster does not adhere 
well to the bearded skin of men, the Fuchs’ lattice is used in the 
195 
Fig. 138.—Diagram representing the eye and spatula during the reposition in 
natural size. For the purpose of reposition the spatula is introduced into the angle of 
the wound between cornea and iris. 
Fig. 139.—In order to accomplish the backward stroking more easily, the spatula is 
rotated a few degrees (set on edge) and then by a suitable movement the angular 
extremity of the sphincter is smoothed down. 
Fig. 138. 
Fig. 139. 
manner shown in the illustration (Fig. 141). The patient is then put 
to bed. Very old persons, especially if they suffer from bronchitis, 
remain seated in a comfortable armchair after the extraction. In this 
way hypostatic pneumonia is best prevented. 
Fig. 140.—The Snellen cup 
In excited and nervous patients, in whom the closing of both eyes 
is likely to provoke a psychosis, the unoperated eye is not covered. 196 
EXTRACTION OF SENILE CATARACT 
The simple omission of the bandage from this eye usually suffices to 
remove all anxiety, and the individual may then keep the eye closed 
spontaneously. 
Drinking men are conceded a sufficient amount of alcohol, and 
users of tobacco are permitted to smoke the following day. The diet 
Fig. 141.—Fuchs’ lattice. 
is restricted to liquids, milk, coffee, and nourishing soups with eggs. 
Diabetics are given 30 grains of sodium bicarbonate daily besides 
the appropriate diet. 
Change of Dressings.—On the day following operation the dress- 
ings are removed from both eyes, the patient keeping the lids closed 
as in sleep, and the lids are gently cleaned with physiologic salt-solu- 
tion. If the margins of the lids are adherent, a simple ointment 
should be used before the dressings are re-applied. The patient is 
directed to open the lids slightly, and the surgeon examines to see if 
there is excessive congestion, if the anterior chamber has reformed, 
and the pupil is round or distorted. The upper lid is not to be raised 
nor the patient directed to look downward unless some complication 
requires that the surgeon inspect the wound. EXTRACTION WITH ROUND PUPIL 
197 
No harm can follow the change of the dressings on the day after 
operation if expertly done, and we deem it inadvisable to wait until 
the third or fourth day before removing the bandage. 
If the eye shows no irritation and the pupil and coloboma are 
black, no atropin will be required, but if there is considerable injec- 
tion and remnants of the cataract are seen in the pupillary area a 
mydriatic is used to prevent attachments of the iris and the lens 
capsule. 
At the first change of dressings the sound eye is not re-bandaged, 
unless the wound remains open and it is necessary to keep both eyes 
quiet. If healing has progressed favorably, the patient is dressed 
by the nurse, and allowed to remain out of bed in an armchair. All 
use of the unoperated eye for close work is forbidden for the entire 
period of the after-treatment. 
The dressings are changed regularly every day, and, at the expira- 
tion of a week, they are omitted in the day time, and a pair of dark 
smoked glasses worn for protection from the light, but at night the 
aluminum cup or lattice is re-applied without any dressings beneath. 
At the end of two weeks after operation the patient may leave the 
hospital, as the wound is so securely cicatrized that no further special 
protection is necessary. It is advisable for patients whose occupa- 
tion demands severe physical labor to rest for several weeks longer or 
perform lighter work. 
EXTRACTION WITH ROUND PUPIL 
The extraction of cataract without iridectomy (complete colo- 
boma) is of considerable optical value, since the dazzling is pre- 
vented by the ability of the pupil to contract under the influence of 
light the same as in the sound eye. Furthermore, the normal pupil 
of old people is usually small, and sight without glasses is relatively 
better. 
The incision is made in the same place and in the same way as in 
the extraction with iridectomy, and the anterior capsule is opened 
with the capsule-forceps. Even though the pupil is not dilated, it is 
not difficult to pick up a fold of the capsule. If the pupil is narrow 
the arms of the forceps push the pupillary margin of the iris aside in 
order to secure a large piece of the capsule. To prevent pinching 
of the iris with the posterior part of the forceps, a check pin keeps the 
two arms apart, and, after a fold of the capsule is picked up, the for- 198 
EXTRACTION OF SENILE CATARACT 
ceps are slightly turned, so that only the toothed parts impinge and 
the posterior portions are free in the anterior chamber. The rigid 
iris in old people often causes some resistance to the passage of the 
cataract through the pupil, so that occasionally the sphincter is torn 
at one or more points. Should the upper pupillary margin stretch 
over the advancing lens, the assistant may facilitate the delivery by 
elevating the edge of the iris with the spatula. Pressure should not 
be excessive so as to avoid prolapse of the vitreous. If it is found 
that the resistance to the passage of the lens is too great, an iridec- 
tomy is to be done. If the vitreous appears, and the iris floats into 
the wound, it is to be excised. Often the iris turns back toward the 
ciliary body, with an apparent large upward coloboma. Through 
this opening the lens may be extracted by the loop or double hook. 
Removal of lens remnants is done in the usual way by stroking 
movements. If the pupil is displaced upwards, the large opening 
above allows the lens particles to be readily massaged out through 
the wound. The iris is then replaced with the spatula the same as in 
extraction with iridectomy. The spatula may be introduced straight 
from above through the center of the wound either in a perpendicular 
or slanting direction, or from the side. 
The tendency of the iris to prolapse into the wound was con- 
sidered by many to limit the method of extraction with a round pupil 
to a few selected cases, but the excision of a small piece of iris tissue 
at its root, as recommended by Chandler, of Boston, and Pfluger, of 
Berne, entirely removed this complication in simple extraction. 
This procedure has recently been strongly advocated by Hess. 
After the removal of the lens and replacing of the iris, fine 
toothed, specially made iris-forceps are introduced into the wound 
and the smallest possible piece of the root of the iris drawn up and 
excised close to the wound with fine curved scissors. In most cases a 
tiny opening (Fig. 142) results, which is often so covered by the 
limbus that it is only perceived when the patient looks upward. 
Occasionally the excised portion of the iris is greater than desired 
and a larger hole is formed, but this is of no serious matter. 
A special forceps for picking up the periphery of the iris were 
suggested by Hess (Fig. 143). As the ends of the forceps are turned 
backward, a minute fold of the iris is readily picked up and drawn 
forward. The lens is removed before the button-hole is made, so 
that there is no danger of the cataract passing through the opening ACCIDENTS AND ERRORS 
199 
and causing lateral lacerations of the iris. When the peripheral 
opening is made the eye is not fixed. In order that the pupil will 
remain small through normal tonicity of the iris-fibers, no atropin is 
instilled before operation, and miotics are not required afterwards. 
The advantages of this method are apparent. Prolapse of the 
iris only exceptionally occurs, less than i per cent, of 
the cases, even should there be a re-opening of the 
wound with sudden escape of the aqueous. There is 
also less tendency for soft lens masses to remain in the 
eye, as the remnants that ordinarily accumulate behind 
the iris escape through the peripheral opening by 
massage. The button-hole lessens the risk of glaucoma 
in extraction without iridectomy. 
With this modification more extractions may be done with 
preservation of a round pupil than by the usual method. The 
operation is not indicated in all senile cataracts. Certain com- 
plicated cataracts, and cataracts in very old people, are best treated 
by extraction with complete iridectomy. The peripheral button- 
hole operation, however, permits the preservation of a round pupil 
Fig. 142.— 
Peripheral 
button-hole in 
the iris. 
in a class of cases where, owing to a flabby iris, or later where the 
iris had to be excised, simple extraction was attempted unsuccessfully. 
On the day following operation, if the anterior chamber is 
reformed, atropin is instilled to prevent posterior synechia and keep 
the capsular opening free for the absorption of any lens remnants. 
Fig. 143.—Iris-forceps after Hess. (Natural size.) 
ACCIDENTS AND ERRORS IN THE CATARACT OPERATION 
The foregoing descriptions concern the uncomplicated operation 
for the extraction of senile cataract. Untoward accidents, however, 
may complicate each step of the operation, and they are described 
and classified under the particular stage in which they may occur. 
Fixation of the Eyeball.—In elderly people the conjunctiva is 
often friable, and likely to be torn by the forceps in fixation. If, after 
the beginning of the incision, the conjunctiva tears and the patient 200 
EXTRACTION OF SENILE CATARACT 
will not voluntarily turn his eyes downward, the inferior rectus or 
preferably the superior rectus will serve as a firm point of fixation. 
It would be useless to seize the conjunctiva in another place, for it 
would tear out again. It is not permissible to bring the knife to a 
standstill while it is in the anterior chamber, as the aqueous humor 
escapes and the iris falls in the way of the knife. If the forceps tear 
Fig. 144.—Sharp-toothed fixation forceps. 
out before the incision is begun, the disadvantage of fixation of the 
muscle is that the knife, in making the puncture, causes a marked 
rolling of the eye. Under these circumstances it is preferable to 
fix the eye with the sharp-toothed forceps (Fig. 144). The sharp 
teeth of the forceps are pressed into the scleral tissue and render 
fixation of the eye independent of the conjunctiva. 
The Incision.—The errors possible in regard to the incision 
concern (A) the position, (B) the length, and (C) the manner in 
which it is executed. 
Fig. 145. 
Fig. 145.—Faulty counter-puncture in the sclera. 
Fig. 146.—Faulty counter-puncture in the cornea. 
Fig. 147.—Faulty position of the incision in the sclera. 
Fig. 148.—Faulty position of the incision in the cornea. 
Fig. 146. 
Fig. 147. 
Fig. 148. 
(A) Position of the Incision.—The principal errors in the position 
of the incision may be conveniently studied under several heads: 
Faulty situation of the counter-puncture (a) too far away from the 
limbus posteriorly in the sclera or (b) anteriorly in the transparent 
cornea; the incision made in the wrong plane, (c) backward toward 
the sclera or (d) forward toward the cornea. The two latter errors 
are therefore in general independent of the situation of the puncture 
and counter-puncture, although mistakes in the position of the counter- 
puncture are often associated with errors in the line of the incision. 
The sketches (Fig. 145-148) indicate the errors clearly arranged—e is THE INCISION 
201 
the point of puncture, a the point of counter-puncture, and the curved 
black line the faulty incision. 
It is exceptional that an error is made in the position of the 
puncture. If the operator understands that it is to be made in the 
sclera immediately back of the limbus, not more than i mm. above 
the horizontal plane, he will select the proper plate, especially as 
there is plenty of time to judge the correct situation. The beginner 
usually enters the knife too far above the horizontal meridian, and 
in consequence the incision is too short. It is only in special 
instances (young patients with small nuclei) that the incision may 
be made higher than the i mm. stated. 
Before discussing the details of the above errors, mention may 
be made of the complications which occur in the passage of the knife 
through the anterior chamber, of which a brief statement has already 
been made. Any pause as the knife is carried across the anterior 
chamber leads to escape of the aqueous, and consequently the iris 
comes forward and falls in the way of the knife. The beginner 
starts to withdraw the knife if the point is caught in a few fibers of 
iris tissue. It is necessary to again emphasize that the incision is 
to be continued without hesitation even if the point of the knife is 
caught in the iris. If only a few fibers have been pierced, they will 
soon cut through if the blade is carried forward. The iris is then 
free without any serious effect of the injury. If the knife has per- 
forated the entire thickness of the iris, the incision is still to be con- 
tinued, although the resulting coloboma is larger than desired. An 
attempt to withdraw the knife to disentangle the iris, and to again 
push the blade forward, would cause still greater injury. Complete 
withdrawal of the knife, and postponement of the operation until 
the anterior chamber is reformed on the following day, is indicated 
if the advancing knife fails to cut through the caught fibers of the 
iris, otherwise, if an attempt is made to push the knife forward, the 
iris is pulled away from its insertion. The evil consequences of an 
extensive iridodialysis justifies interruption of the operation. 
There are two circumstances that contribute to the picking up 
of the iris by the point of the knife on the part of the beginner, 
especially if the cataract to be extracted is swollen and the anterior 
chamber is shallow—one the faulty position of the knife, the point 
being turned too far backward at the moment of puncture, thereby 
penetrating the iris tissue; and the other slowness of the incision, 202 
EXTRACTION OF SENILE CATARACT 
by which the aqueous escapes before the knife has passed upward 
above the pupillary space. 
Faulty Counter-puncture.—In the description of the proper counter- 
puncture, mention is made of the possible errors and how they are 
avoided. The exit point of the knife may be even more than 3 mm. 
behind the limbus, so that one portion of the incision is displaced 
in the sclera and the other mostly in the cornea (Fig. 145). The 
operator tries in vain to get the incision in the proper position in the 
limbus, by turning forward the cutting edge of the knife. Several 
drawbacks originate from this error: 
1. Injury of the ciliary vessels causes a severe hemorrhage, 
and the blood in the anterior chamber obscures the iris and lens 
and renders the subsequent steps of the operation difficult. 
2. The iris falls in the way of the knife and is injured. In the 
properly-situated puncture and counter-puncture back of the limbus 
the knife is in a sufficiently sagittal distance from the iris, but in the 
peripheral incision the knife approaches the iris so closely that 
slight escape of the aqueous carries the iris upon the cutting blade of 
the knife. 
3. Injury of the iris and ciliary nerves is painful, and, as the 
cocain does not produce full anesthesia of these structures, the patient 
winces, which causes the aqueous to escape prematurely and thereby 
favors injury of the iris and lens. If, at the same time, the fixation 
forceps press upon the eye, the lens is dislocated and comes forward 
into the incision or protrudes later through the gaping wound and the 
vitreous pours out behind it. 
If the point of the knife has advanced too far towards the angle 
of the anterior chamber, and the counter-puncture has not been 
started, the handle of the knife may be depressed towards the temple, 
whereby the point of the blade is turned perpendicularly to the sclera, 
in which direction the counter-puncture is performed. Many oper- 
ators often make the counter-puncture in this way, carrying the 
knife behind the limbus and piercing the sclera perpendicularly. 
In order to prevent escape of the aqueous through the wound, which 
gapes by this change of position of the knife, the incision must be 
rapidly completed. The latter method cannot be recommended, 
therefore, to the novice. 
The Counter-puncture in the Transparent Cornea (Fig. 146).—This 
error is sometimes due to the endeavor to avoid the mistakes just THE COUNTER-PUNCTURE 
203 
referred to. Occasionally the corneal reflex renders it difficult for the 
operator to judge the position of the point of the knife, and it is 
therefore advisable before starting the operation to bring the eye in a 
position to avoid the disturbance of the reflex. A counter-puncture 
a slight distance from the limbus in the cornea is of little consequence, 
but a high degree of displacement causes serious complications: 
1. The greater the distance of the counter-puncture in the cornea 
the shorter becomes the incision and the more difficult the delivery 
of the lens. 
2. An incision which in its whole length is situated in the cornea 
lacks the conjunctival flap which quickly closes the wound. The 
wound-edges, because of the lack of blood-vessels, do not adhere firmly, 
and with separation of the incision epithelium grows down into the 
narrow opening that forms. The healing is thereby protracted, the 
anterior chamber is slow to reform, and if restored may again re-open 
upon the slightest traumatism, such as may follow cleansing of , the 
eye or sudden opening or closing of the lids. The slight gaping, 
especially of the superficial layers of the wound, leaves a furrow at the 
place of incision, covered by epithelium, which by its brilliant luster 
may be recognized for a long time. 
3. The peripheral portion of the iris back of the corneal incision, 
which is not excised when the iridectomy is done, may become 
attached to the posterior surface of the cornea at the line of incision, 
as may also one or both edges of the iris forming the coloboma, espe- 
cially if restoration of the anterior chamber is delayed. These adhe- 
sions may be the cause of secondary glaucoma. 
4. Epithelium from the cornea may push down between the 
wound-edges into the anterior chamber and lead to blocking of the 
filtration angle and secondary glaucoma. 
Instead of carrying the knife up in a plane parallel with the limbus 
the beginner turns the edge slightly backwards, and the incision 
deviates posteriorly into the sclera. Although the puncture and 
counter-puncture may be properly placed close behind the limbus, 
the incision, especially in its central portion, is several millimeters 
back of its proper position (Fig. 147). The beginner is recom- 
mended to learn on animals’ eyes to carry the knife parallel to the 
plane of the iris through the entire incision. The complications 
which follow a counter-puncture made too far back in the sclera are of 
similar nature. It is an error that should be avoided. 204 
EXTRACTION OF SENILE CATARACT 
If the knife with its cutting edge is turned too far forward, the 
entire incision is in the cornea, the anterior displacement increasing 
with the greater angle of rotation (Fig. 148). The drawbacks of such 
an incision have been described. In this situation the incision is too 
short, and in addition delivery of the cataract is rendered more 
difficult by the upper lens margin being forced to make a greater 
rotation during expression to reach the corneal incision. As greater 
pressure is exerted, the danger of vitreous loss is increased. 
(B) Length of the Incision.—On an average the incision should 
include about a third of the corneal periphery. No difficulties are 
presented in finding the right point of the insertion—1 mm. above 
the end of the horizontal meridian. It is only through an abnormally 
oblique passage of the knife through the anterior chamber that an 
improperly situated counter-puncture can result, in consequence of 
which the cut will be too short. The relative shortness of a corneal 
incision has already been mentioned. The type of patient must, 
however, be always taken into consideration in determining the 
length of the cut. If a comparatively young individual (in the early 
forties), in all probability a shorter incision will suffice, as at this 
age the lens-nucleus is still small, while one of greater length will be 
necessary if a large brown cataract, a totally sclerosed lens, is present. 
Should the patient have an abnormally small cornea, the puncture 
must be made further below, if necessary at the horizontal meridian, 
to insure a diameter of sufficient size. 
(C) Manner in Which the Incision is Made.—In the description 
of the normal incision, the faults have been repeatedly mentioned. 
The error of using only a small portion of the cutting edge instead of 
the entire length of the blade leads to short sawing moments, with the 
knife repeatedly carried backward and forward until the incision 
is finished. The knife is to be pushed forward and upward as soon 
as the counter-puncture is made, so that the main portion of the incis- 
ion is completed with this first forward movement, and the cutting 
edge has passed beyond the pupillary margin before the knife is 
drawn back to continue the incision. If the knife is drawn back after 
the point has emerged only a short distance beyond the counter-punc- 
ture, there is only a small part of the cutting portion available, 
and the blade must be again pushed forward, and by repeating the 
same error, an irregular wound is made by the continuous sawing 
movement instead of a smooth incision. Premature escape of the INTRALAMELLAR INCISION 
205 
aqueous and injury of the iris are the principal consequences of this 
error. Faultypr essure of the knife backward toward the sclera also 
favors these complications. The progression of the incision may 
become delayed with the forward and backward movements, because 
the power, which has to act in the upward direction, has not been 
exerted to the full strength. All these errors lead the inexperienced 
operator to believe that a dull knife has been used whereas the fault 
is entirely in his technic. Premature loss of aqueous and injury of 
the iris may also be due to violent squeezing by the patient. 
The experienced operator may deviate from the rules given, and 
withdraw the knife for a short distance and carry it to the proper 
position if it is seen that the counter-puncture will come too far 
forward in the cornea. 
Introducing the Knife with the Cutting Edge Directed Downward. 
This error is usually discovered only after the counter-puncture is 
made, and it is found that the knife fails to cut upwards. If recog- 
nized immediately after the point of the knife enters the anterior 
chamber, the counter-puncture is completed and the blade of the 
knife rotated as quickly as possible i8o° in its long axis, so that its 
edge becomes directed upward. The quick rotation prevents the 
escape of the aqueous humor. Turning of the knife in the wound is 
without disturbing consequences, if its edge passes the arch in the 
direction toward the cornea. 
If the knife is held with its point directed too far forward, it may 
happen that, instead of entering the anterior chamber at once, the 
blade courses between the lamellae of the cornea for some distance—- 
the so-called intralamellar incision. This error results in a wound 
much too small. An intralamellar incision is, however, rare in the 
cataract operation. If the position of the knife between the lamellae 
of the cornea is noticed early enough, that is, before a puncture into 
the anterior chamber has resulted in escape of the aqueous, the knife 
can be withdrawn and entered at once in the correct place. If the 
aqueous humor has already escaped, the operator must continue with 
the incision, no matter how it terminates, and widen it later with the 
scissors. 
Turning the Knife before the Sclera is Cut Through.—As the 
incision is nearly completed the knife is turned forward but not until 
it appears beneath the conjunctiva, otherwise the cut is flattened 
and becomes irregular and displaced into the cornea. The rotation 206 
EXTRACTION OF SENILE CATARACT 
of the knife is done to prevent a too-large conjunctival flap, so that 
all the layers of the sclera must be cut through before the edge of the 
blade is turned anteriorly. 
The operator who prefers small and thin Graefe knives may have 
disagreeable experiences with a blade of great flexibility resistance 
in making the counter-puncture, so that the knife bends within the 
chamber, usually with convexity forward, and the point emerges 
several millimeters back of the limbus; or the point of the blade may 
bend or break, so that the counter-puncture is made in a slanting 
direction. 
Finally, there is to be considered which hand should make the 
incision. To operators who are not naturally lefthanded, the cut 
Fig. 149.—Blunt hook. 
made with the ]eft hand does not present any unusual difficulties. 
The surgeon who only employs the right hand must operate on the 
right eye from behind, and on the left eye from in front. There are 
operators who always operate from behind, and who, for that reason, 
use the right and left hand alternately. The great objection to this 
position is that the surgeon must bend over the patient, which 
certainly is not favorable for proper asepsis of the wound. 
As iridectomy may be necessary in any case of extraction, the 
cataract incision is made above, so that the upper lid will cover the 
coloboma. Since the patient during operation is prone to rotate the 
eye upward, the lower limbus is more accessible than the upper, but 
incision at the lower limbus is only made in cases of ptosis in old 
people in whom the pupil is covered by the upper lid, and in certain 
palsies of the ocular muscles, particularly the depressors. A small 
iridectomy downward displaces the pupil in the area of the lid- 
fissure. 
The Iridectomy.-—Usually the iridectomy is not painful, as the 
cocain dropped into the conjunctival sac exerts its action on the iris. 
In the event of hemorrhage in the anterior chamber, by which 
the field of operation is obscured, it may be necessary to seize the 
iris without seeing it. With an intractable patient who does not 
look down, or rolls the eye, a blunt hook (Fig. 149) may be substituted OPENING THE CAPSULE 
207 
for the forceps with which to withdraw the iris. The eye is almost 
never fixed during the iridectomy, as the fixation invariably causes 
the wound to gape. 
If, after the iris is in the grasp of the forceps, the patient suddenly 
moves his eye or head, there may ensue a separation of the iris at its 
ciliary margin unless the operator is quick enough to open the forceps. 
As a rule considerable hemorrhage occurs, which greatly adds to the 
difficulties of continuing the operation. The operator should there- 
fore open the forceps and release the iris as soon as the patient begins 
to move the eye. 
If the iris should be cut during the incision, and the excised portion 
remain in the anterior chamber or in the wound, it must be removed. 
If it should be connected with the rest of the iris, it has to be excised 
at the point of attachment. Only the periphery of the iris may have 
been cut by the knife, so that a bridge-shaped coloboma, with a more 
or less wide portion of the pupillary margin, is formed. The bridge 
may be permitted to remain, as the cataract will either pass through 
the coloboma or tear it away. 
Method of Wenzel.—If, following a severe iridocyclitis, cataract 
forms, and the whole posterior surface of the iris is bound to the 
lens, the extraction of the cataract is performed as follows, according 
to the method of Wenzel: 
The knife is introduced as usual at the limbus, passes back of the 
iris, and pierces it again just before the counter-puncture is made. 
During the incision the knife in its upward passage opens the lens cap- 
sule and makes a broad cut through the iris. After expression of the 
lens, two converging incisions meeting in the pupil are made with de 
Wecker’s scissors through the diaphragm formed of membrane, iris, 
and lens capsule, and the circumscribed piece seized with fine iris- 
forceps and drawn out. This forms a large upward coloboma. The 
pointed blade of the scissors remains in the anterior chamber, while 
the blunt point is behind the diaphragm. 
Opening the Capsule.—The capsule-forceps is preferable to the 
cystotome, although, if the anterior chamber is filled with blood 
and the boundaries of the pupil cannot be seen, the forceps might 
easily grasp a fold of the iris by mistake and pull it out. In restless 
patients and also if the pupil is narrow, in an extraction without 
iridectomy, it is preferable to resort to the cystotome or tenaculum 
to avoid a possible seizure of the iris by the forceps. 208 
EXTRACTION OF SENILE CATARACT 
In a greatly distended cataract, and a hypermature, complicated 
cataract with thickened capsule, the employment of the capsule-for- 
ceps will be influenced to a considerable extent by the condition of the 
capsule. If the lens is so swollen that the capsule is tense, a fold of 
it cannot be lifted up with the forceps, except by exerting more force 
than is safe. If the operator feels that he cannot grasp a fold of 
capsule between the teeth of the forceps by gentle pressure, he should 
use the cystotome. 
Should the capsule be thickened, it is an advantage to remove the 
anterior portion, especially if it occupies the whole extent of the 
pupillary area. It may happen that the thickened capsule offers 
more resistance than does a defective zonula, the fibers of the 
latter tear through, and the whole lens in its envelope is withdrawn 
from the eye. The operator must be prepared to assist in the exit of 
the lens by a downward pressure on the scleral wound-margin at the 
moment he sees the lens yielding. This is done in order to remove 
the obstacle presented by the sclera, so that the capsule may not 
finally rupture and leave the half-luxated lens behind in the eye. If 
the patient is quiet and the vitreous of normal consistency, a prolapse 
of the latter does not of necessity occur, but sometimes it cannot be 
avoided. Should extraction with the capsule succeed, the result is 
excellent, as the pupil is free of all remnants of tissue. 
Expression of the Cataract.—If the pressure through the lower lid 
is made too high up, against the middle of the cornea, the operator 
will wait in vain for the appearance of the lens in the wound. How- 
ever, even with pressure made in the proper direction and with 
the proper degree of force, the cataract may fail to appear in the 
wound. This may be due to a small incision, to resistance of the 
sphincter, to failure to open the lens capsule, to subluxation of the 
lens, or to diminished size of the lens-nucleus. 
If the wound is too small, which is shown by the lens pressing 
against the wound but not making its way through, the incision 
must be lengthened either at one or both ends with a pair of 
small curved, blunt scissors, one blade of which is carefully pushed 
into the angle of the chamber between the cornea and iris, while 
the other blade remains on the outside of the eyeball. If shortness 
of the incision is the real cause that prevents the proper delivery of 
the lens, the latter easily slips out of the eyeball after the cut has 
been enlarged. DISLOCATION OF THE LENS 
209 
It may be that the incision is sufficiently long, but the lens nucleus 
is exceptionally large. In cases of black cataract, the incision should 
be made larger than usual at the beginning of the operation. A cut 
which is too short, because made too far into the cornea, presents still 
another factor which may hinder the exit of the lens. The further 
the incision in the cornea is removed from the limbus, the more 
must the edge of the lens rotate forward to present in the wound. 
That is, the greater the force which the operator must exert on the 
eye, the more danger there is of prolapse of the vitreous. Therefore, 
the only remedy is to prolong the incision by making lateral cuts 
along the limbus, and the same procedure is indicated if it is too short 
on account of being made some distance between the corneal lamellae. 
Should the operator not be certain of having sufficiently opened 
the capsule, he should introduce the forceps a second time or have 
recourse to the cystotome. 
Dislocation of the lens, usually a slight subluxation upward, may 
be due to traction of the forceps on the capsule, to pulling too strongly 
on the tunics of the eyeball during the incision, or to the pressure 
having been exerted in a direction which pushed the lens slightly up- 
ward instead of rotating it about its horizontal axis. It is therefore 
impossible to deliver the cataract, as the pressure made by the finger 
falls only on the vitreous, and has no longer any influence on the posi- 
tion of the lens. The latter does not rotate its margin into the 
wound, and any increase of the pressure simply forces the vitreous 
into the opening, and at the same time completely luxates the lens 
backward. The removal of the lens can then only be accomplished 
by returning it to its original position, which may be done by intro- 
ducing a spatula into the anterior chamber and bringing the instru- 
ment into contact with the anterior surface of the lens, pushing it 
downward into its normal position. After this maneuver the expul- 
sion of the lens may be accomplished, especially if, by depressing the 
scleral wound-margin with a spatula, the lens is prevented from again 
taking a faulty position. 
If the lens becomes luxated in any direction other than upward, 
for example, internally or externally, it must be extracted either with 
a loop or a double tenaculum. 
When the lens-nucleus has become considerably diminished in 
size, as is frequently seen in complicated cataract and invariably in 
overripe cataract (Morgagnian cataract), delivery is also difficult. 210 
EXTRACTION OF SENILE CATARACT 
Pressure is useless if the lens is not normal in position and size. If 
the cortical substance has liquefied and pours out after the anterior 
lens capsule has been opened, the small nucleus either sinks down to 
the bottom of the capsule sac or is carried slightly upward behind the 
iris by the escaping cortical matter. In neither instance is it possible 
through the regular expression to influence the position of the lens 
nucleus. If the lens lies far down, it may be gradually worked 
upward by gentle stroking movements, and finally delivered with 
Daviel’s spoon. If, however, it has been pushed up behind the iris, 
it must be first stroked down by means of the spoon into the pupil and 
from there guided upward out of the wound. 
Some of the conditions above mentioned may lead to tilting 
of the lens on its horizontal axis, so that the lower margin approaches 
Fig. 150.—-Weber’s loop. 
the wound first. This accident is liable to occur if the lens is slightly 
dislocated and the upper margin is prevented by the sclera from 
rotating forward. If the operator, unaware of this complication, 
makes increased pressure on the eye, the vitreous body pushes the 
lower lens margin forward and causes the wound to gape. If the 
direction of the pressure is changed and exerted more upward, as 
previously mentioned, the lens continues to tilt forward and leaves 
the wound with the lower margin first, after having performed a rota- 
tion of 180 degrees. The same forward rotation may occur if the lens 
is small and the lower margin relatively high. The complication is 
rare, and under the conditions mentioned the vitreous usually appears 
before the lens and forces the operator to another method of delivery. 
Prolapse of the vitreous usually occurs during the act of expression 
of the cataract, but it may happen in any stage of the operation. 
It is of less significance when it ensues after the removal of the lens, 
and at that time it is best to do nothing further than make sure that 
the corneal flap remains in its proper position, and is not bent forward 
through the pressure which the vitreous exerts from behind. To 
undertake a reposition of the iris is not advisable, as this would 
only cause further protrusion of the vitreous. The best proced- 
ure, therefore, is to close the patient’s eye as soon as the vitreous 
appears, and guide the upper lid over the flap with the assistance of PROLAPSE OF THE VITREOUS 
211 
the spoon held beneath the lid. As the protrusion of the vitreous 
causes pain, the patient usually winces, which may cause still more 
vitreous to be lost. Moreover, it is easily possible for the upper lid 
to fall into the open wound and to turn the flap forward. 
After the patient has closed the eye, the upper lid is slightly raised 
by means of the eyelashes, the lower lid drawn away from the eye, and 
the position of the flap inspected, and, if necessary, smoothed out by 
a spatula. After this, the patient should not be allowed to open his 
eye, and both eyes are closed by a bandage. 
Fig. 151.—Reisinger’s double tenaculum. 
If the vitreous appears prior to the removal of the lens, and the iris 
has not as yet been excised, an iridectomy can be performed only if 
the iris has floated into the wound and can be seized readily by the 
forceps. If, however, the iris has not fallen forward, any attempt to 
seize it with the forceps must be hopeless, as the instrument picks up 
only the vitreous. The iris has floated backward under the ciliary 
body, as shown by the large upward coloboma. 
Continued efforts at expression after appearance of the vitreous 
cause further prolapse. Extraction of the lens in its capsule must be 
resorted to, and for this purpose, either a loop (Weber’s, Fig. 150), 
or a double tenaculum (Reisinger’s, Fig. 151), is employed. The 
former is preferable for the inexperienced. 
The loop (Fig. 150), directed obliquely backward (Figs. 152 and 
154), is introduced through the wound until it reaches a position in 
the middle of the vitreous and about opposite the posterior pole of the 
lens. It is then carried forward (Figs. 153 and 155), so that the lens 
is pressed against the posterior surface of the cornea and forced out 
between the cornea and the instrument; in other words, it is lifted out 
of the eye by the loop. 
Reisinger’s double tenaculum (Fig. 151) is inserted closed in a 
similar manner, and, in order that the points may not become 
entangled in the edges of the wound, it is held with the plane of the 
bent portion parallel to the wound, therefore, in a frontal direction. 
Not until it is found to be behind the middle of the lens, is it rotated 
about 90 degrees on its long axis, so that the points are now directed 
forward. The two arms are then separated and sink into the posterior 212 
EXTRACTION OF SENILE CATARACT 
surface of the lens, which is now pressed against the posterior aspect of 
the cornea, and in this manner withdrawn from the eye. This instru- 
ment, therefore, can only be used when a firm lens-nucleus is present. 
If the nucleus is soft, the loop is recommended, as the tenaculum 
would cut through the soft mass without bringing it out. 
Pig. 152.—Introduction of Weber’s loop. The loop is directed backward through 
the gaping wound behind the lens into the vitreous. The assistant holds the upper lid 
well-fixed with the thumb of the right hand and has the spoon in the left hand ready, 
after the extraction has been completed, to guide the upper lid down over the gaping 
wound. The operator himself fixes the lower lid. 
Both instruments must be carried backward into the vitreous in 
an oblique manner, for the reason that, if held vertically, they would 
push against the margin of the lens and produce a luxation into the 
vitreous. During the entire manipulation, the lids must be drawn 
away from the eye in order to avoid pressure on the globe. The USE OF THE LOOP 
213 
upper lid is raised by means of a Desmarres elevator (Fig. 156). 
In every cataract operation the loop and tenaculum should be 
sterilized and ready for use, as the vitreous occasionally prolapses 
unexpectedly. 
The greater the dexterity of the operator, the rarer will vitreous 
prolapse in operations on uncomplicated cataract. Severe straining, 
Fig. 153.—Use of Weber’s loop. The loop has been placed upright in such a fashion 
as to press the lens against the posterior aspect of the cornea and can now be drawn along 
the latter and out of the eye. 
holding the breath, etc., by the patient may be responsible, while the 
surgeon may induce it by undue pressure on the eye with the forceps 
during the incision, in delivery of the lens, or in forcing out the lens 
remnants. Quite unavoidable often is the prolapse in the presence EXTRACTION OF SENILE CATARACT 
214 
of complicated cataracts, when the zonula is ruptured, or the vitreous 
has lost its normal consistency. 
Prolapse of the vitreous is a most serious complication, and it is 
absolutely necessary to recognize at the right time whether a prolapse 
is imminent, and, if so, to prevent it if possible. 
Several phenomena are associated with prolapse of the vitreous: 
1. Very characteristic is the forward bulging through the pupil 
and coloboma of the vitreous while the hyaloid membrane is still 
unruptured. If, after the expression of the cataract, the pupil and 
Fig. 154. 
Fig. 155. 
Fig. 154.—Diagrammatic representation of the introduction of the loop. The loop 
is directed backward obliquely. 
Fig. 155.—The loop is raised and the lens pressed against the posterior wall of the 
cornea. 
coloboma are filled with grayish lens remnants which suddenly 
separate at one point, and the pupil in this locality becomes a deep 
black, we have the first sign that the vitreous, still contained within 
its uninjured membrane, has pushed forward and penetrated the 
tissues in front. No experienced operator will continue to exert 
pressure to remove the remaining lens particles, for the rupture of the 
hyaloid membrane will occur the next moment. One should be 
satisfied with carefully stroking back the iris, and this is possible 
only when the patient remains quiet, but unfortunately the iris often 
is prolapsed again by the vitreous. 
2. The same bulging forward of the vitreous in the unruptured 
hyaloid membrane may also occur, with a simultaneous marked deep- PHENOMENA ASSOCIATED WITH VITREOUS PROLAPSE 
215 
ening of the anterior chamber. A hernia of the vitreous presses at the 
same time through the pupil into the anterior chamber, filling it out 
and pushing back the iris. 
3. Another characteristic sign is the deepening of the anterior 
chamber in consequence of the accumulating vitreous, which has 
already poured in through a rupture in the hyaloid membrane. This 
is followed by an outflow of the vitreous through the wound. The 
Fig. 156.—Desmarres elevator. 
first indication of the vitreous in the anterior chamber is manifested 
by the changes in the color and coagulation of the blood after it has 
been mixed with vitreous. 
Deepening of the anterior chamber may also be produced by the 
entrance of air, but as the air-bubble is always clearly seen, it cannot 
be confounded with the appearance just described as due to the vitre- 
ous. The air in itself is not harmful, but it may so disturb the appa- 
rent relations of the anterior chamber, especially the position of the 
margins of the iris, that an attempt should be made to remove it 
from the eye by massage. 
4. If the lens is still in the eye, the tendency to vitreous prolapse is 
indicated by eversion of the edges of the wound, or gaping of the 
entire cut. 
During peripheral incisions the hyaloid membrane may rupture in 
the region of the wound, and the vitreous extrude through the widely 
gaping wound, without any previous sign whatever having been 
noticed in the anterior chamber. 
If the vitreous is perfectly fluid, it will ooze steadily from the eye 
immediately after the incision, without any gaping of the wound. 
Great loss of fluid is recognized by collapse of the eyeball. As this 
precludes regular extraction of the lens, the loop or tenaculum must 
be resorted to. On the whole, the loss of perfectly fluid vitreous is in 
general much better tolerated than the loss of the normal vitreous. 
In a few hours it is replaced by new fluid, by which the eye is restored 
to its normal tension. The wound heals smoothly, but after the 
loss of normal vitreous, the cicatrix remains ectatic for a long time. 216 
EXTRACTION OF SENILE CATARACT 
In instances in which the protruding vitreous repeatedly turns the 
corneal flap forward, and it cannot be permanently replaced with the 
spatula, the wound-edges should be united with two or more silk 
sutures. 
The sequelae of prolapse of the vitreous include attachment of the 
margins of the iris to the wound, cystic scars, glaucoma, and chronic 
iridocyclitis. Hemorrhage into the open vitreous chamber leads to 
opaque membranes, either floating or hanging from the point of 
attachment. Detachment of the retina occurs only after great loss of 
vitreous, except in an eye especially predisposed (myopia, etc.). 
Several other accidents during the cataract operation remain to 
be mentioned. 
The lens may be displaced back into the vitreous chamber, either 
spontaneously or through the unskillful manipulation of the operator. 
Any attempt to recover it is useless and results only in further injury 
to the eye. Occasionally a lens, which has fallen back into the 
vitreous, comes up again into the pupillary area. It is advisable to 
wait a half hour, and if the lens floats up within the pupil to extract 
it with a tenaculum or loop. This may be attempted several days 
later if the lens is seen in a position to be removed with the loop. 
If the lens remains in the vitreous chamber the eye is usually lost by 
iridocyclitis. 
The so-called collapse of the cornea, which is occasionally met 
with in very old patients immediately after completing the incision, 
is of absolutely no importance. The cornea, owing to atmospheric 
pressure, is deeply depressed in the center. The rigid sclera of old 
people does not sufficiently contract after the tension of the eye has 
become diminished. 
Expulsive hemorrhage is fortunately an infrequent complication. 
It rarely occurs during operation, but usually appears suddenly 
several hours afterward; it is seen not only after extraction compli- 
cated by the loss of the vitreous, but also following normal operations. 
The hemorrhage is retrochoroidal and is so extensive that the vitreous, 
choroid, and the retina are driven outward through the wound. 
Immediate enucleation spares the patient a long period of suffering. 
Unfortunately, we have no means to prevent this accident; indeed, we 
do not even know of a single symptom which will afford warning of 
the danger before the operation. As associated factors the following 
must be taken into consideration: the sudden lowering of the intra- KALT SUTURE 
217 
oc. lar pressure caused by the operation; the rigidity of the external 
tunic of the eye; arteriosclerosis and the concomitant tendency of 
the blood-vessels to rupture; and increase in blood-pressure during the 
operation on account of the increased activity of the heart due to the 
excitement of the patient. To at least exclude the last factor, Fuchs 
gives those patients who have lost one eye through an expulsive 
hemorrhage, a large dose of bromids (2 grams) before the operation. 
The danger that hemorrhage may follow extraction of a cataract 
from the other eye is not sufficiently great to warrant the operator 
in performing a depression of the cataract into the vitreous humor 
after the old method instead of the usual extraction. 
Kalt Suture.—Before the corneal incision is made Kalt introduces 
a fine, sharp, perfectly round, curved needle, with fine silk, through 
the cornea in the upper vertical meridian close below the limbus, and 
brings it out on the border of the limbus without entering the anterior 
chamber. The needle is then passed through the conjunctiva and 
episcleral tissue 1 mm. above the limbus. The loose loop of the 
thread between the two stitches is laid inward toward the nose, so 
that it is not injured by the knife as the cataract incision is made 
between the two needle openings. After extraction of the cataract 
the thread is knotted. The great advantage of the suture is that it 
corrects gaping of the wound, particularly after escape of vitreous, 
and prevents sudden gush of aqueous with prolapse of iris in the 
wound, although not entirely guarding against this accident in simple 
extraction. In instances where complications are anticipated the 
application of the Kalt suture is to be recommended. 
Kuhnt Conjunctival Flap.—This procedure is valuable in extrac- 
tion complicated by gaping of the wound and a tendency to slow 
healing, which often follow corneal incisions. The conjunctiva, close 
to the limbus, is incised around the upper half of the cornea with a 
pair of small, curved scissors, and the membrane undermined for a 
short distance from the limbus. A curved incision is then made 
through the conjunctiva a short distance above and parallel with the 
limbus, forming a conjunctival flap, which is to be drawn down by 
sutures to cover the extraction incision (Fig. 201). These two sutures 
are entered through the lower margin of the bridge of conjunctiva 
near the two attached ends and are fastened further down on the 
conjunctiva of the globe. The tying of the two threads covers the 
operative wound entirely with conjunctiva and brings the wound 218 
EXTRACTION OF SENILE CATARACT 
edges in apposition. The conjunctival bridge, which at first covers 
the entire portion of the cornea, draws back to its normal situation 
in several days. 
The conjunctiva can be drawn down over the wound incision 
apron-like, as shown in Fig. 202, without the necessity of making the 
second incision to form the detached bridge. 
The Kuhnt flap may be made prior to the cataract incision if a 
complicated operation and course of healing is anticipated, as in 
restless patients, and also in exophthalmos and in complicated 
cataract. 
COMPLICATIONS DURING HEALING 
Delayed Closure of the Wound.—In twenty-four hours usually 
the wound is found to have closed and the anterior chamber restored. 
Occasionally, however, the wound is not healed for days or weeks. 
Delayed healing is often due to lodgment between the lips of the 
wound of lens remnants, particles of iris, and particularly shreds of 
capsule. It is therefore important that in opening the lens capsule 
with the forceps that the membrane should be detached from all 
sides before the forceps are withdrawn, otherwise the attached upper 
portion of the capsule may be drawn into the wound. Protrusion of 
the vitreous, indicated by gaping of the wound, may be a cause. 
A corneal incision contributes to slow wound closure. In the 
healing of the cornea, the epithelium usually sinks into both borders 
of the cut, and, as surfaces covered with epithelium do not unite, 
the two edges are only loosely adherent and readily re-open. The 
wound presents the appearance of a shining groove. 
Restlessness and coughing cause the aqueous to be repeatedly 
forced out of the wound, and prevent its healing. Prolonged cocain- 
ization has also been blamed for delayed restoration of the chamber. 
The closed wound may re-open after a few days without apparent 
cause. An ophthalmoscopic examination will show the brownish 
elevated areas in the periphery of the fundus characteristic of choroi- 
dal detachment. 
In many instances no explanation can be given of the failure of 
the wound to unite. If a shred of capsule is recognized between the 
wound-edges, an attempt may be made to remove it. 
Prolapsed iris is not uncommon after extraction. Also, after 
iridectomy, one or both of the iris pillars may be caught in the corners COMPLICATIONS DURING HEALING 
219 
of the incision or at least are higher than they should be. Occa- 
sional protrusion of the vitreous prevents proper reposition and 
crowds the iris continually toward the wound, or a restless patient 
may cause periodic gushes of aqueous through the wound, washing 
between its edges the previously properly-replaced iris. If the iris 
lies exposed in the wound immediately after operation, it should be 
excised, but if not caught sufficiently to permit excision, no attempt 
to remove it is to be made. Eserin is of no value to draw the edges 
in proper position. 
Eversion of the Corneal Flap.—On the day after the operation, 
the corneal flap may be turned downward, because the patient with 
a gaping wound opens the eye beneath the bandage, and the upper 
lid enters the wound. After instilling cocain solution the flap must 
be carefully stroked upward and brought into its proper position. 
Unless infection ensues, which, however, is a likely result, the eye 
need not be considered as lost. For a long time a straight white 
line remains as a sign of corneal injury. 
Lens Particles in the Pupil.—Lens cortex in the pupil becomes 
opaque a few hours after operation. It is of little significance 
unless operation was complicated by loss of vitreous. Atropin is 
to be used to keep the pupil dilated, and later dionin to accelerate 
absorption. 
Blood in the Anterior Chamber.—Hemorrhage during operation 
will be most likely to occur if the incision is some distance back of the 
limbus in the sclera, although a correctly-placed wound may give rise 
to troublesome bleeding in persons with diseased blood-vessels. 
Attempts to remove the blood by massage are sometimes successful, 
but after recurring hemorrhages a firm, tough coagulum forms in 
the anterior chamber that cannot be expressed. Most of the blood 
will have disappeared by the following day, the portion left forming 
an insignificant hyphemia or a thin layer over the iris and pupil. 
The use of atropin is all that is required. Occasionally hemorrhage 
follows the breaking open of the wound under the dressing. 
Iridocyclitis and increased tension are also factors in causing 
hemorrhage. The bleeding repeatedly recurs, and, owing to the slow 
absorbing power of the inflamed eye, contributes to the formation 
of a membrane in the pupil. 
Cloudiness of the Cornea (Striped Keratitis).—On the first few 
days after operation there is often found in the upper half of the EXTRACTION OF SENILE CATARACT 
220 
cornea a number of vertical lines or stripes. In rare instances the 
cloudiness is intense, and may spread over the entire cornea in large 
gray polygonal areas between which transparent strips run in differ- 
ent directions. The more difficult the expression of the lens, whether 
because of the size of the nucleus or shortness of the incision, the 
greater is the cloudiness. It usually disappears during the first two 
weeks after operation, but in exceptional cases it may be the origin 
of degeneration of the cornea. 
Post-operative Delirium.—This is a rare complication and is 
prevented by allowing the necessary quantity of alcohol to drinkers 
and by keeping the non-operated eye unbandaged in nervous and 
excitable persons. The omission of the bandage from this eye in 
most cases removes all anxiety, and the patient will spontaneously 
keep the lids of the eye closed. 
Pain.—During the operation the patient does not have much pain 
if the local anesthesia has been properly applied. The beginning of 
dilatation of the pupil is a sign that the cocain has begun to exert its 
action also on the iris. The cutting of the iris is then only slightly 
painful. In exceptional cases the iris may remain sensitive, but com- 
plete anesthesia may be secured by a subconjunctival injection of 
cocain a short distance back of the limbus above. This somewhat 
complicates the incision by the edema of the conjunctiva and under- 
lying tissues. With a spatula the edema may be stroked back from 
the limbus. In some patients, especially women, injections of cocain 
are likely to cause repeated vomiting, which may lead to serious 
complications. After operation there is a slight and transient burn- 
ing with the disappearance of the cocain anesthesia. It is advisable 
to inform patients of the discomfort that will come with the return of 
the normal sensibility of the cornea, so that they will not be unneces- 
sarily alarmed. Severe burning and irritation may follow erosion of 
the cornea due to prolonged application of cocain or failure to keep 
the lids closed during its instillation. Retention of tears in the 
conjunctival sac from spasm of the lids is also a cause of unusual pain. 
The surgeon should not consent to remove the dressings on the day 
of operation unless the severity of the pain indicates that some- 
thing is radically wrong. Nervous patients are prone to magnify 
their ailments, particularly after an operation on the eyes. 
Pain on the second or third day after operation indicates sudden 
breaking open of the wound or beginning iridocyclitis. It usually SIGNS OF INFLAMMATION 
221 
appears at a time when clinically there are as yet no symptoms of an 
iridocyclitis. The pain is often localized not only in the eye but also 
in the forehead on the side of the operated eye. Frequently ciliary 
injection is the only objective symptom. Under these circumstances, 
aspirin should be administered internally, and atropin locally, 
especially if the pupil is not sufficiently dilated. 
Rupture of the Wound.—This accident results from muscular 
straining, restlessness, or traumatism, and is more common in large 
clinics than when the patient is under the constant watchfulness of an 
attendant. The parts adjacent to the wound become suffused, blood 
collects in the anterior chamber, and the iris may be prolapsed, with 
vitreous in the wound. The prolapsed iris must be excised, atropin 
instilled, the bandage reapplied, and the patient kept absolutely 
quiet. 
Signs of Inflammation.—The external signs of inflammation 
vary considerably even in eyes that follow an uncomplicated course 
in healing. While some remain quite pale, the majority show 
moderate ciliary injection, and others present decided engorgement 
of both the conjunctival and ciliary vessels, types of irritation not 
explainable alone by conjunctival catarrh or iritis. Anemic individu- 
als usually have pale eyes after operation, while plethoric persons 
with dilated vessels of the face incline to hyperemia. The ordinary 
inflammatory complications are as follows: 
Infection.—Suppuration usually occurs during the first two or 
three days, but may be delayed for a week—the so-called secondary 
infection. Acute infection may be due to unclean instruments, im- 
perfectly sterilized solutions, or the entrance of germs from the con- 
junctiva into the wound. 
The picture of beginning infection varies. Usually on the day 
after operation there is noticed some edema of the eyelids, the gauze 
dressing shows a streak of yellow discharge, a suppurative exudate 
lies between the swollen lids and accumulates in the inferior culdesac 
in the form of yellowish, cloudy flakes, and the wound has a gray 
or yellow coating. The anterior chamber has usually reformed, and 
the iris and pupil may be normal. In a few hours the inflammation 
increases. An abundant muco-purulent discharge accumulates in 
the culdesac, the entire wound is infiltrated with a grayish material, 
and fine yellowish lines pass from the cut into the adjacent corneal 
layers or run in cloudy threads into the anterior chamber. The 222 
EXTRACTION OF SENILE CATARACT 
process slowly or rapidly advances, depending on the virulence of 
the infection, until all the signs of a suppurate iritis appear, with 
later possibly panophthalmitis. The cornea adjacent to the wound 
may become purulently infiltrated, or a ring abscess may form. 
If the infection proceeds from the anterior chamber, the con- 
junctiva and wound may at first remain normal, and the disease begin 
with symptoms of suppurative iritis—discoloration of the iris, 
cloudiness of the aqueous, hypopyon, and a yellowish exudate in the 
pupil and coloboma. 
Acute suppurative infection does not always follow the destruc- 
tive course which has been outlined. Often the disease is beneficially 
affected by treatment, and the inflammation gradually subsides, not 
without, however, leaving a coarse membrane in the pupil and 
coloboma. 
Treatment.—Therapy is almost powerless against a severe infec- 
tion, but if recognized early prompt measures may be of service in 
checking the spread of the disease. If limited to the wound, imme- 
diate cauterization with carbolic acid or the actual cautery should 
be made, and the conjunctiva frequently douched with 1-3000 
bichlorid of mercury solution. Repeated subconjunctival injections 
of solutions of bichlorid (1-2000) or cyanid of mercury (1-5000) 
seem to act favorably in some cases of infection arising in the anterior 
chamber. Nothing can be expected from serum injections. The 
opening and washing out the anterior chamber with physiologic 
salt-solution is almost always fruitless. Besides these measures, the 
energetic use of atropin, dionin in powder form, and hot compresses 
should be employed. 
Intramuscular injections of one of the forms of protein, of which 
sterilized milk (6 to 10 c.c.) is an example, have been recommended. 
The injections are often followed by rise of temperature, but this is 
no contraindication even in elderly people if there is no advanced 
cardiac disease. The injections are started with the first symptoms 
of inflammation, and repeated for several days. In some instances 
they exert a favorable influence on the cause of the infection, and 
may result in saving eyes which otherwise would be lost; in others 
there appears to be only a temporary check of the process. The 
usual local treatment is to be continued—cocain with dry atropin, 
dionin in powder form, and continuous hot compresses. Urotropin 
may be given internally. IRIDOCYCLITIS 
223 
So long as light-projection is preserved, the case should not be con- 
sidered hopeless. It is only after the perception of light is lost that 
all chance is gone of preserving vision. If panophthalmitis appears 
unavoidable, enucleation is indicated to relieve the patient of weeks 
of suffering; but should sudden increase in the edema of the con- 
junctiva and lids point to infection having already begun in the 
vitreous, the proper course is to excise the cornea and allow free 
egress of the pus. The acute purulent infection does not always 
lead to destruction of the eye. In a certain proportion of cases the 
inflammation subsides, leaving the pupil and coloboma closed by a 
coarse membrane. 
Iridocyclitis.—Slowly beginning inflammation of the iris and cil- 
iary body is also due to an infection with microorganisms, and may 
start a few days or a week or more after the extraction with pain in 
the eye or in the forehead and with pericorneal injection. Under 
proper treatment these symptoms subside in most instances, leaving 
the eye unimpaired, or they may progress to the severe type of irido- 
cyclitis, in which the cornea becomes stippled, the aqueous clouded, 
the iris discolored, the eye tender on pressure, and the pupil and 
coloboma veiled with a fine web-like exudate. Even in these severe 
types of inflammation, the eye may slowly recover, with preservation 
of useful sight. If the ciliary body is chiefly affected, the induration 
extends to the choroid, the vitreous is clouded, the retina becomes 
detached, and the eyeball ultimately shrinks. This form of irido- 
cyclitis is feared, not alone because of the possible complete loss of 
light-perception, but of the danger of affecting the other eye. There 
are no means of recognizing clinically the type of iridocyclitis that 
may cause sympathetic disease, so that, if light-perception fails and 
no hope for sight remains, the surgeon should not delay in urging 
the patient to consent to the removal of an eye which is both useless 
and dangerous. 
Treatment.—From the beginning of the inflammation atropin is to 
be employed regularly, leeches to the temple, hot compresses and 
dionin, and internally aspirin and small doses of calomel. A course 
of pilocarpin sweats with mercury inunctions sometimes exerts a 
favorable influence. In the progressive types of uveal inflammation 
therapy is unfortunately powerless to stay the degenerative processes. 
In the favorable cases, upon subsidence of the inflammation, the 
coarse membrane which occludes the pupil reduces vision to the per- 224 
EXTRACTION OF SENILE CATARACT 
ception of light, and necessitates iridotomy. The operation must not 
be undertaken until all signs of irritation have subsided. Early 
operation is followed by a relapse, and the opening made in the mass 
in the pupil is closed by blood or by granular tissue which develops 
from the edges of the incised area. So long as the patient complains 
of occasional pain, or there are periods of inflammation, even though 
hardly more than injection of the ciliary vessels, operation must be 
deferred. From four to six months after all inflammation has sub- 
sided seems to be the shortest time before operation is recommended. 
Secondary Infection.—If a cystic scar remains after operation, 
either from healing in the wound of the iris or a shred of capsule, infec- 
tion may occur months or years afterward, and follow the course of a 
slight iritis to a well-developed panophthalmitis. 
Increased Tension.—An attack of acute glaucoma may occur 
during the first few days after operation. The diagnosis is not easy, 
as the intense pain, chemosis, swelling of lids, and cloudiness of the 
cornea simulate an incipient infection, and especially as it is difficult 
to test the tension of the recently-operated eye. The cause of the 
increased tension after an uncomplicated extraction is problematical, 
especially in instances in which the pupil is free of any cortical 
remains. 
In extraction complicated with considerable loss of fluid vitreous, 
even with no incarceration of the wound, there may follow irregular 
attacks of pain, slight dullness of the cornea, and increased tension, 
indicating mild glaucoma. Miotics usually restore the tension to 
normal in a few days. It is only in rare instances that paracentesis 
of the cornea is performed, because of the risk of inciting a post- 
operative increase in tension. 
Increase of tension which occurs a considerable time after an 
extraction complicated with healing of the iris in the wound is readily 
explained, but it is somewhat difficult to account for the glaucoma 
symptoms after operation with a correct coloboma or with a round 
pupil. 
These late forms of glaucoma frequently have a chronic course, 
and the patients do not seek treatment until the process has consider- 
ably advanced. One of the earliest symptoms is recurring attacks of 
bullas on the cornea. If there is an incarcerated iris it must be 
excised. Cyclodialysis and sometimes anterior sclerotomy are of 
value in cases with round pupil or normal coloboma. INCREASED TENSION 
225 
A rare form of glaucoma, not benefitted by treatment, follows the 
growth of epithelium through the wound into the anterior chamber. 
Clinically, epithelial-cell lining of the anterior chamber is only recog- 
nized when the membrane covers a part of the cornea and is reflected 
cyst-like upon the anterior surface of the iris. Should there be a 
uniform epithelial lining of the entire chamber, it can only be sus- 
pected but not with certainty diagnosed. 
Iridocyclitis may be followed by increased tension. 
Detachment of the retina does not follow extraction with loss of 
vitreous if the eye had normal refraction; in high myopia the retina 
may become detached after this complication of the extraction. CHAPTER XI 
CATARACT (continued) 
DISCISSION 
Discission is the term applied to incision of the anterior lens 
capsule or to the cutting of the opaque posterior lens capsule after 
cataract extraction, (after-cataract, secondary cataract.) The an- 
terior lens capsule is also incised for the removal of an opaque lens 
in young persons or of a transparent lens in high myopia. 
The operation is performed with a discission knife-needle, a 
small knife which has a double cutting edge (convex and concave) 
(Fig. 157). The discission is usually made anteriorly through the 
anterior chamber, discission through the cornea, or in secondary 
Fig. 157.—Knife-needle for discission. (Natural size.) 
cataract the knife-needle may be carried through the sclera behind 
the ciliary body, incising the membrane posteriorly, discission 
through the sclera. 
Discission Through the Cornea (Figs. 158 and 159).—After the 
pupil has been dilated with atropin, the eyeball is fixed and the 
cornea pierced on the outer side at the limbus (Fig. 158). The 
operation on the right eye is performed with the left hand, and on the 
left eye with the right hand, the operator in each instance sitting to 
the right of the patient. The pupil is dilated to expose a large area 
of the anterior lens capsule, and particularly to protect the iris from 
injury. 
The knife-needle, held between the thumb and the first and 
second fingers, with its handle resting upon the base of the phalanx 
of the forefinger, perforates the cornea to the outer side near the 
limbus, about the horizontal meridian, and is pushed forward and 
upward, until it reaches the upper margin of the pupil. Using the 
corneal perforation as a fulcrum, the handle of the instrument, 
226 DISCISSION 
227 
inclined at an angle of about 45 degrees with the capsule, is moved 
from below upward, describing an arc of about 90 degrees, and the 
blade cuts through the capsule and anterior lens-fibers. The handle 
is now depressed, and the knife point brought to the inner margin of 
the dilated pupil, and entered through the capsule in the horizontal 
meridian. The handle is then raised through an arc of about 45 
Pig. 158.—Discission through the cornea. Diagram showing how the vertical 
incision is made in discission through the capsule of the lens. The handle of the needle is 
lowered, thus bringing its point into such a position (a.) that it lies near the upper mar- 
gin of the pupil. Next, while the needle inclines to the plane of the lens capsule at an 
angle of about 45 degrees, the handle is elevated from a. to b., thus making a vertical 
incision through the capsule. 
degrees, and, with the corneal perforation still as a fulcrum, the 
knife blade makes a horizontal incision through the capsule (Fig. 
159). In order that the point does not sink too deeply and injure 
the posterior capsule, the needle is withdrawn slightly while making 
the cut and finally quickly pulled out of the eye in the same direction 
in which it was entered. 
The knife-needle may be entered either in the outer part of the 
cornea, in the limbus itself, or even beyond it in the sclera. In enter- 
ing through the sclera the needle is pushed forward slightly under 
the bulbar conjunctiva before the perforation is' made. This pro- 
duces immediate closure of the perforation-wound, as the opening in 228 
CATARACT 
the conjunctiva and that in the eyeball occupy different positions. 
Entering the knife through the cornea is preferable in those cases in 
which, because of a shallow anterior chamber or a pupil which has 
remained small in spite of atropin, an injury to the iris is to be feared 
if a peripheral incision is made. 
We prefer a crucial incision of the capsule, because a permanent 
opening is thereby assured. The four flaps retract, so that healing 
Fig. 159.—Discission through the cornea. The eye is fixed below at the limbus by 
forceps. With the discission needle held in the right hand, when the left eye is operated 
on, the cornea is perforated at the limbus, and a horizontal incision is then made through 
the anterior lens capsule. 
of the wound in the capsule is prevented. If only a single incision is 
made, closure of the wound not infrequently occurs. On the other 
hand more than two incisions are superfluous. 
Discission is the only safe operation in congenital total cataract of 
children. It is preferable to linear extraction, as no extreme pre- 
cautionary measures are demanded and there is ample time to wait DISCISSION FOR HIGH MYOPIA 
229 
until spontaneous absorption of the lens has taken place. The latter 
progresses usually promptly and completely in young patients. 
Occasionally it may be necessary to perform discission a second or 
even third time, if the opening in the capsule closes, and absorption 
of the lens substance does not progress. As long as flakes of opaque 
lens continue to come forward into the anterior chamber, it indicates 
that the capsular wound is open, and no repetition of the operation 
is necessary. 
Not infrequently after discission of even shrunken cataracts in 
children, an increase in intraocular pressure develops, which usually 
disappears, however, within a few days by the use of eserin and cold 
compresses. Only in rare instances will puncture of the cornea be 
necessary, and then the incision should not be longer than 2 mm. at 
the most, so that danger of prolapse of the iris may be avoided. 
Discission for High Myopia.—Discission of a transparent lens 
is undertaken in high-grade myopia only for the purpose of com- 
pletely removing the lens. The immediate consequence of discission 
is a traumatic cataract, and the rapidity with which this forms de- 
pends chiefly upon the size of the capsular wound. If only a single 
cut has been made, the opacity not infrequently remains limited to 
the tissue immediately surrounding it, as the capsular wound may 
close. Therefore, if after a few days the cataract should make no 
progress, the discission must be repeated and the capsule incised 
more freely. If the anterior lens capsule is well opened, total opac- 
ity of the lens quickly follows, and the anterior chamber is soon filled 
with lens substance. 
During the period of swelling of the lens the pupil must be kept 
widely dilated by atropin. The development of the cataract is suffi- 
cient in itself to set up a state of intense irritation and ciliary hy- 
peremia, and atropin not only hinders the formation of posterior 
synechia, but prevents increase of pressure and incarceration of the 
swelling lens substance in the narrowing pupil. 
The swollen lens substance is absorbed rather slowly, and many 
weeks may elapse before it entirely disappears, during which time 
the eye is in a state of constant irritation. Hence, we prefer after 
about fourteen days, by which time the entire lens has become 
opaque and soft, to remove the masses from the eye by an incision 
made with the lancet at the lower corneal margin. Provided the 
posterior lens capsule has not been injured by the discission, this 230 
CATARACT 
trifling operation is performed without accident, especially as an 
incision 5 mm. long usually suffices. 
The indications for the operation in high-grade myopia are as 
follows: 
1. The degree of myopia must be more than 16 diopters; if the 
myopia is less than this amount the patients will require after opera- 
tion convex glasses for distance vision and still stronger lenses for 
near vision. The difference in the refraction produced by the 
removal of the lens in myopia amounts to nearly 20 diopters on an 
average, as against 10 diopters in normal eyes. 
2. The visual acuity of the eye to be operated upon must not have 
suffered too severely through intraocular changes, and must at least 
be one-sixth to one-quarter of the normal and not seriously disturbed 
by a central scotoma. 
3. The patient’s other eye must still be useful, that is, it must not 
have suffered detachment of the retina, severe choroiditic processes, 
or other diseases. 
4. The operation is limited to patients under forty years of age. 
Narrowing the foregoing indications down to these limits, the 
results obtained by the operation are on an average good. It is of 
especial importance that no injury is done to the vitreous body, par- 
ticularly in myopic eyes, in which the vitreous is not healthy. In 
a properly-executed discission of the lens, no such injury occurs, 
although all operations for secondary cataract must involve the 
anterior portions of the vitreous. There is no doubt that eyes 
operated upon for myopia are especially prone to develop detach- 
ment of the retina, and the patient’s attention should be called before 
the operation to all the possibilities of disaster, and especially 
should it be stated that the operation is no guarantee against the 
serious intraocular changes that usually occur sooner or later as a 
consequence of the high-grade myopia. 
Accidents of Discission and Complications during Healing.— 
These include escape of aqueous, increased intraocular tension, 
prolapse of the vitreous, and infection. 
Escape of Aqueous. This is prevented by employing a knife with 
a shank of a diameter that closes the opening made by the blade, 
and also by withdrawing the knife quickly at the same angle at 
which it entered the anterior chamber. Escape of aqueous may be 
followed by adhesion of the iris to the place of perforation, with the ACCIDENTS AND COMPLICATIONS DURING HEALING 
231 
formation of anterior synechia. Where the anterior chamber 
is of normal depth, the entrance of the knife-needle at the limbus or 
slightly posterior in the sclera prevents escape of the aqueous and 
obviates all risks of infection, which sometimes follows puncture 
through the cornea. 
Increased Tension.—Extensive incisions in the capsule and lens are 
not infrequently followed by rapid swelling of the lens. If tension 
increases and the pupil is not dilated sufficiently, it should be our 
first task to open the pupil as much as possible by thorough cocainiza- 
tion, followed by the application of dry atropin, and at the same time 
apply iced compresses to the closed lids. If the pupil is sufficiently 
dilated, we must not instill miotics with the hope of decreasing pres- 
sure. If the glaucomatous symptoms are marked, and do not 
disappear within twenty-four hours, the anterior chamber should be 
opened with the keratome, and the swollen lens removed. 
Prolapse of the Vitreous.—The posterior lens capsule must not be 
injured in discission for either the opaque or the transparent lens. 
Should it be decided later to incise the cornea to permit the swollen 
lens particles to escape, prolapse of the vitreous immediately follows. 
This makes it impossible to massage the soft lenticular masses from 
the eye, as more vitreous would be squeezed out. The iris is likewise 
displaced from its proper position by the vitreous and remains 
permanently distorted. This accident may result from introducing 
the needle too deeply, and directing it too perpendicularly. On 
that account the needle should be made to glide obliquely through 
the substance of the lens during the vertical incision, and be drawn 
out of the eye during the horizontal incision. 
Injury of the vitreous is especially to be avoided in the discission 
of the clear lens for high myopia. The vitreous is fluid in this refrac- 
tive error, and no more injury should occur than the slight amount 
that must follow cutting the secondary cataract which develops 
through subsequent thickening of the lens capsule. 
Infection.—This is a rare complication, the infection following the 
bruising of the tissues by the shank of the knife in prolonged at- 
tempts to cut dense capsular membranes. It is more likely to occur 
when the puncture is made through the cornea instead of at or 
slightly posterior to the limbus in the sclera. 
Discission of Secondary Cataract.—As a secondary cataract 
forms the only septum between the aqueous and the vitreous cham- 232 
CATARACT 
bers, discission cannot be performed without some injury to the 
vitreous, which should be always as little as possible. Operation 
is performed with the pupil widely dilated, and with the condensed 
illumination of a lamp or other artificial light, especially in those 
cases with a glassy membrane in which the pupil occasionally appears 
quite black. 
The same general directions given for discission of congenital 
cataract are followed in the operation for secondary cataract. If, 
after the first incision, a free space is noted at once, the needle must 
be withdrawn. Only when the first cut is without result is a second 
or third made in different directions, never penetrating the vitreous 
body deeply. 
Complications.—If the pupil is held by posterior synechia, so 
that dilatation by atropin is impossible, the operation becomes more 
difficult, although the injury to the iris can be averted in consequence 
of the great depth of the anterior chamber. 
If the membrane is tough and has become adherent to the margin 
of the pupil, it may evade the needle and be pushed back, the iris 
dragged or even separated at its ciliary attachment (iridodialysis); 
or it gives way to the knife by detaching itself from the iris at one 
point and becomes pressed backward like a lid, returning quickly 
to its original position in the pupil when the needle is drawn forward, 
so that the result of the operation is frustrated. 
Discission with Two Needles (Bowman).—If we fail to incise 
the membrane by the usual method, it is necessary to employ two 
needles, one introduced from the outer and the other from the inner 
side of the cornea. The points of the knife-needles enter close to- 
gether through the center of the membrane, and by raising the 
handles of the instruments the needles are moved in opposite direc- 
tions, tearing asunder (dilaceration) the membrane. Combined 
discission with one needle entered through the cornea and the other 
through the sclera may also be of advantage. The operation with 
the needle is suited for cases in which the secondary cataract consists 
only of the capsule and the remnants of the lens. 
If the capsular membrane contains a layer of connective tissue, 
following an iridocyclitis, the needle is not sufficiently strong to 
freely divide it, and must be replaced by the Graefe knife. This 
operation is then called capsulotomy, or, if some of the iris is cut into 
at the same time, iridotomy. IRIDOTOMY 
233 
Iridotomy (Figs. 160 and 161).—'The application of iridotomy 
may be illustrated by a typical case. If, after an extraction with 
loss of vitreous, the pupil is drawn upward into the region of the 
dense scar and closed by a membrane consequent upon an iritis, the 
accompanying picture (Fig. 161) may be seen. Before any operative 
procedures are undertaken, it is necessary to determine that good 
light-perception and light-projection exist, that all inflammation 
Fig. 160.—Iridotomy. The pupil is displaced upward by the scar resulting from the 
cataract operation, and is obstructed by a membrane. The patient is looking well 
upward; the eye is fixed at the side. The Graefe knife, directed obliquely upward, is 
introduced into the cornea in the vertical meridian rather close to the lower limbus; the 
edge of the knife is directed backward. 
of the eye has completely subsided, and that there is no irritation of 
the eyeball, as manifested by the appearance of mild ciliary injection. 
The contemplated operation must accomplish two purposes, namely, 
to clear the pupil and to alter its position, so that it will come to lie 
behind the center of the cornea. It is not sufficient to simply cut the 
membrane in the pupil, but the incision must extend through the iris 
and the dense fibrous membrane which lies behind it. For this 
purpose the cornea is penetrated below by a sharp Graefe knife, the 
cutting edge of which is backward while the point is directed upward 
toward the pupil (Fig. 160). By a slow sawing movement, using the 
back of the blade against the corneal tissue as a fulcrum, a vertical 
incision (Fig. 161) from above downward is made through the pupil- CATARACT 
234 
lary membrane and the iris, producing a vertical fissure which 
extends to below the center of the cornea. Only a very sharp knife 
will divide the membrane without pulling on the iris. Immediately 
after division, the cut borders retract, and a broad, often triangular, 
opening is formed in the diaphragm. Iridodialysis may occur if the 
membrane together with the attached iris evades the knife and is 
pressed backward. It is frequently observed that the 
dense membrane is readily divided, while the delicate 
tissue of the iris escapes the knife, resisting all attempts 
to incise it. 
After the incision has been completed, the knife is 
withdrawn and pressure immediately exerted on the 
eye through the closed lids by means of the finger, and 
a pressure-dressing applied at once. 
Hemorrhage.—This can occur not only from the cut vessels of 
the iris, if the latter has been incised, but also from division of the 
newly-formed vessels found in the dense fibrous secondary membrane. 
Such hemorrhage would make the final result of the operation doubt- 
ful, and in most cases render it worthless. From extensive experience 
we know how difficult of absorption is a hemorrhage in the anterior 
chamber in eyes affected by a chronic iridocyclitis. If after many 
weeks the blood gradually disappears, it will usually be found that the 
clear space obtained by the operation is again closed by a fibrous 
membrane formed by organization of the clot. 
If pressure is exerted upon the eye as soon as the knife is with- 
drawn, and a firm bandage is applied at once, the risk of hemorrhage 
is lessened. The bandage may be replaced by the ordinary protective 
dressing six or eight hours later. By this time closure of the injured 
vessels has taken place, and a secondary hemorrhage need not be 
feared. The many published bad results of the iridotomy can usually 
be traced to neglect of the proper procedures for the prevention of 
hemorrhage. 
The depth of the anterior chamber is not decreased by iridotomy, 
and a prolapse of the vitreous does not occur. In withdrawing the 
knife, however, a thread of vitreous may be pulled out through the 
point of perforation, so that careful after-treatment must be con- 
tinued, with thorough cleansing of the conjunctival sac at frequent 
intervals with an antiseptic solution. If the thread of vitreous is seen 
exposed in the wound, it may be touched with the thermo-cautery. 
Fig. 161.— 
Direction of 
the incision in 
iridotomy. DISCISSION THROUGH THE SCLERA 
235 
Rest in bed is indicated only for the first twenty-four hours, but the 
eye should be kept bandaged for several days. Provided that no 
serious intraocular conditions exist, such as dense vitreous opacities 
and retino-choroiditic areas, vision may become good. However, 
these complications are not infrequent, and the unsatisfactory results 
must not be attributed to the operation. 
A vertical incision gives the advantage of cutting approximately 
parallel to the fibers of the iris without seriously injuring any of its 
vessels. The disadvantage of making the incision in the direction of 
the fibers of the iris arises from the fact that the cut shows no tend- 
ency to gape and sometimes exists only as a fine line, which soon 
closes completely through the accurate application of the wound- 
edges. If a horizontal incision, running transversely to the direction 
of the iris-fibers, is used, we are able to make it at any height desired 
(therefore, exactly behind the center of the cornea), and in addition 
produce a broader gap through retraction of the iridal tissue. A hori- 
zontal incision, it is true, divides many more of the blood-vessels of 
the iris, and, therefore, the pressure-dressing must be applied to the 
eye with special rapidity after the incision has been made. If, 
however, as is not infrequently the case, the iris has undergone a 
fairly high degree of atrophy, a large number of the iridal vessels will 
have been obliterated and injury to them is of but little importance. 
Should the result be unsatisfactory, there is no objection to an 
early repetition of the operation, provided that the eye is not irritated. 
The foregoing method of iridotomy is the only operation we 
employ in cases of complicated secondary cataract. Its superiority 
over the operation after de Wecker consists in not opening the anterior 
chamber, thus making a loss of vitreous impossible, in its greater 
rapidity, in the careful handling accorded to the iris, and in the almost 
invariable satisfactory result, if such an issue of the operation is at all 
possible. 
Discission through the Sclera (Fig. 162).—This operation is 
adapted only to secondary cataract. The needle should be stronger 
than that ordinarily employed for discission through the cornea. 
By entering through the sclera, there is the advantage of being able 
to use more force in dividing the membrane than is possible by the 
operation from the front. 
To avoid various unpleasant complications, the perforation with 
the needle must be made posterior to the ciliary body, that is, at a 236 
CATARACT 
distance of at least 6 mm. from the limbus, and either above or 
below the horizontal meridian, so as not to injure the posterior long 
ciliary artery. It is easier to enter at the outer and inferior side, 
while the patient looks upward and inward, and the eye is held in this 
position by forceps. The needle is directed forward and pushed 
through the membrane in the pupil so that the point appears in the 
anterior chamber (Fig. 162). By elevating the handle of the instru- 
ment the membrane is divided. In order not to injure the vitreous 
more than is necessary, as few cuts as possible are made. If, after the 
Fig. 162.—Discission through the sclera in the left eye. The discission-needle is 
introduced from the outer and lower side and pushed forward through the sclera, at a 
distance of at least 6 mm. from the limbus. The secondary cataract is pierced, so 
that the point of the needle appears in the anterior chamber. Lastly, the membrane is 
divided by bringing the needle into an erect position. 
first cutting movement, a black space is seen to appear in the mem- 
brane, the needle is quickly withdrawn from the eye. Only in case the 
first incision fails to produce a free opening, and simply depresses 
the membrane so that it springs back again into the pupil, must a 
second or third attempt be made to incise it. The injury to the vitre- 
ous incurred by this method is no greater than when the operation is 
performed through the cornea. In all cases of secondary cataract 
injury to the vitreous cannot be avoided. 
A great advantage of this operation is that the surgeon is able to 
move the needle in a larger area of excursion than when the needle EXTRACTION OF SOFT CATARACT 
237 
must be pushed perpendicularly through the cornea into the deep 
anterior chamber. The latter procedure leaves very little freedom of 
motion. After discission through the sclera, complications such as 
increase of intraocular pressure and cyclitis are common. The former 
usually disappears within a few days under the use of eserin and 
cold compresses. In most cases the cyclitis is also a transient 
phenomenon. 
LINEAR EXTRACTION 
Linear extraction is employed for the removal of soft cataract, the 
thirty-fifth year being approximately the upper age limit; as a second- 
ary operation after discission of total cataract of young adults; for 
glaucoma which may occur from rapid swelling of the lens after dis- 
cission; and for the removal of traumatic cataract. 
Extraction of Soft Cataract.—The operator sits to the right of the 
patient, and uses the right hand for either the right or left eye. The 
fixation is made at any suitable point, and the keratome is held in 
the same manner as described for the incision for iridectomy (Fig. 163). 
After dilatation of the pupil with homatropin, the lancet is applied 
rather perpendicularly below and exactly at the limbus, and, as soon 
as the point has entered the chamber, the blade is turned parallel to 
the iris (Fig. 164), and, without either forward or backward pressure, 
pushed in until the incision has reached the desired length, 6 to 8 mm. 
If the iris is well retracted, it is not exposed to any danger of injury. 
As with all cuts which open the anterior chamber, the instrument 
must not stop in its progress, otherwise escape of the aqueous humor 
would render impossible a further lengthening of the incision. The 
lancet is slowly withdrawn from the eye so that the aqueous humor 
escapes gradually. At the moment the anterior chamber is emptied, 
the pupil either becomes narrow, or the iris floats into the wound by 
the aqueous humor. 
Opening the Lens Capsule.—We prefer the use of the capsule- 
forceps, as described under the operation for senile cataract. They 
must be slightly raised after they have entered the pupil, so that the 
posterior untoothed part of the closed blades does not seize the iris. 
With a relatively short incision and a narrow pupil it may be difficult 
to use the forceps, and the pointed cystotome is to be employed to 
incise the capsule several times, without, however, making pressure, 
or the lens will be dislocated. The sharp hook may also be carried 238 
CATARACT 
through the lens substance in different directions, to cut it into small 
pieces, especially if the central portions should be sclerosed, as occurs 
in some cataracts of children and in zonular cataract. 
Removal of the Lens.—If the cataract is soft, it suffices to merely 
depress the scleral wound-margin slightly by means of the spoon, in 
order to allow the soft mass to slide out through the gaping wound. 
Fig. 163.—Linear extraction in the right eye. The operator’s left hand fixes the eye 
with a pair of forceps, above at the limbus, while with the right hand he applies the 
lancet almost vertically below, exactly at the limbus. The pupil is dilated by atropin. 
If, at the same time, the cataract is gently stroked from above 
downward with another spoon against the cornea (Figs. 165 and 166), 
the escape of the lens substance will be rendered easier. Occasionally 
after the pupil has become black, new opaque particles appear, 
from above and behind the iris as the result of this gentle massaging. 
These must be removed through the wound by further massage. LINEAR EXTRACTION 
239 
Fig. 164.—Linear extraction. In the second part of the incision, the lancet is turned 
over and has penetrated far upward. The incision lies exactly at the limbus. 
Fig. 165.—Linear extraction.-—After opening the capsule the soft cataract remnants 
are massaged out of the eye. A spoon held in the right hand of the operator depresses 
the scleral wound-margin somewhat, thus causing the wound to gape, while with another 
spoon held in his left hand he makes stroking movements over the cornea from above 
downward. 240 
CATARACT 
The iris is now smoothed in place, a dressing applied to both eyes, 
and the patient put to bed. If no complications have occurred, the 
dressing may be discarded after three days. 
Complications.—If the lens is found to contain a fairly large 
nucleus, and this is occasionally seen even in young people, the 
hardened nucleus presses against the wound and fails to pass out. In 
these cases the incision is to be lengthened at one or both ends by 
means of the scissors, allowing the nucleus to escape easily, and thus 
Fig. 166.—Diagram showing the position of the two spoons for the expression of the soft 
lens-masses in linear extraction. 
avoiding the risk of a prolapse of the vitreous by applying too strong 
pressure. 
Prolapse of the iris occasionally follows the expression of the lens, 
and care should be exercised that the iris is not injured during replace- 
ment with the spatula. The membrane may also be injured during 
the incision, in opening the lens capsule, and in massaging out the 
cataract with the spoon. A torn iris may give rise to most unpleas- 
ant sequels, by shrinking or by adhering to the corneal scar. If the 
iris has been considerably injured it should be excised. The resultant 
coloboma lying exposed in the palpebral fissure, however, causes 
annoying visual disturbances. As the operation usually passes off 
smoothly, the incision below is preferable, because the patients more 
readily look upward, and so freely expose the field of operation. If 
performed near the specified age-limit, it is better to make the corneal 
incision above, so that in the event of a large nucleus the wound can 
be lengthened and the iris, should it prolapse, excised. TOTAL CATARACT OF YOUNG ADULTS 
241 
Prolapse of the vitreous is a rare complication, but may occur in 
old and complicated cataracts in which the capsule is thickened and 
the lens together with its capsule is pulled out of the eye with the 
capsule-forceps. Occasionally, removal of the lens and capsule 
is performed in blind eyes for cosmetic reasons, but here there is 
always danger of vitreous prolapse. However, as the vitreous is 
fluid and the eyeball soft, the wound shows no tendency to gape, and 
the iris usually retains its normal position. Much more unpleasant 
is prolapse of vitreous of normal consistency during the course of a 
linear extraction. In this instance, not only is the further removal 
of the soft lenticular mass prevented, but no replacement of the iris 
can be attempted, and the pupil remains permanently distorted. 
Moreover, the wound frequently gapes, and has its healing process 
interfered with by the lower lid pressing against it during the ocular 
movements. Application of a suture to produce coaptation of the 
edges of the wound may become indispensable. 
Total Cataract of Young Adults.—Linear extraction gives the 
most rapid results in total cataract of young adults, usually those over 
12 years of age, who have sufficient intelligence to remain quiet during 
and after operation. Even in these cases discission followed eventu- 
ally by puncture of the anterior chamber may be given preference. 
As the cataract is often a complicated one, it may happen that the 
fluid vitreous escapes from the wound as soon as the incision has been 
made with the lancet. In this event a supplementary discission of 
the capsule of the lens must suffice, as it would be impossible to 
remove by massage the lens-masses from the eye. For several weeks 
the pupil is kept dilated with atropin to permit the aqueous to enter 
the capsular sac and absorb the lens-remnants. A secondary discis- 
sion of the capsule and unabsorbed lens may be required. CHAPTER XII 
OPERATIONS FOR GLAUCOMA 
PRIMARY GLAUCOMA 
I. EXCISION OF THE IRIS (GLAUCOMA IRIDECTOMY) 
Indications.—Iridectomy is indicated in primary glaucoma and 
in secondary glaucoma not of temporary character, such as that 
caused by anterior synechia, exclusion of the pupil following iritis, 
luxation of the lens, cysts of the iris, and beginning ectasia of the 
cornea or sclera. 
Fig. 167.—Anterior portion of the eyeball in cross-section to demonstrate the rela- 
tions in position of the angle of the chamber and limbus (enlarged). The limbus reaches 
about 2 mm. further forward than is represented by the situation of the angle of the 
chamber, a. and a'., limbus; ab. and a', b'., position of the incision for the extraction of 
cataract. The Graefe knife, which in cataract incisions is inserted just at the limbus, at 
a., perforates the posterior wall of the cornea at b. In order that the knife shall come 
out exactly again at the limbus at a'., the counter-puncture must be begun already at b'., 
that is, at a point which to the operator seems to lie about 1 mm. from the limbus, in the 
direction toward the cornea; c.d., direction of incision with keratome in glaucoma. 
Before operation the pupil should be contracted as much as 
possible by the frequent use of eserin, which, however, is often with- 
out effect when the pressure is considerably increased and advanced 
atrophy of the iris is present. 
In highly inflamed and painful eyes scopolamin-morphia narcosis 
or general narcosis is employed, otherwise thorough local cocain 
anesthesia suffices. As cocain dilates the pupil, alypin is substituted INCISION WITH THE LANCET 
243 
in those cases in which miotics previously failed to contract the pupil. 
The lack of vaso-constrictor action may be remedied by the 
simultaneous use of adrenalin. 
The Incision.—The incision for iridectomy in glaucoma is made 
through the sclera, from i to i34 mm. behind the limbus, either with 
a keratome or a Graefe knife. 
Fig. 168.—Iridectomy for glaucoma in left eye. Beginning of the incision. The 
assistant fixes the upper lid with one finger of his right hand in such a manner that the 
operator is not interfered with in the second act of the incision, when the position of 
the lancet is changed. The lancet is applied slantingly against the sclera at a distance of 
at least i mm. back of the limbus. 
Incision with the Lancet.—The operator is seated at the right side 
of the patient, and fixes the eyeball below in the vertical meridian. 
The lancet is held in the right hand between the thumb and first and 
second fingers, while the little finger is steadied against the head. 
The patient is directed to look well downward, and the point of the 
knife is placed against the sclera, i to mm. back of the limbus, 244 
OPERATIONS FOR GLAUCOMA 
the blade forming an angle of about 45 degrees to the curvature of the 
sclera (Fig. 168). In the illustration, Fig. 167, the line, cd, shows the 
direction of the point of the keratome applied vertically to the sclera, 
but, with a shallow anterior chamber or with the root of the iris 
Fig. 169.—The position of the lancet is changed to the plane of the iris and is held so 
that the incision on all sides is the same distance from the limbus. Before the incision 
is completed the lancet penetrates further downward than is shown in the figure. 
iii contact with the posterior wall of the cornea, injury to the iris 
would be unavoidable. Besides, as the rotation of the lancet in order 
to come in the plane of the iris has to be considerable, it is recom- 
mended not to apply the knife too vertically against the sclera in 
making the puncture. By a slight pressure the point penetrates 
the sclera, and, as soon as it is seen to have entered the angle of the 
anterior chamber, the direction of the knife is changed, so that the INCISION WITH THE • LANCET 
245 
surface of the blade is parallel with the iris (Fig. 169). The knife 
is now pushed downward without interruption until the point passes 
the lower border of the pupil, or the cut is as large as needed (Fig. 
17c). After the lancet has entered far enough downward, and the 
incision is of the desired length, the knife is slowly withdrawn from 
the eye, with the blade parallel to the iris and the point directed 
toward the posterior surface of the cornea, so that 
the capsule of the lens is not injured as the aqueous 
escapes. 
The turning of the lancet at the proper time 
from its slanting position to parallel with the iris 
can only be determined by the sense of touch, as 
after the point has perforated the sclera the re- 
sistance of the globe is no longer felt. If the 
direction of the knife is changed too soon, the cut 
is made irregularly and too far forward, and the 
internal opening, instead of piercing the angle of 
the chamber, is found nearer the cornea. 
During the incision the lancet must not be pressed backward 
against the sclera, as the wound will gape and the aqueous flow away, 
in which case the incision could not be lengthened and the iris and 
lens would be exposed to injury. The knife must not be withdrawn 
until the incision is completed, as this will also permit escape of the 
aqueous. If the aqueous is allowed to escape rapidly the iris will 
float forward with it, but with the blade slowly withdrawn the 
aqueous flows out gently, and the pupil then remains round. 
The incision must be maintained at a uniform distance from the 
cornea (Fig. 170, a b), by keeping the blade parallel with the limbus. 
If one edge of the knife is turned slightly forward, the cut on this side 
will not remain at the same distance from the limbus at which the 
point of the lancet was first placed, but will deviate forward into the 
cornea. Indeed, the difficulty of the incision with the lancet lies in 
the fact that the eye of the operator must at the same time control 
the point of the instrument penetrating more and more downward, 
and also the appearance of the cut above at the limbus. 
The point of the knife must not be turned backward, otherwise 
the lens capsule will be injured while passing the pupil. This can be 
avoided by a slight sideward movement of the point of the lancet, 
which is thus carried upward in front of the iris. In withdrawing the 
Fig. 170. — The 
lancet is pushed far 
down. The solid line 
a.b. denotes the posh 
tion of the cut. 246 
OPERATIONS FOR GLAUCOMA 
lancet the length of the incision may be increased by pushing the 
lancet somewhat forward along the side of the limbus. 
Incision with the Graefe Knife.—The Graefe knife may be used: 
(i) If the anterior chamber is very shallow. (2) If the pupil is dilated. 
(3) If the cornea is so opaque as to prevent the operator’s view of the 
path of the knife. (4) In restless patients. 
The same rules apply in the fixation of the eye, the position of the 
operator, and the employment of the right and left hand as in the 
operation for cataract. On the right eye, if the anterior chamber is 
very shallow, it may be preferable to operate from behind, as in this 
position the right hand can be steadied on the head of the patient 
better than the left when operating from the front. The length of 
the incision should be the same as when the lancet is used, about 
8 mm. To obtain a sufficiently peripheral position, the knife point 
is entered in the sclera 1 mm. from the limbus, and passed approxi- 
mately parallel to the plane of the iris. If held more upright against 
the sclera, an injury to the iris, and indeed even to the lens, is easily 
incurred. After the point of the knife has appeared in the angle of 
the chamber, the instrument is pushed forward to the outermost part 
of the opposite angle, always remaining in front of the iris to avoid 
the pupil, and the counter-puncture is made. The knife is carried 
upward with a sawing motion, during which it is held in a plane paral- 
lel with the iris, so that the incision remains at a uniform distance 
from the limbus throughout. Not until the blade has arrived beneath 
the conjunctiva above is its cutting edge turned forward to form the 
short conjunctival flap, as in the cataract operation. 
Advantages and Disadvantages of the Two Knives. The ad- 
vantage of employing the lancet is that the edges of the wound are 
smooth and easily apposed, and healing is complete in a few days. 
The incision with the Graefe knife is more inclined to gape, and, on 
account of its irregular edges, does not heal so promptly. But this 
factor may be considered as an advantage in eyes with an increase 
of pressure, inasmuch as fluid will ooze out more easily and for a 
longer time through a wound which does not close rapidly than 
through one which heals promptly and solidly. 
The lancet is easily injured by handling or boiling, and if force is 
used in an attempt to penetrate the sclera with the dull point, the 
knife may suddenly slip forward and injure both the iris and lens. 
The same accident may occur with a perfectly sharp lancet if EXCISION OF THE IRIS 
247 
the patient makes a sudden movement with the eye or head. The 
Graefe knife is undoubtedly much less dangerous, especially for the 
beginner, and a peripheral incision is more easily attained with 
it than with the lancet. On this account the lancet is only used in 
those cases in which the anterior chamber is not too shallow, and those 
with a contracted pupil, when quiet behavior of the patient is 
probable. 
While the performance of the incision with the Graefe knife lessens 
somewhat the danger of injuring the iris and lens through too rapid 
and too deep penetration, it occasionally leads to the opposite error— 
the intralamellar incision. The faulty position of the knife is recog- 
nized by the feeling of resistance as the blade is pushed forward, 
which disappears if the point has penetrated into the anterior 
chamber. Another indication of the intralamellar position of the 
knife is a depression which appears in the cornea if the operator 
attempts to press the knife slightly backwards. As stated in the 
description of the operation for cataract, the knife may be withdrawn 
and the incision made at the proper 
place, if the anterior chamber has not 
been opened, but if the aqueous has 
escaped, the operation must be post- 
poned until the next day. 
Excision of the Iris.—The iridec- 
tomy is performed in the same general 
manner and with the same instruments 
as described in the operation for cata- 
ract. The iris-forceps are held in the 
left hand and are introduced closed into 
the wound until they reach nearly to 
the upper margin of the pupil, then 
opened, and a fold of iris drawn out 
and excised with the de Wecker scissors 
which have been held ready. The iris 
section is, however, essentially different from that in cataract 
operation. As the object is not only to excise the iris close to its 
attachment, but also to remove as large a piece as possible, the 
scissors, held parallel and close to the wound (Fig. 171), which may 
even be slightly depressed by them, sever the right half of the iridal 
fold first, after which the rest of the iris is drawn with the forceps 
Fig. 171.—The iris drawn out 
from the eye is cut off near its at- 
tachment by the scissors, the 
blades of which are held parallel 
with the limbus. 248 
OPERATIONS FOR GLAUCOMA 
still further toward the other angle of the wound, thus pulling still 
more membrane from the eye, and the left half is cut through. As the 
excision of the iris is ordinarily quite painful, the scissors should 
be ready close to the wound to make the cut as soon as the iris is 
grasped. 
The sensitiveness of the iris is considerably diminished by repeat- 
edly dropping a 3 per cent, solution of cocain on the incision, at 
the same time depressing the scleral wound-margin with the spatula, 
so that the solution reaches the iris through the gaping opening. In 
about three minutes the anesthesia of the iris is practically 
complete. 
Reposition of the Iris.—The iris is replaced in exactly the same 
manner as described in the operation for cataract, although reposition 
is much more difficult, because the relatively higher pressure squeezes 
the margins of the coloboma into the angles of the wound, and, as the 
iris is frequently atrophied, it shows little tendency to resume its 
normal position. Attempts at reposition are not to be discontinued 
until both sphincter-margins are in place, as healing of the iris in 
the wound is likely to lead to a renewed attack of glaucoma. After 
the margins are stroked from the angles of the wound, the spatula 
is withdrawn in the area of the coloboma, so that the edges of the 
iris are not again displaced. Contact of the spatula with the lens 
capsule may cause injury of this delicate membrane. Therefore 
the instrument is withdrawn from the eye in a plane parallel 
with the iris. 
Under some circumstances it may be advisable to desist from 
replacement of the iris—if the wound gapes or a restless patient 
cannot be induced to look downward. Fixation of the eye has the dis- 
advantage that the wound is made to gape, which increases the likeli- 
hood of injury to the lens, and presentation of its upper border in the 
wound. 
If, in spite of correct replacement, the iris presses up toward the 
wound, indicating that the contents of the eye show a tendency to 
push forward, further attempts at replacement are not advisable, 
as escape of the lens and prolapse of the vitreous may follow. If the 
iris from the beginning is incarcerated in the edges of the wound, it 
is to picked up and excised. The cut margins then spontaneously 
retract in proper position. COMPLICATIONS OF THE INCISION 
249 
If the incision was made with the Graefe knife, the final procedure 
is to restore the conjunctival flap in position before the dressings are 
applied. 
Complications of the Incision.—These have mostly been described 
in the operation for cataract, and need only brief mention here. 
The most important are: 
Laceration of the conjunctiva when grasped by the forceps. 
Intralamellar incision. 
Transfixion of the iris by the Graefe knife. If the anterior chamber 
is shallow, the point of the knife may catch in a protrusion of the 
surface of the iris and penetrate its tip. This piercing of a few fibers 
of the iris with the knife is of no significance, as they are always cut 
through during the continuation of the operation, so that the freed 
iris again resumes its normal position. As in all other incisions which 
open the anterior chamber, the knife is not to be withdrawn with the 
intention of freeing the point, as escape of the aqueous prevents a 
continuation of the incision. The only indication for the withdrawal 
of the knife is when the operator, while making the puncture, passes 
the point back of the iris. If the faulty incision were continued, 
even more extensive injury to the iris and lens would occur than by 
the withdrawal of the knife. As the incision is relatively much shorter 
than that in cataract extraction, and is ordinarily above the region of 
the pupil, “falling of the iris in the way of the knife” is an extraor- 
dinarily rare occurrence in spite of the shallow chamber. 
Production of an Iridodialysis during the Incision with the Lancet. 
If the point of the lancet catches in the iris, the latter may be pushed 
down and thus torn off at its ciliary attachment. This is usually fol- 
lowed by hemorrhage, which greatly impedes the further course of the 
operation, especially as it is difficult to pull the severed piece of iris 
out with the forceps without endangering the exposed lens capsule. 
It is then safer to employ the blunt hook for withdrawing the iris 
instead of the forceps. 
Incorrect position of the incision is due to a faulty manner of hold- 
ing the knife (turning the cutting edge forward) or through improp- 
erly inserting the point. A cut directly forward against the cornea 
naturally lessens the likelihood of excision of the root of the iris. 
Especially to be avoided is too long an incision, which may be produced 
by introducing the knife too low down. The high intraocular pressure 
would cause the wound to gape and the lens to appear in the wound. 250 
OPERATIONS FOR GLAUCOMA 
Hemorrhage may become a disturbing factor during the perform- 
ance of the incision, originating either from dilated conjunctival or 
anterior ciliary vessels or from injury to Schlemm’s canal. The 
anterior chamber becomes filled with blood so that the iris is hidden 
from view. At first we must try to remove the blood from the eye by 
stroking it out, assisting it to escape by slightly depressing the periph- 
eral edge of the wound. Usually the blood reaccumulates quickly. 
It may be impossible, however, to remove the blood, as it becomes 
attached to the walls of the anterior chamber in the form of a clot. 
As the pupil cannot be seen, the lens capsule is in danger of injury 
during the withdrawal of the iris. The presence of the blood also 
greatly disturbs the replacement. 
Complications of the Iridectomy.—The excision of the iris is 
on the average much more painful than in cataract extraction. The 
influence of the anesthetic is less on account of the injection of the eye, 
and perhaps also because of the alteration in absorption conditions. 
Partial or complete detachment of the root of the iris may occur by 
the patient suddenly moving the eyeball while the forceps still grasp 
the membrane. Severe hemorrhage follows, obscuring the field of 
operation, but the blood is usually absorbed. It is our custom after 
the incision to instil several drops of a sterile 3 per cent, solution of 
cocain upon the wound, which, by direct contact, appreciably reduces 
the sensitiveness of the iris. 
A subconjunctival injection of cocain-adrenalin solution before 
the incision is made anesthetizes the iris, but the edema that follows 
and the retraction of the iris under the influence of the cocain com- 
plicates both the incision and the iridectomy. The larger the pupil 
the greater the danger of injury of the lens capsule and the more 
difficult the replacement of the iris. The edges of the coloboma are 
difficult to control on account of their shortness, and the iris itself 
does not contract because of the complete relaxation of its tissues. 
The iris may be so atrophic that the forceps tear out at each 
attempt to withdraw a fold. In well-advanced glaucoma the upper 
half of the iris may be turned back behind the limbus, necessitating a 
somewhat broader iridectomy below. The disturbance to vision due 
to the uncovered coloboma is of no importance, as sight is already 
seriously damaged by the glaucoma. 
The Earlier the Iridectomy in Glaucoma, the Easier the Operation.— 
So long as the anterior chamber is not too shallow, and the iris almost COMPLICATIONS OF THE IRIDECTOMY 
251 
normal, a large coloboma may be made and the root of the iris included 
in the section. If the angle of the chamber has been obliterated by 
adhesion, the incision cannot be made as near to the periphery as 
desired. Clinical experience shows that, where the operation has been 
delayed until the root of the iris is adherent in the angle of the anterior 
chamber, little relief can be expected by the operation of iridectomy. 
Injury of the Lens Capsule.—This is caused by the point of the 
knife, the iris-forceps, or the spatula. The injury occurs in the pupil- 
lary region, and is usually followed by cataract. If examination is 
made by lateral illumination, the scar of the capsule wound, from 
which the cataract had its origin, can always be demonstrated. The 
cataract does not always become complete, but may be confined either 
to a clouding in the neighborhood of the capsular wound, or to a 
stellar opacity in the anterior or posterior lamellae of the cortex. 
The injury to the capsule is frequently due to the iris-forceps. 
They should always be introduced into the wound parallel with the 
iris and pushed close to the margin of the pupil, but not brought 
within the pupillary space itself. If the iris has already floated into 
the wound, the forceps need not be entered into the interior of the eye 
at all, but should lift up the exposed iris, which becomes plainly visi- 
ble after the conjunctival flap has been laid back on the cornea. 
Should the patient not look well downward, the excision of the iris 
may become difficult and the danger of injury to the lens capsule 
increased, especially if he moves his eyes around or suddenly looks 
up while the forceps are in the eye. In such cases it is better to 
fix the eye with forceps, which ordinarily we avoid in iridectomy. 
Instead of the iris-forceps it may be necessary to draw out the iris 
with a blunt hook which has been bent in a suitable direction. Only 
a small piece of the iris can be excised, the removal of a large portion, 
under the circumstances, being inadvisable or impossible. 
Spontaneous Rupture of the Lens Capsule.—After completing 
the iridectomy, a subchoroidal hemorrhage may produce an increase 
in the intraocular tension, with rupture of the lens capsule. Spon- 
taneous rupture occurs in the equator of the lens, and no wound is 
seen in the capsule by lateral illumination. The lens is usually dis- 
placed forward, and its border presents in the wound, or the capsule 
may burst over a wide area, and the lens-substance with the nucleus 
be either discharged from the eyeball or become incarcerated in the 
wound (Hernia lentis), which remains widely gaping under the con- 252 
OPERATIONS FOR GLAUCOMA 
junctiva. The operator must be prepared for this accident in eyes 
with long-continued high tension, when the eye is of stony hardness, 
the anterior chamber almost obliterated, the sclera becoming ectatic, 
the iris markedly atrophic, and the eye itself painful. The operation 
often cannot be performed in these cases without a general anesthetic. 
If the eye is completely blind and painful, enucleation should be 
advised. 
Subluxation of the lens may occur in connection with its altered 
position after the anterior chamber has been opened and the aqueous 
humor has escaped. The lens then inclines forward, and its upper 
border tends to turn forward on account of the lessened resistance of 
the coverings of the ball in the region of the wound. This presages 
a bad prognosis for the later behavior of the eye. The anterior 
chamber does not become re-established for a long time, intense 
attacks of renewed increase in pressure follow, and in spite of repeated 
sclerotomies and other operations such eyes are usually lost. 
Prolapse of the vitreous is relatively rare, but is likely to occur in 
absolute glaucoma, especially if there is ectasis of the sclera. The 
prolapse not only makes excision of the iris impossible, but also a 
reposition of its margins. Besides, the wound gapes because of the 
interposition of the vitreous, and, although an ugly ectatic scar is 
formed, it is one of the relatively good outcomes of the operation. In 
most instances, however, renewed attacks of increase in pressure fol- 
low, which, on account of their painfulness, finally render enucleation 
of the eye compulsory. 
Occasionally the vitreous prolapse leads to a still graver complica- 
tion, namely, expulsive hemorrhage. On account of the sudden de- 
crease in pressure, severe hemorrhages under the choroid occur, and 
the latter is pushed forward with the retina and squeezed out of the 
eye through the wound. Particularly in the operations for old abso- 
lute glaucoma is this accident seen. Such eyes must be immediately 
enucleated, otherwise weeks would pass before the eye atrophied and 
became quiescent. The bleeding is usually considerable, and to 
arrest it the application of a pressure-dressing is necessary. 
Recurrence of Glaucoma due to the Healing of the Iris in the 
Wound of Incision.—If one or both edges of the coloboma become 
healed in the operative incision, and tension is again increased, the 
attached iris must be freed. The liberation of the incarcerated iris 
is made with a Graefe knife, which is inserted at one angle of the ANTERIOR SCLEROTOMY 
253 
corneal scar, carried through the anterior chamber until it reaches 
the other side of the site of adhesion, and is then brought out as far in 
the periphery as possible. The incision is completed with sawing 
movements. Frequently the knife has already separated the iris 
from the scar, and the membrane assumes its proper position immedi- 
ately after the incision has been completed. If this result is not 
secured, the iris must be brought out from the wound with the iris- 
forceps, and as large a piece as possible excised. The cut edges are 
then replaced. Because of the state of ocular irritation, this opera- 
tion is often difficult of performance, but is usually followed by a 
favorable result. The blackish scar, which has been ectatic, soon 
flattens out during healing, and increase in pressure does not recur. 
This operation is also indicated in adherent iris after cataract 
operations in which there has been an increase in tension. In order 
to prevent a gaping of the wound and a prolapse of the vitreous, it is 
recommended to leave a bridge of conjunctiva and then bring the iris 
out under it. By the same method one has to remove the so-called 
cystic scars after cataract operations. 
II. ANTERIOR SCLEROTOMY (DE WECKER) 
This operation was designed to produce a filtration cicatrix in the 
angle of the anterior chamber which would permit the aqueous to 
filter out of the eye, and prevent increase in the intraocular tension. 
Such a filtration scar is not actually secured, as the wound-edges are 
so close to each other that direct union takes place. 
Indications.-—De Wecker recommended the operation, combined 
with miotics, in chronic simple glaucoma, and in cases of high tension 
and shallow anterior chamber, with a view of later performing iridec- 
tomy. It has also been employed in hemorrhagic glaucoma, painful 
blind glaucomatous eyes, and hydrophthalmos. 
The Incision.—The opening into the anterior chamber resembles 
the incision made for the extraction of a senile cataract, except that it 
is placed more peripherally, and may be made above or below, the eye 
being fixed at such a point that the forceps will not be in the way of 
the knife. As the operation has for its object an incision into the 
angle of the chamber, the points of entrance and exit of the knife 
must lie in the sclera at least i to mm. from the limbus (Fig. 172). 
A Graefe knife is held as in the extraction of senile cataract, and 
the point is thrust through the sclera, 3 mm. from the horizontal me- 254 
OPERATIONS FOR GLAUCOMA 
ridian and parallel to the surface of the iris, and slowly carried across 
the anterior chamber, between the cornea and iris, and penetrates the 
sclera on the opposite side at the same distance from the limbus as 
the first puncture (Fig. 173). 
Fig. 172.—Anterior sclerotomy in the left eye, performed below. Beginning of 
the incision. The left hand of the operator fixes the eye, either laterally or above; 
the cutting edge of the knife is directed downward. The incision is begun at least 1 
mm. away from the limbus in the sclera. The lower lid is drawn far downward by the 
assistant. 
The incision is continued with sawing movements, as described in 
the operation for senile cataract, but the cut is not completed, the 
Fig. 173.—Diagram showing the position of the knife in the eye during the incision of 
the sclera. It lies in the sclera at least 1 mm. away from the limbus. 
knife being withdrawn from the eye before the incision is finished, 
leaving a small bridge of sclera. As it is the intention to also cut 
into the angle of the anterior chamber at the bridge of tissue (Fig. 
174), the direction of the handle of the knife is changed as the blade INTRALAMELLAR INCISION 
255 
is removed, so that the point incises from within the tissues in the 
angle of the chamber beneath the bridge of sclera (Fig. 175). The 
length of the entire incision is somewhat less than that of the cut in 
the cataract operation. Usually after completion of the incision the 
iris remains in its normal position, especially if the patient is quiet, 
but should the pupil be distorted or the iris prolapsed, reposition is 
done. If the iris is prolapsed when the dressings are changed on the 
following day, the prolapsed portion must be excised. 
Fig. 174.—Termination of the incision. In order to cut through the inner lamellae 
of the sclera in the neighborhood of the scleral bridge, which is permitted to remain, the 
knife is turned by an elevation of its handle in such a manner that its point produces the 
desired incision into the angle of the chamber. 
Compare the position of the operator’s hand holding the knife while performing the 
first act of the operation (Fig. 172) and while withdrawing it (Fig. 174). 
Accidents.—These usually follow errors in entering the knife, and 
have been previously described in the operation for cataract. 
Intralamellar Incision.—If the knife is directed slightly forward, 
instead of parallel to the iris, the point is pushed between the layers of 
the cornea, an error that is detected by the experienced operator by 
the resistance offered to the advance of the blade. If the faulty 256 
OPERATIONS FOR GLAUCOMA 
incision is discovered before the anterior chamber is perforated, it 
is best to withdraw the knife and to make a new puncture, but if the 
aqueous humor has already escaped, the operation must be postponed, 
as it is impossible to continue it without injuring the iris. The 
traumatic opacity of the cornea consecutive to an intralamellar 
incision is of no real significance, as it eventually clears up. 
Injury of the Iris.—If the point of the knife is thrust through the 
sclera too vertically the iris may be pierced and the lens injured. 
Fig. 175.—In this diagram the solid line represents the perforating cut, the dotted 
line that part of the incision in the range of which only the inner lamellae of the sclera are 
cut through. 
The knife may also divide the root of the iris which in certain condi- 
tions fills up the angle of the anterior chamber, causing iridodialysis 
and severe hemorrhage. 
Favorable results can be expected only if the incision passes 
through the angle of the anterior chamber. It is a mistake to make 
the cut at the limbus or in the cornea except when the root of the 
iris is adherent to the posterior surface of the cornea, thus displacing 
the angle of the chamber further forward and making it impossible 
for the operator to begin the incision to the outer side of the limbus, 
as the knife would then be passed in back of the iris. 
Results.—In the greater number of cases the results of operation 
are not only temporarily good but permanently lasting, if reserved 
for acute glaucoma in which after the usual iridectomy there is a 
renewed increase of pressure. In such cases it is our custom not to 
perform a second iridectomy at once, which, as it would have to be 
made below, is always followed by a severe disturbance in the 
visual power, but to place our reliance on an anterior sclerotomy. 
When necessary this operation may be repeated several times on the 
same eye, and it is optional whether the incision is made above, below 
or at any other favorable point. In the eyes with a coloboma 
upward we prefer to make the sclerotomy below, so that the knife is 
separated from the lens by the iris, to insure against a possible injury 
of the capsule. IRIDOENCLEISIS 
257 
In this, as in every glaucoma operation, the eye must be energeti- 
cally treated with eserin before the operation, in order to bring about 
as marked a contraction of the pupil as possible. 
III. IRIDOENCLEISIS (HOLTH) 
This method is employed for glaucoma simplex and has given 
satisfactory results. 
The Incision.—A short horizontal incision is made in the conjunc- 
tiva with the scissors about 10 mm. above the limbus, and the mem- 
brane is undermined to a point 3 mm. from the limbus. 
A lancet, 6 mm. broad, bent at an angle of 135 degrees, is intro- 
duced beneath the loosened conjunctiva, and the point entered into 
Fig. 176.—Iridoencleisis (Holth). Above, the incision through the conjunctiva, 
At a distance of 2 mm. from the limbus the incision through the sclera, at both ends of 
which little black dots indicate the interposition of iris. Small coloboma upward, 
with the edges of the sphincter slightly drawn up. 
the sclera 2 mm. from the limbus and pushed into the anterior cham- 
ber. The scleral incision is therefore not more than 6 mm. in 
width. 
Iridectomy.—The assistant draws the conjunctival fold down over 
the limbus with a blunt double hook, exposing the scleral incision, 
and the operator enters the iris-forceps to the sphincter margin, as 
for the usual iridectomy, and draws out a fold of the iris, which is 
incised in a meridional direction with the scissors. As soon as the 
blades of the forceps are opened, the iris usually retracts to such an 
extent that only two small black dots are seen at the angles of the 
wound (Fig. 176). Should a larger part of the iris tissue remain 
exposed it is excised. 
The assistant then releases the conjunctiva, which is stroked in 
place with the spatula. A suture is inserted only when the con- 
junctival wound gapes. Atropin is instilled immediately before or 
once after the operation. The after-treatment is the same as in 
iridectomy. No marked irritation follows the operation. 258 
OPERATIONS FOR GLAUCOMA 
It is important that the opening into the anterior chamber is no 
wider than 6 mm. The iris is easily recognized in an opening of this 
size. The assistant in drawing down the conjunctival flap is careful 
not to cover the entire iris above. As soon as the iris is drawn out 
of the wound, the de Wecker scissors should be ready to at once make 
the desired meridional cut, so that, if the patient should make any 
movement, the forceps are released but at the same time the incision 
is made by closing the scissors. 
The advantages over the scleral trephining of Elliot claimed by 
those who have followed this method are: 
1. A fistula is formed, the walls of which are covered with iris 
epithelium, so that the opening does not close with non-filter- 
ing cicatricial tissue, as is a frequent occurrence after scleral 
trephining. 
2. As the conjunctiva is not undermined to the limbus, where it 
is extremely thin, a large thin cyst does not usually form, as in the 
trephine operation, so that, with the iris covered with a thicker and 
more resistant tissue, late infection is less liable to occur, although 
it is not impossible. 
3. The ciliary body, protected by the scleral spur, is never 
touched, so that healing is not complicated by the irritation which 
often follows trephining, especially in the instances in which the 
ciliary body prolapses in the opening. In most cases tension is 
permanently diminished, and further decrease in vision is prevented. 
Sometimes the operation exerts no influence on the tension, or the 
pressure only slowly subsides to normal after a period of several 
months. If the tension has not been reduced to normal at the end 
of ten days, pilocarpin is to be used regularly. 
IV. EXCISION OF THE SCLERA 
Sclerectomy (Lagrange).—The anterior sclerotomy of de Wecker 
was intended to produce a scar through which the intraocular fluid 
could pass (filtration scar), so that by the continuous escape of the 
aqueous there could be no further rise in tension. The operation, 
however, fails to produce such a filtering scar, as the wound margins 
are so well adapted that primary healing occurs. A simple incision 
through the sclera, therefore, does not suffice, and it is only by the 
excision of a piece of scleral tissue, as Lagrange recommended, that a 
permanent opening is made from the anterior chamber into the LAGRANGE OPERATION 
259 
subconjunctival space. As the operation is usually combined with 
iridectomy, it is referred to as irido-sclerectomy. 
Indications.—Lagrange does not recommend the operation for 
acute glaucoma. It is indicated in (1) simple glaucoma, which 
experience has proved is little influenced by iridectomy; (2) increased 
tension in eyes on which iridectomy has previously been performed 
for glaucoma, the sclerectomy being preferred to a second iridectomy, 
Fig. 177.—Sclerectomy. Puncture 
and counter-puncture as in ordinary 
iridectomy. 
Fig. 178.—Sclerectomy. Cutting 
edge of the knife turned back. Incision 
begins to deviate from the limbus 
backward. 
as the coloboma is not enlarged, and, if performed above, prolapse of 
the iris cannot occur; (3) secondary glaucoma of various origin, for 
instance, anterior synechia, inflammatory affections in which previ- 
ous iridectomy has proved of no value, and in eyes with increased 
tension when it is desired to leave the iris untouched, as in sympathe- 
tic ophthalmia; (4) in all cases of glaucoma in which iridectomy has 
failed to act beneficially in one eye, sclerectomy would appear to be 
indicated if operation for the same affection becomes necessary in 
the other eye. 
The Incision.—After the full effect of eserin has been obtained, 
the point of the Graefe knife, with the plane of the blade parallel with 
Fig. 179.—Sclerectomy. Cutting edge ot the knife turned forward for excising the con- 
junctiva, behind which the scleral incision is visible. 
the iris (Fig. 177), pierces the sclera at a point 1 mm. back of the 
limbus, and about 4 mm. above the horizontal plane, crosses the 
anterior chamber in front of the iris, and emerges at a corresponding 
spot. As soon as the knife reaches the upper part of the angle of 
the anterior chamber the edge of the blade is turned slightly back- 
ward (Fig. 178), cutting obliquely through the sclera, about 3 mm. 
from the limbus, and forming a conjunctival flap, which latter is 260 
OPERATIONS FOR GLAUCOMA 
limited in its length by turning the blade directly forward (Fig. 179). 
Excision of a Piece of Sclera.—The conjunctival flap, which has 
attached to its under surface a piece of the sclera (Fig. 180), is turned 
over the cornea, and the scleral fragment grasped with fine forceps, 
and cut close to its conjunctival attachment with a pair of flat, 
curved scissors (Fig. 181). We prefer and have had made especially 
Fig. 180.—Sclerectomy. Vertical section through the eye. c., cornea; s., sclera; 1., 
limbus; e., piece of sclera to be excised. 
for the purpose a pair of de Wecker scissors with large and strong 
blades. 
Iridectomy.—The iridectomy is not an essential part of the opera- 
tion, and is usually added to prevent an iris prolapse. A narrow 
incision of the iris is made, so that a small coloboma results, or a 
peripheral portion only of the iris may be removed, leaving the 
Fig. 181.—Sclerectomy. Excision of the scleral flap. Conjunctival flap turned down 
over the cornea. 
sphincter intact. In simple glaucoma, where no special risk of pro- 
lapse exists, the iris is not excised. 
Immediately after operation the pillars of the coloboma are 
stroked in place, the conjunctival flap restored to its proper position, IRIDO-SCLERECTOMY 
261 
and dressings applied. A dark spot visible beneath the conjunctiva 
(Figs. 182 and 183) corresponds to the scleral opening. Directly 
after operation the conjunctival flap above this area is slightly 
sunken. 
Complications.- If the fixation forceps tear out, it is occasionally 
impossible to turn the knife and obtain the desired scleral section, and 
iridectomy is all that can be done. 
If the knife injures the root of the iris, especially when a so-called 
peripheral synechia exists, the iris is to be drawn out with a blunt 
Fig. 182.—-Irido-sclerectomy. Ap- 
pearance of the wound immediately 
after the operation. Complete iri- 
dectomy. 
Fig. 183.—Irido-sclerectomy. 
Peripheral iridectomy. 
hook instead of the forceps, to avoid injury to the lens capsule. In 
excision of the piece of sclera the iris often protrudes hump-like into 
the wound and is injured. Generally, the hemorrhage is more pro- 
fuse than in the ordinary iridectomy. 
Excision of the wedge of sclera will be difficult if the conjunctiva 
is pathologically adherent to the sclera. 
Prolapse of the ciliary body may follow a too peripheral incision, 
and will result in ectasia of the scar or shrinking of the eye after a 
lingering inflammation. 
Prolapse of the lens and vitreous may follow, as in ordinary iridec- 
tomy, although perhaps more frequently, especially in eyes with 
marked intraocular tension. 
Results.—The day after operation the conjunctival flap has 
usually become adherent, is somewhat swollen, and the anterior 
chamber remains shallow. There is usually more sensitiveness to 
light than follows ordinary iridectomy. The scar may show varied 
appearances: 
i. The conjunctival flap appears swollen and distinctly protrud- 
ing (Fig. 184), with the excised opening in the sclera distinctly shown 
as a black spot, but the wound-margins are in normal position. This 
is the most characteristic appearance, and is found in about one- 
third of the cases. 262 
OPERATIONS FOR GLAUCOMA 
2. The flap is flat, but the dark spot is distinctly seen, indicating 
a thinning of the sclera at that point. 
3. A round or oval opening is visible in the sclera in the area of 
the scar, back of the scarcely changed conjunctival flap—a conjunc- 
tival fistula. 
4. The scar is black, distended, the wound-margins of the sclera 
erect, and the conjunctival flap unchanged. This form of scar is the 
Fig. 184.—Filtration scar after sclerectomy. 
most unfavorable, as the pressure usually does not subside, the 
anterior chamber continues shallow, and the eye remains painful and 
must finally be removed. 
Irido-sclerectomy exerts a decided influence in reducing intra- 
ocular tension, probably frequently greater than any other glaucoma 
operation. In a few instances, even with the development of a typi- 
cal ampulla-shaped scar, the operation does not reduce the tension of 
the eye or influence the course of the disease. 
Disadvantages.—The objections made to sclerectomy are inabil- 
ity to accurately regulate the size and depth of the excised portion 
of the sclera, danger of injury to the lens, possibility of the formation 
of a distended scar, occasionally iritis, loss of vitreous, agglutina- 
tion of the pupillary border to the lens capsule, and the possibility of 
secondary infection through the scleral opening. 
V. SCLERO-CORNEAL TREPHINING (ELLIOT) 
Trephining the sclera immediately back of the limbus to secure 
permanent filtration has been suggested by both Fergus and Elliot. 
Both operations are modifications of the Lagrange sclerectomy, that 
of Fergus being combined with cyclodialysis. Fergus dissects a large 
conjunctival flap to the corneo-scleral margin, and removes from near ELLIOT OPERATION 
263 
the limbus a piece of sclera with the Bowman trephine. A spatula 
is then entered through the opening in the sclera, and kept in close 
contact with the sclera and cornea until it appears in the anterior 
chamber, separating the pectinate ligament, as in cyclodialysis. 
Indications.—While sclero-corneal trephining has the advantage 
of being accomplished easily and without much risk, it would appear 
to be justified only in those cases of glaucoma in which the ordinary 
iridectomy cannot be performed without extreme difficulty or danger, 
as in high degrees of tension, in extreme shallowness of the anterior 
chamber, and other unfavorable conditions, such as advanced age 
and serious general disease; also in instances in which other opera- 
tions have been done without result, and another attempt is to be 
made to prevent complete loss of sight from the increased tension. 
Although recommended and employed in acute glaucoma, the opera- 
tion is a much less efficient procedure than a properly-performed 
iridectomy, and is not free from the dangers of late infection. 
Because of the possibility of infection the operation is not indicated in 
young persons or if the patient has only one eye. The statement 
that late infection does not occur in children, or that in primary 
hydrophthalmos the opening is closed by a solid scar, is not found 
by experience. In eyes which have suffered from inflammations, 
such as deep keratitis, scleritis, or iridocyclitis, and become ectatic, 
resembling true hydrophthalmos, there is a tendency to a cicatricial 
closing of the scleral opening and recurrence of the glaucoma, but in 
primary hydrophthalmos the typical scar develops as frequently as in 
eyes of grown persons, and late infection is consequently as apt to 
occur. 
The Incision.—Under local anesthesia an incision is made in the 
conjunctiva with small curved scissors 8 mm. above and concentric 
with the limbus and about 1.5 cm. in length (Fig. 185 E). The con- 
junctiva is seized with forceps at the centre of the cut, and the flap 
as outlined is dissected in its central portion towards the limbus. 
Within a few millimetres of the limbus the subconjunctival tissues 
are loosened so that the sclera is exposed. As the conjunctiva is 
more closely adherent at the limbus, it is more readily loosened with a 
lancet held perpendicularly to the sclera. Elliot prefers the points of 
the scissors for this purpose, and splits the superficial corneal layers. 
The conjunctival flap is turned down (Fig. 186), or at least sufficiently 
pulled away from the sclera to lay bare its insertion to the cornea. 264 
OPERATIONS FOR GLAUCOMA 
Application of the Trephine.—The trephine (1.5 mm. in diameter) 
is placed perpendicularly on the sclera and slid as far forward as 
possible and bored with slight pressure, care being taken that the 
edge of the conjunctival flap is not button-holed. The operator is 
conscious of the completion of the cut by the lack of resistance, by the 
Fig. 185.—Elliot Trephining. Incision through the conjunctiva E. The eye is 
looking well down. 
escape of the aqueous, and by the movement of the patient due to the 
slight pain which accompanies the opening of the chamber. 
Elliot advises that the upper end of the trephine should be sloped 
slightly towards the feet of the patient, so that the blade first cuts 
through the corneal tissue and leaves the disc, hinged on its scleral 
Fig. i 86.—Elliot Trephining. The conjunctival flap (Bl) has been detached from 
its base down to the cornea and is turned down. From the cornea-scleral limit a round 
disc had been excised with the trephine. 
side. The iris pushes up into the opening and the disc with the iris 
is then cut with one snip of the scissors. The excised disc is from 
the corneal-scleral junction (Fig. 186. Bl). A sharp trephine is used, 
as the smoother the edges of the opening the less is the tendency of the 
wound to close later. Bruising of the wound edges, and the presence AFTER-TREATMENT AND ACCIDENTS 
265 
of particles of tissue, lead to the development of cicatricial tissue with 
later obliteration of the opening. 
Iridectomy.—The prolapsed iris is either entirely excised and a 
complete coloboma formed or only a small piece of the root removed 
(button-hole iridectomy). The iris retracts spontaneously to its 
proper position or may be replaced by slight massage of the sclera 
just above the opening. If a spatula has to be employed, it must be 
of small size on account of the size of the opening. 
Replacing the Conjunctival Flap.—The conjunctival flap is 
carefully replaced upward with the spatula, and catgut sutures are 
employed only if the flap shows a tendency to turn downwards. 
After-treatment.—Rest in bed for twenty-four hours, at the end 
of which time the unoperated eye is left unbandaged. The operated 
eye is bandaged daily for a week. Atropin is instilled after the second 
day if the tension is reduced, and continued regularly until all irrita- 
tion has subsided. 
Accidents.—If the conjunctival flap should be perforated either 
at the time of the dissection or by the trephine, the flap must be 
sutured in a slanting direction so that the scleral opening is covered 
with intact conjunctiva. 
If the excised disc drops into the anterior chamber, it may be 
brought to the opening by slight massage and picked up with forceps 
or removed with a blunt hook. The disc should not be allowed 
to remain in the anterior chamber, as it may come into the opening 
in the sclera, and cause the formation of cicatricial tissue. 
The iris may be injured if there is extensive anterior synechia. 
If the iris is adherent to the disc, both are pulled out and excised at 
the same time. Injury of the lens can only occur if the trephine is 
forcibly pushed into the interior of the eye. 
As the point of the scleral opening is immediately in front of the 
ciliary body, the latter may be injured if the trephine is not placed 
well forward. In the human eye the distance between the limbus and 
the ciliary body is 1.5 mm., so that this size of opening is preferable. 
If a trephine of 2 mm. is chosen, as Elliot recommends, the corneal 
lamellae must be split or injury of the ciliary body is likely to occur. 
Prolapse of the vitreous is usually associated with injury of the 
ciliary body, indicating that the trephined opening is too far back. 
If there is open communication between the vitreous and anterior 
chambers, owing to luxation of the lens or liquefaction of the vitreous, 266 
OPERATIONS FOR GLAUCOMA 
the latter will ooze from an opening made in the proper situation. 
Expulsive hemorrhage occurs only in rare instances. 
The scar after operation is similar to that of the Lagrange pro- 
cedure. Frequently the scar is ampulla-shaped, although in eyes 
that have suffered from long-standing inflammations, like kerato- 
scleritis, the opening may be so well closed by a flat scar that it is 
difficult to recognize it afterwards. 
After Complications.—Without any apparent irritation of the 
eye, posterior synechia may develop during the first two or three 
days, so that atropin must be instilled early. Sometimes pigment 
covers the pupillary space. Serious chronic iridocyclitis results 
from injury of the ciliary body, and follows a malignant course. 
The iris, which retracts spontaneously into proper position at 
the time of operation, has a tendency later to be displaced towards 
the scleral opening. 
The tension of the eye may become considerably reduced below 
normal and remain in this condition without serious deterioration 
of vision. 
The danger of late infection must be regarded as one of the serious 
sequels of the operation. The latest researches show that in about 
40 per cent, of the eyes a free fistula is formed, and the aqueous 
oozes continuously from the anterior chamber into the conjunctival 
sac either spontaneously or when pressure is applied to the eye. 
Fistulation beneath the conjunctiva into the subconjunctival space 
is obtained only exceptionally, although it was the result originally 
expected from the operation. In about 60 per cent, of the cases 
therefore no fistula is created, but notwithstanding this fact the 
tension is reduced. It is the eyes with the free fistula that are 
exposed to late infection, and there is apparently no certain means of 
prevention, as germs are always present within the epithelial cells of 
the normal conjunctiva, and if they become pathogenic infection 
unexpectedly appears. 
The several modifications of the Elliot operation—Muller’s 
method of covering the opening with the excised disc after the 
iridectomy, and Purtscher’s flap from the superficial layers of the 
sclera behind which the inner layers alone are trephined—are not 
free from the same drawbacks. 
The infection may remain limited to the ampulla-shaped flap, 
but more frequently it invades the interior of the eye, leading to POSTERIOR SCLEROTOMY 
267 
purulent iritis and panophthalmitis. Many of the eyes become 
nearly blind from opacities in the vitreous, membranes in the pupil, 
and other effects of inflammation. It is exceptional to save the 
eye with useful sight after these inflammatory attacks. The danger 
of late infection continues during the life of the patient. 
Fig. 187.—Posterior sclerotomy. The eye, which is directed well upward and 
inward, is fixed with forceps, at the limbus and the Graefe knife is introduced at the outer 
and lower portion in a meridional direction, the cutting edge looking backward, the point 
toward the center of the eyeball. The assistant pushes the lower lid far downward. 
VI. POSTERIOR SCLEROTOMY 
This operation consists in the puncture of the vitreous space 
through the sclera with a Graefe cataract knife. 
Indications.—Posterior sclerotomy is used in glaucoma only as a 
preliminary operation in cases in which iridectomy is technically im- 
possible because of the complete obliteration of the anterior chamber 268 
OPERATIONS FOR GLAUCOMA 
in the presence of enormous increase in pressure. In most cases an 
iridectomy may be proceeded with immediately after the posterior 
sclerotomy, as the escape of the vitreous produces a softening of 
the eyeball and simultaneously the anterior chamber commences to 
reappear. 
Posterior sclerotomy is of small value as an operation for glau- 
coma, as the diminution of pressure induced by it usually soon dis- 
appears, sometimes after a few hours, and the scar at the site of the 
incision is so dense that a filtration of the 
ocular fluids outward cannot take place. 
The Scleral Opening.—The perforation of 
the sclera is made posterior to the ciliary body, 
at least 6 to 7 mm. from the limbus, preferably 
at the outer and lower portion of the eyeball, 
between the external and inferior rectus 
muscles, while the patient, looks inward and 
upward. The eye is fixed with forceps and the 
cutting edge of the knife is directed backward 
from the ciliary body so as not to bring this 
organ into danger. The incision is made in a 
meridional direction, corresponding to the fibers 
of the sclera and the blood-vessels in the 
choroid. An equatorial incision, that is, one 
parallel to the limbus, would divide a series of 
blood-vessels in the choroid, and a cut in the 
horizontal meridian would injure the posterior 
long ciliary artery and destroy the eye through a severe hemorrhage 
into the vitreous. 
During the puncture the point of the knife is directed toward the 
center of the eyeball, in order not to pierce the posterior capsule of 
the lens, which could readily occur if the blade were passed obliquely 
forward (Fig. 187). Moreover, the puncture must have a definite 
length—as long as the breadth of the knife. In order to lower the 
tension of the eye by the escape of a small amount of vitreous humor, 
the knife must be turned while in the scleral wound from a meridional 
direction to an equatorial one (Fig. 188), so that the wound is caused 
to gape. After the knife has been returned to its original position, 
it is withdrawn from the eye. 
Fig. 188.—Posterior 
sclerotomy. In this dia- 
gram, the knife, which 
is now in the eyeball, is 
turned to the equatorial 
direction, so that the 
wound gapes, allowing 
the vitreous to exude. OPERATION OF CYCLODIALYSIS 
269 
VII. CYCLODIALYSIS (HEINE) 
This operation is designed to establish a communication between 
the anterior chamber and the suprachoroidal space. It was sug- 
gested to Heine by Fuchs, who gave detailed descriptions of the 
choroidal detachment following iridectomy for glaucoma and extrac- 
tion of cataract, pointing out the co-existent diminution of pressure, 
and presuming that the choroidal detachment was brought about by 
the aqueous humor oozing backward through tears in the ligamentum 
pectinatum produced by the operation. Heine tried, by establishing 
through an artificial cleft in the ligament a communication between 
the anterior chamber and the suprachorioidal space, to give rise to a 
detachment of the choroid and thereby to a reduction of the intra- 
ocular pressure. In conceiving the method of the cyclodialysis he 
took for granted, first, that the tear would not heal again spon- 
taneously, and, second, that the suprachoroidal space represented 
either a natural passage for the intraocular circulation for the carry- 
ing off of the liquids from the interior of the eye, or that it was created 
such a one by the operation. But the expected detachment of the 
choroid failed to appear, even when the eyes had been perfectly soft. 
The fact that in successful cases the tension remains below normal for 
months proves that the result is independent of a supposed detach- 
ment of the choroid, which, as a rule, passes away within a few days 
or, if extensive, within a few weeks, and with it the lowering of the 
tension. The theory, therefore, on which the operation had been 
based seems to be incorrect. But this should not bias our judgment. 
It is likely that the occasional success is accomplished by the under- 
mining of the angle of the anterior chamber. Cyclodialysis should 
be regarded as an operation to free this angle, just as many other 
methods that have been recommended for glaucoma, to which iridec- 
tomy also probably belongs. 
Indications.—Cyclodialysis is indicated in: 
1. The early stages of glaucoma to check the progress of the disease 
process. It is a simple procedure, which leaves a round pupil so that 
the patient does not suffer from the dazzling effect of bright light as is 
often found after the iridectomy coloboma. 
2. Primary glaucoma, in which the iridectomy is not only difficult 
but dangerous, either because of an obliterated anterior chamber, 
atrophic iris, or maximal dilatation of the pupil from increased ten- 
sion or advanced intraocular changes. The performance of the cyclo- 270 
OPERATIONS FOR GLAUCOMA 
dialysis is independent of the existence of the anterior chamber. Even 
though the reduction of pressure may be only temporary, the opera- 
tion is valuable as a preliminary to iridectomy. If the tension is 
diminished by the cyclodialysis, an iridectomy can be performed 
without danger. 
3. In patients who have lost one eye by malignant glaucoma 
or a severe hemorrhage after an iridectomy, and also in old, infirm, 
Fig. 189.—Cyclodialysis on the left eye. The eyelids in this operation are held 
apart by a spring-speculum. After the conjunctiva has been incised and the sclera 
exposed to view, a short incision is made with the lancet (keratome) parallel to the 
limbus and at a distance of about 5 mm. to the outer and lower side of it. The lancet is 
made to cut with its side and not with its point. 
coughing or restless people, because rest in bed is not required after 
operation. 
4. Secondary glaucoma caused: (a) By anterior synechia, in 
which after iridectomy the tension increases, (b) By luxation of the 
lens in the vitreous chamber, in which loss of vitreous would be 
unavoidable in performing an iridectomy and its result uncertain. 
(c) After cataract extraction, provided that the edges of the coloboma 
are in proper position. If there is adhesion of one or both sides of the 
coloboma to the operation scar, excision of the attached iris is the 
proper treatment for the glaucoma. OPERATION OF CYCLODIALYSIS 
271 
Cyclodialysis, although able to diminish the intraocular pressure, 
cannot be regarded as preferable or even equal to iridectomy. It 
should not be used indiscriminately in place of iridectomy, but should 
be considered as a valuable aid when iridectomy fails or is contra- 
indicated. 
Anesthesia.—As cyclodialysis is occasionally painful, a small 
quantity of a 3 per cent, cocain-adrenalin solution may be injected 
beneath the conjunctiva in the lower outer quadrant near the limbus. 
Fig. 190.—Cyclodialysis. The spatula, held parallel with the surface of the sclera, 
is now inserted through the wound in the sclera in front, between the sclera and the 
ciliary body, and appears in the angle of the chamber. 
In five minutes afterward the iris and ciliary body are anesthetic. 
An objection to this anesthesia is that the operator is without the 
co-operation of the patient to indicate by the sensation of slight pain 
when the sclera has been perforated and when the spatula is in con- 
tact with the ciliary body. 
The Operation.—The patient is directed to look upward, and an 
opening is made with scissors in the conjunctiva in its outer and lower 
part, at a distance of about 5 mm. from the limbus, and the sclera 
exposed by undermining. The eye is fixed with forceps, the assistant 
holds the wound open with two double tenacula, and a cut 2 mm. long 
is made, with the lancet vertically, through the sclera at a distance of 
5 mm. from the limbus and parallel to it (Fig. 189). If the conjunc- 272 
OPERATIONS FOR GLAUCOMA 
tiva is friable or flabby, the sharp-toothed forceps grasp the episcleral 
tissue at the time the incision is made. The tissues are divided 
layer by layer until the uvea may be seen through the wound. 
Care must be taken that the ciliary body, which lies immediately 
beneath, is not injured. The incision is made with the lateral edge of 
the knife, assuring the same depth in the entire length of the wound. 
A spatula, such as is used in reposition of the iris, is carefully 
carried forward through the wound between the 
sclera and the ciliary body with its plane parallel to 
both (Fig. 190). If all the fibers of the sclera have 
been divided, this can be done without difficulty. 
If the sharp teeth of the forceps are inserted into 
the sclera immediately in front of the incision, 
the edge of the wound may be lifted slightly and 
the spatula readily passed forward in the proper 
position. 
The point of the spatula soon appears below 
in the angle of the chamber and is pushed forward 
with lateral movements to the right and to the 
left (Fig. 191) until the ciliary body is detached 
from the sclera. The aqueous does not escape 
unless one edge of the spatula is turned forward slightly, causing the 
wound to gape. If the ciliary body is not injured during the incision, 
no bleeding occurs into the anterior chamber. 
After withdrawing the spatula from the wound the conjunctiva is 
sutured and the eye bandaged. 
A more extensive undermining is secured if the spatula is carried 
to the upper end of the vertical meridian. In this way the whole 
lateral half of the ciliary body is detached. Salus lays great stress 
upon the importance of detaching the ciliary body in its entire 
breadth. 
Complications.—The anterior ciliary veins, which are often dilated 
in glaucomatous eyes, should not be injured, as the hemorrhage com- 
plicates the operation and causes the blood to be sucked into the 
anterior chamber during the introduction of the spatula. Bleeding 
from the small scleral vessels is prevented by repeated dropping of 
adrenalin into the wound during the incision. Severe bleeding from 
a ciliary vein at its point of exit from the sclera should be stopped by 
application of the thermo-cautery. If the incision of the sclera is not 
Fig. 191. — The 
position of the spatula 
is shown during the 
performance of the 
lateral movement in- 
tended to detach the 
ciliary body. RESULTS OF CYCLODIALYSIS 
273 
carefully made, the knife opens through the choroid, and vitreous 
appears in the wound. 
As the spatula is pushed forward, it must be held close to the inner 
surface of the sclera, in order not to get behind the iris. As the 
point enters the anterior chamber the ligamentum pectinatum is 
divided, the angle of the chamber opened, and the ciliary body 
detached from the sclera. 
A frequent complication is detachment of Descemet’s membrane. 
If the spatula is dull, the fibers of the ligamentum pectinatum are not 
severed, and the spatula is caught in Descemet’s membrane and the 
parenchyma of the cornea, detaching the latter and leading to opacity, 
which, however, disappears in a few weeks. This faulty position of 
the instrument is recognized by marked resistance to its further ad- 
vance. By slightly withdrawing the spatula it will be freed from 
entanglement and then the undermining is continued. Generally 
the spatula finds its right way even in eyes in which the root of the 
iris is attached to the posterior surface of the cornea (peripheral 
anterior synechia), and an iridodialysis is an exceptional occurrence. 
An iridodialysis is no more to be feared than an injury to the 
canal of Schlemm, as the iris arises from the anterior surface of the 
ciliary body, and the latter is sufficiently protected through a pro- 
jection of the scleral spur. Occasionally, the detachment of the 
ciliary body from the sclera may be plainly distinguished by the recess 
of the chamber becoming black just as in iridodialysis. After with- 
drawal of the spatula the ciliary body resumes its original position 
and the angle of the chamber shows no further visible alteration. 
If, during the operation, a hemorrhage into the anterior chamber 
occurs, a pressure-dressing must be applied at once. This not only 
prevents a further accumulation of blood, but also causes a disappear- 
ance of part of the blood already present in the eye. 
The operation is undoubtedly much less radical and associated 
with much less danger to the eye than an iridectomy. 
After an extensive separation of the ciliary body the eye fre- 
quently remains for a long time in a condition of ciliary injection, 
and homatropin must be used to prevent the formation of posterior 
synechia. 
Results.—Cyclodialysis has an immediate influence on tension 
only in those cases in which the aqueous is allowed to escape. In 
this respect it acts the same as paracentesis of the anterior chamber, 274 
OPERATIONS FOR GLAUCOMA 
and the lowering of the tension caused by escape of the aqueous is 
just as temporary as puncture. The true action of the operation 
develops gradually, and appears as an evident lowering of the tension. 
The previously hazy and opaque cornea becomes lustrous and trans- 
parent, the irritation of the eye disappears, and the pupil begins to 
react to miotics as far as the condition of the iris tissue permits, 
although the anterior chamber remains shallow or is somewhat 
deeper in the area of undermining than before. In typical cases the 
tension sinks beneath the normal, and in this condition the eye may 
remain permanently, preserving the degree of sight which had been 
left by the previous glaucoma. Observations extending over ten 
years show the harmlessness of the softness of such eyes. This favor- 
able result, however, is secured in only a small proportion of the 
cases, about 20 per cent. The earlier the glaucoma is recognized, 
and the more extensive the separation of the ciliary body, the 
greater the influence of the operation. In the majority of cases the 
increase of tension recurs after a longer or shorter period, and in a 
small group of cases, especially in absolute glaucoma, the operation 
has no effect, not even temporarily. 
VIII. INCISION OF THE ANGLE OF THE ANTERIOR CHAMBER (DE VINCEN- 
TIIS’S OPERATION) 
Indications.—This operation is employed in instances of a return 
of tension after other glaucoma operations; in hemorrhagic glaucoma, 
especially if the other eye has been lost by severe hemorrhage after 
an iridectomy; in secondary glaucoma occurring during cyclitis; and 
in hydrophthalmos. 
The Operation.—De Vincentiis employs a slightly curved, needle- 
like instrument (Fig. 192), which has a small, pointed, sickle-shaped 
Fig. 192.-—De Vincentiis’s operation. The needle-like instrument employed. 
end, sharp on its convex edge. The shaft thickens gradually toward 
the handle, so that the puncture hole is completely closed and the 
aqueous does not escape. The pupil is contracted with eserin, the 
eye cocainized, and the needle entered obliquely through the sclera 
about i mm. back of the limbus and a little below the horizontal 
meridian, with the convex blade directed downward (Fig. 193). The SECONDARY GLAUCOMA 
275 
needle is advanced across the anterior chamber, parallel to the iris, 
until the point reaches the angle of the chamber at a spot somewhat 
lower than the puncture. The point then penetrates into the tissue 
of the angle a distance of about 1 mm. As the needle is gradually 
withdrawn, the handle is turned so that the convex blade incises all 
Fig. 193.—De Vincentiis’s operation. Knife introduced and its point inserted in the 
angle of the chamber. 
of the tissues of the inferior periphery of the angle, including the inner 
scleral layers, until it reaches near the original puncture (Fig. 194). 
The shallower the chamber the more difficult is the operation. 
Fig. 194.—De Vincentiis’s operation. Incision nearly finished. The handle of the 
instrument turned up. 
The advantages of the operation are that a large opening is not 
made into the eyeball, and there are not the complications to be 
feared that are likely to follow an iridectomy in the type of cases 
mentioned. Should hemorrhage occur in the anterior chamber, a 
firm pressure-bandage should be applied. In cases of peripheral 
anterior synechia the iris is incised by the knife and cut off from its 
insertion without serious consequences. 
In many instances the operation exercises a favorable influence; 
in others it fails to reduce the tension. 
Indications.—The necessity for operation depends upon whether 
the increase of pressure is only temporary or whether it will remain 
permanent. 
SECONDARY GLAUCOMA 276 
OPERATIONS FOR GLAUCOMA 
Paracentesis of the Cornea.-—Operation is indicated in transient 
increase of pressure, as, for example, in traumatic cataract with 
rapid swelling of the lens; and in acute iritis, in which the increased 
tension is associated with pathologically deep anterior chamber. 
The operation should not be done until after the usual local applica- 
tions of ice-compresses and atropin have failed, especially in cases 
of iritis. 
The Incision.—The eye is cocainized, fixed laterally, and a narrow 
keratome, held almost vertically against the limbus below, is entered 
through the cornea. As soon as the point appears in the anterior 
chamber, the blade is changed to the plane of the iris, and the 
incision completed, which must not exceed 3 mm. in length. All 
backward movement of the lancet should be avoided, so that the 
aqueous will not escape. 
When the lancet is withdrawn, the wound-edges come together 
and the aqueous cannot flow off. The operator may permit it to run 
out as slowly as he desires, and in any quantity he pleases, by slightly 
depressing the scleral wound-margin with the spatula, thus causing 
the wound to gape slightly. Sudden escape of the aqueous is not 
only painful, but may cause prolapse of the iris and hemorrhage in 
the anterior chamber and even in the retina as a result of the sudden 
diminution of pressure. 
If the pressure is greatly increased, it is our custom not to permit 
all the aqueous to escape, but only sufficient to reduce the tension to 
normal or a trifle below. Thus, we are more likely to prevent disas- 
trous intraocular hemorrhage. If the iris has floated out during the 
sudden escape of the aqueous, it is at once accurately replaced with a 
spatula. When the incision is too long the protrusion of the iris is 
often repeated, and excision of a small piece is indicated. 
Puncture of the cornea may be repeated as often as needed. If, 
for example, in acute iritis the tension increases the next day, the eye 
is cocainized, the scleral lip of the wound slightly depressed with the 
spatula, and the aqueous allowed to again escape. The wound does 
not heal so firmly for several days as to prevent easy re-opening by 
passing the spatula carefully between the edges. 
If the increased tension is due to a swollen lens, a larger incision 
(5 mm.) is made to permit some of the lens masses to escape by mas- 
sage, as in linear extraction. IRIDECTOMY AND OTHER OPERATIONS 
277 
Iridectomy and Other Operations.—Increase of pressure not of 
transient nature requires the typical iridectomy or other operations 
employed in primary glaucoma. Among the conditions which require 
operation may be mentioned increased tension due to adhesion of 
the iris to the cornea, change in the normal position of the lens, 
and seclusion of the pupil from iritis, or after cataract extraction. 
The condition in the individual case will indicate the character of 
operation required. Frequently many different operations must be 
performed on the same eye before the tension is permanently reduced. 
In general, iridectomy exerts the most favorable influence, and the 
other methods, as cyclodialysis and trephining, are employed as; 
substitute operations if iridectomy does not achieve the desired result 
or is considered too dangerous a procedure for special reasons. 
The performance of the iridectomy in secondary glaucoma may be 
difficult because of the accompanying pathological changes in the eye. 
For instance, the iris may be so atrophic from the chronic inflamma- 
tion that it tears at each attempt to withdraw it with the forceps, 
and we must be satisfied with tearing out single pieces instead of 
excising one section. Again, the iris may have grown fast to the lens 
capsule, and we may succeed in drawing it forward and in excising a 
portion, but the pigment layer remains adherent to the capsule, ren- 
dering valueless the optical effect of the operation. 
Dislocation of the Lens.-—In luxation of the lens or ectasia of the 
sclera severe complications during operation are due to prolapse of the 
vitreous. Operation should not be undertaken in luxation or sub- 
luxation of the lens (except luxation into the anterior chamber) un- 
less rendered necessary by an increase of tension. Experience has 
shown that some eyes tolerate a displacement of the lens without a 
corresponding increase of pressure, at least for some time. As the 
zonula is torn, the vitreous presents in the wound as soon as the inci- 
sion is made. If the iris floats forward, it may be easily grasped and 
excised. If, however, the vitreous pushes the iris backward, all 
attempts to bring it forward would terminate in failures and should, 
therefore, be abandoned. Occasionally we may be able to catch the 
iris with a blunt hook. Should that also fail, one has to desist from 
excising a piece of the iris. 
In increased tension due to luxation of the lens into the vitreous, 
trephining can be more readily performed than an iridectomy, but 
its influence is less certain. In addition, the danger of late infection 278 
OPERATIONS FOR GLAUCOMA 
after trephining is increased in eyes where by the free communication 
between vitreous and anterior chambers the vitreous body extends 
into the scleral opening. In most cases of this character cyclodialy- 
sis is the safer procedure. 
If the lens is dislocated into the anterior chamber immediate 
operation is required for its removal, as experience has shown that 
increased intraocular tension quickly follows. In order to prevent a 
Fig. 195.—Transfixion. (Fuchs.) 
slipping of the lens backward into the vitreous- chamber, the pupil 
is first contracted with eserin. After a conjunctival flap has been 
made, as described in the operation for cataract (page 217), the 
anterior chamber is opened by an incision with the Graefe knife at 
the upper or lower limbus and the lens brought forward with the 
Fig. 196.—Transfixion in seclusion of the pupil. 
loop. As the vitreous and anterior chambers communicate, the 
appearance of vitreous in the wound is the rule, notwithstanding 
every precaution. By tying the sutures the conjunctival flap is 
drawn over the wound. 
A cyst of the iris may lead to increase of pressure, and we must 
not be satisfied with iridectomy alone, but endeavor to extirpate the 
entire cyst by suitable incision. 
Transfixion.—This is especially indicated in seclusion of the pupil 
from complete annular synechia, in which the body of the iris is pushed 
forward in a hump. The usual iridectomy is hardly possible, as the TONOMETRY 
279 
root of the iris is often applied extensively against the posterior wall 
of the cornea. The operation is done with a Graefe knife, which is 
pushed into the anterior chamber through the cornea i mm. to the 
inner side of the temporal border of the cornea and a counter-punc- 
ture made at a corresponding point (Fig. 195). The knife is then 
withdrawn. The points of entrance and exit lie in the horizontal 
meridian of the cornea, and the blade of the knife, held parallel to the 
base of the cornea, penetrates through the projecting iris and produces 
in it several openings (Fig. 196), through which a new communication 
is established between the anterior and posterior chambers. In most 
cases the iris assumes its normal position almost immediately, and 
the intraocular pressure becomes normal. If no new inflammation of 
the iris follows, a permanent result may be expected. If, however, 
there is a new outbreak of iritis, which would cause a closure of the 
openings through a formation of an exudate, it is better to proceed to 
establish a normally deep chamber, and then to perform iridectomy, 
in order to prevent a recurrence of the increase in tension. 
TONOMETRY 
It is now generally recognized that the Schiotz tonometer fur- 
nishes an accurate and certain means of determining the intraocular 
tension. Even the skilled diagnostician concedes the uncertainty 
of the results of digital palpation, and the uniformity of the readings 
of the tonometer. While determination of tension with the finger 
was of approximate value where one eye was still normal, and allowed 
comparison with the affected eye, it was impossible in binocular affec- 
tions to accurately judge whether the tension exceeded the normal. 
The tests with the tonometer are on the average reliable. Excep- 
tionally great difference is noted between tests with the tonometer 
and with digital palpation. Thickness and rigidity of the external 
coats of the eye influence the determinations, as Schiotz himself has 
stated, since he found a marked difference in the measurements made 
on the cornea and those on the sclera, the former showing the greater 
movements of the index-arm of the instrument. This difference 
must be due to the greater rigidity of the sclera. Measurements 
made on the thinned cornea of a hydrophthalmic eye of a child must 
therefore cause greater movement of the index-arm, and hence make 
the pressure seem lower than it is. On the other hand, the pressure 
would appear higher in elderly people because of the greater rigidity 280 
OPERATIONS FOR GLAUCOMA 
of the sclera. These are, however, exceptions which can scarcely 
lead to a clinical error. 
Description of the Instrument:—The cylindrical sleeve, b, has two arms, a, by which 
the apparatus is held between the thumb and index finger. In this sleeve, b, there 
glides easily the tube, c, which widens at its lower end into a foot-piece, 9 mm. in diam- 
eter. The bottom of the foot-piece has a concave surface, with a radius of curvature of 
15 mm. Fastened to the tube is the support, d, which carries the scale, e, and a small 
pin, f, as fulcrum for the unevenly-armed lever, gg'. In the interior of the tube, c, is 
the long rod, h, 3 mm. in diameter, which slides easily up and down. The lower end 
of the rod, which during the examination rests on the cornea, is concave, with the radius 
Fig. 197.—Schiotz tonometer. 
Fig. 198.—The instrument placed on the 
patient’s cornea. 
of curvature the same as the foot-piece, 15 mm. The upper end of the rod is pointed, 
and slips through a hole in the different sized weights. At one side of the central open- 
ing in the weights is a groove, into which slides a projection on the side of the rod. A 
slight turn carries the projection out of the groove so that the rod will not fall out as the 
the instrument is held up. When the apparatus is in use, the short arm of the lever, 
g', rests on the upper end of the rod, which it follows in movements up and down. The 
long arm, g, of the lever slides along the indicating scale. The relation of the two arms 
of the lever is 1 to 20. If the end of the rod is level with the concavity of the bottom 
foot-piece, the end of the long arm of the lever stands at o on the millimeter scale, and TONOMETRY 
281 
if the rod descends 1 mm., then the indicator moves to 20 mm. on the scale. The 
radius of curvature of the foot-piece, 15 mm., was selected, so that the curvature of the 
cornea would in all instances be greater than the concavity of the foot-piece. 
In the perpendicular position, the indicator falls to the right of the scale, as shown 
in the illustration (Fig. 197), but in use the upper part of the sliding rod touches the 
short arm of the lever, and the indicator moves to the left. A metal test block, with a 
convex surface of the same curvature as the concave foot-piece comes with the instru- 
ment, and is used to test its correct adjustment. If the foot-piece is rested on the sur- 
face of the test block, the upper point of the rod raises the short lever arm, and the 
indicator stands at o of the scale. 
When the apparatus is used (Fig. 198), the eyes are anesthetized 
with a 2 per cent, holocain solution. The patient lies flat on a table, 
and is instructed to look directly upward. The examiner separates 
the upper and lower lids with the fingers of one hand, exercising care 
that no pressure is made upon the eyeball, and with the other hand 
holds the tonometer with the smallest weight (5.5) in place. The 
instrument is held perpendicular, with the concave foot-piece on the 
cornea, and the sleeve surrounding the tube is moved down until it is 
about the center of the tube, c, so that in this position the apparatus 
stands free. The lever and the small arm, with the attached weight, 
exert pressure on the cornea, and the arm of the indicator gives a 
reading on the scale. If no movement of the indicator occurs, a 
heavier weight is slipped on the rod. The softer the eye the deeper is 
the impression made by the rod, and, with the short arm of the lever 
following the sinking point of the rod, the long lever turns on the 
scale to the right. 
Weights of different size are used, marked 5.5, 7.5, 10, and 15. 
In high tension, no reading on the scale will be given by a certain 
weight, and a heavier one must be used. 
The apparatus should be applied only for a few moments, and the 
results at once read. Three measurements should be made and the 
average taken. The examination is begun with the first weight 
marked 5.5 gm. If tension is normal, the indicator stands at about 
5 mm. In increased tension the indicator rests at or to the left of 
o, and the next weight, 7.5 gm. is then used. Readings from 3 to 7 
on the scale are the most accurate. If, therefore, a lesser weight 
gives a result up to this limit, a greater weight is not employed. 
A diagram of curves, each corresponding to the weighting of the 
apparatus with four weights, accompanies the apparatus. The 
abscisses of the diagram represent the reading of the tonometer and 
the ordinates the intraocular pressure expressed in millimeters of 282 
OPERATIONS FOR GLAUCOMA 
mercury. Thus, a reading of six division lines of the tonometer scale 
with the smallest weight (5.5) is a pressure of 15 mm. of mercury, or 
with the second weight (7.5) a pressure of 42.5 mm. of mercury. 
According to Schiotz the normal intraocular tension, as indicated 
by the tonometer, varies between 15 to 25 mm. of mercury; others 
have found the variation between 9 and 26. It is possible, therefore, 
for an eye to be affected with glaucoma and yet the tension be within 
the normal limits. This may be regarded as exceptional, and eyes 
whose normal tension is on the lower physiological border, such as 
near-sighted eyes, have no particular tendency toward pressure in- 
crease. If increased tension does appear it remains within moderate 
limits, and may be recognized only with the tonometer. 
In normal eyes the pressure does not seem to vary much during 
the course of the day, and is apparently unaffected by the use of 
mydriatics or miotics. In eyes the subject of iridocyclitis, changes in 
the vitreous, spontaneous intraocular hemorrhage, and similar con- 
ditions, marked variations are to be found. Simple glaucoma almost 
always shows with the tonometer a slight increase of tension. Only 
exceptionally is it found below 25 mm. 
The tonometer should be employed in all cases of glaucoma and 
in eyes in which there is a suspicion of increase of intraocular pressure. 
Notwithstanding the recognized value of the instrument, therapeutic 
measures should not rest alone on its findings with the exclusion of 
clinical symptoms. The expressions glaucoma and increase of pres- 
sure are not identical. Abnormal intraocular tension is only one 
symptom of glaucoma, important as it is to the integrity of the eye. 
Even though the tonometer may indicate a pressure, say of 28 mm., 
an operation would not be indicated in the absence of the clinical 
symptoms of cloudiness of vision, narrowing of the visual field, and 
progressive cupping of the optic nerve. If, however, the increase in 
pressure were associated with the usual clinical manifestations of 
abnormal tension, operation would be indicated as soon as the char- 
acter of the disease is established. 
For those who adhere to the medicinal treatment of glaucoma, and 
operate only as a last resort, the tonometer will be of considerable 
value in indicating the value of miotics in controlling the tension, and 
the period when the operation must be performed. 
The tonometer also teaches that in types of advanced glaucoma 
the vision decreases and finally entirely fails notwithstanding decided 
decrease in the intraocular pressure. CHAPTER XIII 
OPTICAL IRIDECTOMY — CONJUNCTIVOPLASTY — OPERA - 
TIONS FOR IRIS PROLAPSE AND ANTERIOR SYNECHIA 
OPTICAL IRIDECTOMY 
The indications for optical iridectomy are (i) perinuclear opacities 
of the lens in young persons in whom sight is improved by dilatation 
of the pupil; (2) central corneal scars; (3) connective-tissue mem- 
branes in the pupillary area following iritis. 
Nuclear Opacities.-—If the opacity only slightly interferes with 
sight, iridectomy is not indicated, but if the disk-shaped cataract is 
small, and tests with the ordinary-sized pupil and with the pupil fully 
dilated show that vision, with dilated pupil, can be made suitable for 
the necessities of the individual concerned, i.e., at least a third of the 
normal acuity, this degree of sight can be obtained permanently by 
an optical iridectomy, whereby the patient has the advantage of still 
possessing the lens and with it the power of accommodation. 
In such cases, the coloboma should be made below and to the 
inner side. 
If, however, the improvement in vision following dilatation of the 
pupil is not marked, discission of the cataract is indicated. By this 
means the opacity can be completely removed, and the visual power 
restored to its normal acuity. The patient, of course, is forced to 
wear permanently strong convex glasses. In the greater number of 
cases of perinuclear cataract the latter operation is indicated, and in 
a much smaller number, iridectomy. The objection made against 
iridectomy that the cataract will probably become progressive and 
lead to total opacity of the lens, thus rendering the operation value- 
less, is, however, not sustained. 
Large central capsular opacities that cover the whole of the pu- 
pillary area also indicate the performance of an optical iridectomy. 
If a senile cataract starts as a nuclear opacity, especially in eyes 
with high myopia, liquefaction of the vitreous, or disease of the 
choroid, an iridectomy may improve vision for a considerable time. 
283 284 
OPTICAL IRIDECTOMY—CONJUNCTIVOPLASTY 
Recognizing that later extraction of the lens must be performed, the 
excision of the iris is to be made above. 
Central Corneal Opacity.—The ideal indication for an optical 
iridectomy is when corneal scars cover the center of the pupillary 
area. Unless a careful examination of the cornea is made with the 
magnifying lens, to ascertain the condition of the so-called trans- 
parent parts of the cornea, the results of optical iridectomy will often 
be disappointing. Delicate diffuse opacities will frequently be found 
in those portions which were judged to be of perfectly normal trans- 
parency when examined with the naked eye. Not until the iridec- 
tomy is completed are the corneal opacities easily visible against the 
black background, and they then often seem quite intense, while pre- 
viously they entirely escaped notice. In examination with the mag- 
nifying lens, not only those portions of the cornea must be looked for 
which are the most central and transparent, but also the areas where 
the opacity contrasts most sharply with the surrounding parts. 
The sharper the margin, the denser the opacity; the broader the re- 
maining transparent border, the better the outlook for a good result. 
Optical iridectomy for corneal opacities should not be performed 
too early. Opacities resulting from deep-seated keratitis, especially 
after parenchymatous keratitis in young people, often clear up slowly 
after many months, but the scars after severe ulcerative processes in 
adults usually remain unchanged. The operation is, therefore, par- 
ticularly suited to cases in which the opacity has resulted from a well- 
circumscribed area of disease (especially from ulcus serpens, infected 
wounds, etc.) while the rest of the cornea has remained practically 
free. A less favorable result may be expected when the opacities 
have resulted from deep corneal inflammations, because the cornea is 
usually so affected that delicate, grayish, indefinite areas are found 
throughout its entire structure. Optical iridectomy, therefore, im- 
proves the vision but little, even when the pupillary area of the 
cornea is affected by a rather dense opacity. It must be remembered 
that the diffuse haziness of the peripheral portion of the cornea often 
causes marked disturbance of vision. 
Before operation it is necessary to make an exact determination 
of the visual acuity after painstaking correction of the errors of 
refraction, especially astigmatism, by the use of a movable stenopaic 
disk. This disk is lodged in a frame that can be adjusted to any pair 
of spectacles, and may therefore be readily rotated into the various TATTOOING THE CORNEA 
285 
meridians. As often only a certain definite position of the slit gives 
the patient a substantial improvement in vision, the ordinary exami- 
nation with the trial frame commonly found in the test-case does not 
serve the purpose. We determine the lens that gives the patient the 
best vision for near work and for distance, order the lenses from the 
optician, and then adjust the disk to the glasses, so as to indicate to 
the optician the position the slit is to occupy on the lenses. This 
method of examination is of the greatest importance, especially for 
those patients who are dependent upon one eye. The improvements 
occasionally produced by application of the stenopaic disk are quite 
marked, and not infrequently the vision can be increased from finger- 
counting at 2 meters to or %8, and restoring also the power of 
reading and writing. Valuable help is rendered by glasses for am- 
blyopic eyes which magnify the image 1.8, 3, or 6 times that of 
normal. Zeiss, of Jena, furnishes trial-cases of lenses of this char- 
acter of combined glasses. 
Tests with Dilated Pupil.—-Before deciding on operation we de- 
termine the effect on vision of an optical iridectomy by dilating the 
pupil with atropin. Artificial mydriasis, however, cannot be exactly 
compared to that produced by an optical iridectomy, as atropin dilates 
the pupil symmetrically; but the operator learns from such an 
examination that in complete absence of improvement from uncover- 
ing a portion of the pupil behind a less clouded part of the cornea, a 
satisfactory result cannot be expected from an optical iridectomy. 
Moreover, if the patient’s vision is lessened by dilatation of the pupil, 
a permanent reduction in his sight will follow an optical iridectomy, 
as it is in such cases that the impairment of the sight is dependent 
upon the irregular diffusion of the rays of light. Many persons with 
diffuse corneal opacities see much better with a contracted pupil, 
comparable to a stenopaic disk, than with the pupillary orifice 
widened. 
Tattooing the Cornea.—Frequently it is necessary to decide 
whether the vision may be improved by tattooing of the cornea, with 
or without subsequent iridectomy. In such cases it is recommended 
to tattoo the corneal scars provisionally, as it were, by applying a 
piece of fine silk paper, absolutely black in color and cut to exactly 
fit the opacity in the cornea. This paper adheres readily and makes 
possible a test of the visual power for comparison with the earlier 
test. In order that the piece of paper can be applied, the cornea 286 
OPTICAL IRIDECTOMY CONJUNCTIVOPLASTY 
should be rendered anesthetic by the use of alypin, which unlike 
cocain has no influence on the pupil, so that there is no artificial 
dilatation to modify the results. (See page 347.) 
The Operation.—The technic of optical iridectomy differs from 
that of iridectomy for glaucoma not only in the method of incision 
but also in the type of excision of the iris. As the purpose of optical 
iridectomy is to alter the position of the pupil slightly, only that por- 
tion of the iris which borders on the pupillary margin should be ex- 
cised. As the periphery of the iris must be preserved for optical 
reasons, the incision is placed in the limbus or a little in the cornea. 
Otherwise, essentially the same details are followed as in iridectomy 
for glaucoma. The incision is made with the lancet, except when a 
shallow anterior chamber, the result of an anterior synechia, compels 
the use of the Graefe knife. Whenever possible, the coloboma is 
made to the inner and lower quadrant, as experience shows that this 
position gives the best optical results. Often, however, there is no 
choice, and the iridectomy is to be made behind any clear portion of 
the cornea. Care must be taken that the coloboma is not entirely 
covered by the upper lid. If in a one-eyed individual only the part of 
the cornea covered by the upper lid remains transparent and is suit- 
able for an optical iridectomy, nothing remains but to produce a 
permanent depression of the eyeball by tenatomizing the superior 
rectus, so that the coloboma will lie uncovered in the palpebral fissure. 
The iris is withdrawn with the forceps in the same manner as pre- 
viously described. It is sufficient, however, to draw out the smallest 
possible fold and to cut off the tip with the blades of the de Wecker 
scissors held perpendicular to the corneal incision. In this manner, 
a coloboma limited to the pupillary border of the iris is produced, 
which at once enlarges considerably by retraction of its margins. 
During the first week or two after operation the cicatricial opacity 
of the cornea is more intense and the vessels of the scar are more 
distended and hyperemic. Gradually the injection subsides and 
the cornea returns to its former condition, and it is then possible to 
judge of the result of the operation. 
Precorneal iridotomy is an operation to obtain a smaller coloboma. 
It consists in drawing the iris out of the wound, making a radial inci- 
sion in the pupillary margin, and then replacing the membrane. As 
the ends of the cut sphincter retract, a small coloboma is formed, and 
it is nearly impossible to tell whether it was produced by an iridotomy PROLAPSE OF THE IRIS 
287 
or an iridectomy. The operation is seldom performed, as the replace- 
ment of the iris after it has been in contact with the conjunctival 
tissue is liable to lead to infection. 
Results of Optical Iridectomy.—The value of the operation in 
corneal opacity is only moderate, and the cases suitable for the opera- 
tion are relatively few. The beneficent clearing effect on corneal 
opacities which has been ascribed to iridectomy depends probably 
only upon a delusion, which has been originated by the improvement 
of vision that follows the natural clearing of the cornea in the eyes in 
which iridectomy was performed before the healing process had 
subsided. 
Optical iridectomy gives much more favorable results in central 
lenticular opacity, that is, large central capsular cataract, and espe- 
cially in dense lamellar cataract in which the opacity is sharply 
defined and has a small diameter. 
Exudates, such as the connective-tissue membranes in the pupil- 
lary area following iritis, also afford an indication for optical iridec- 
tomy. Of course, due consideration must be given to the usually 
existing adhesions of the iris to the capsule of the lens resulting from 
the iritis, and a broader iridectomy performed in order to prevent a 
later rise in pressure. The result may be nullified, however, by 
the pigmented layer of the iris membrane adhering to the capsule of 
the lens and covering the coloboma. 
PROLAPSE OF THE IRIS 
Every Prolapse of the Iris, if Not Too Large, Should be Excised.— 
Attempts at re-position of a prolapsed iris should be avoided, because 
they are useless and expose the eye to infection. The replaced iris 
will again prolapse. It is, therefore, best to excise not only an iris 
that has protruded through the opening of a perforated ulcer or 
through a wound due to injury, but also a prolapsed iris following an 
extraction of cataract without iridectomy. 
The Operation.—After that portion protruding from the opening 
is cut off, the iris should be completely freed from its connection with 
the wound, in order to avoid the formation of an anterior synechia, 
with its sequelae. If a day or more has elapsed since the injury, 
the prolapsed iris is covered with fibrinous exudation, making its 
borders indefinable. This exudate must first be pulled off with 
forceps, after which the black point or swelling of the prolapse makes 288 
OPTICAL IRIDECTOMY—CONJUNCTIVOPLASTY 
its appearance. By means of a conical sound the prolapse is then 
freed from the edges of the wound in all directions, care being taken 
to avoid wounding the capsule of the lens, which, by obliteration of 
the anterior chamber, lies close to the posterior surface of the cornea. 
The sound is carefully pushed around the whole periphery of the 
opening between the prolapse and the posterior surface of the cornea, 
so that the iris is loosened on all sides. During this procedure the 
aqueous humor is continually escaping. The prolapsed iris is then 
seized with the iris-forceps close to the opening, drawn out a little, 
and cut off with the de Wecker scissors close to the edge of the wound. 
As the iris usually retains its power of retraction, it withdraws itself 
immediately after the excision into the anterior chamber and 
produces a well-situated coloboma in place of the previous prolapse. 
If the edges of the coloboma do not lie in a proper position, and 
the size of the opening permits, it is advisable to introduce a spatula 
and replace the iris. Should the corneal wound be too small the 
iris should be again drawn out and excised. If, however, the iris 
does not retract, a blunt tenaculum may be introduced into the 
anterior chamber, and the iris withdrawn from the wound and 
properly excised. After operation a drop of atropin is instilled in the 
eye to retract the iris and prevent its adhesion to the edges of the 
wound. 
Occurrence of the prolapse through perforation of an ulcer is not 
a contraindication to its immediate excision, notwithstanding the 
claim that there is great possibility of an infection of the interior 
of the eye through replacement of the borders of the coloboma. 
Indeed, if the tendency to infection should exist, the prolapse would 
afford the best channel by which the microorganisms could gain 
entrance to the eye. 
Before excision of the iris, a 3 per cent, cocain-solution should be 
instilled. As the eyes are usually much irritated and injected, adren- 
alin should be used simultaneously, as the cocain develops its great- 
est effect after contraction of the blood-vessels. Notwithstanding 
thorough cocainization, the iris often remains extremely sensitive, 
but if y3 c.c. of 3 per cent, cocain-solution is injected under the 
conjunctiva in the neighborhood of the prolapse, the iris becomes 
completely anesthetized in a few minutes. After removing the 
exudate from the surface of the prolapse, a few drops of the cocain- 
solution is dropped on the exposed iris. During excision the eye is LARGE CORNEAL WOUNDS WITH IRIS PROLAPSE 
289 
fixed with forceps, as an abrupt movement of the patient at the 
moment the iris is drawn out and excised may give rise to severe 
injury of the membrane (iridodialysis). In children the operation 
should always be done under general anesthesia. This should also 
be the rule in restless and timorous adults. 
A wound of the capsule of the lens can be readily avoided if the 
operator takes sufficient precautions in introducing the blunt 
tenaculum for the purpose of replacing the iris. However, this 
accident may be caused by restlessness on the part of the patient 
during the undermining of the prolapse with the pointed conical 
sound. 
The wound in the cornea which remains after excision of the 
prolapse usually closes rapidly; frequently the anterior chamber is 
re-established on the day after the operation. The smaller the open- 
ing, the more readily and surely does the wound close. A large 
wound of the cornea should be closed with a conjunctival flap. (See 
page 290.) 
Large Corneal Wounds with Iris Prolapse.—It is our established 
rule not to excise a prolapse of the iris if the opening amounts to one- 
fourth the diameter of the cornea. Naturally, this cannot be readily 
determined in advance. A large prolapse sometimes comes out 
through a small opening and, with mushroom-like swelling, overlaps 
the borders of the corneal wound. If the patient has been seen 
before the prolapse occurred, the operator will not be thus deceived, 
but it may happen that the real conditions are revealed only at the 
time of operation, when undermining the prolapse. If one-fourth or 
more of the cornea has been lost by ulceration, the excision of the 
iris brings the lens capsule to lie in the wound throughout its extent. 
As the scar formation is not as rapid in the cornea as it is in other 
tissues, the wound may remain open for some time, and during this 
period the eye is constantly exposed to the danger of infection. If 
the exposed lens capsule cannot withstand the intraocular pressure, it 
finally protrudes and ruptures, the lens-substance first appears in the 
opening and later the hyaloid membrane bursts, allowing the vitreous 
humor to prolapse. These sequelae are to be feared only in large 
prolapses, such as occur in destruction of the cornea by acute 
blennorrhea or serpiginous ulcer. But, even with the medium-sized 
openings, the operator has to be satisfied if a flat cicatrization results, 
with fusion of the lens capsule and partial or total clouding of the 290 
OPTICAL IRIDECTOMY—CONJUNCTIVOPLASTY 
lens. Frequently these cases end with a slowly developing atrophy 
of the eyeball. Therefore, it is best not to excise the prolapse, which 
is the natural means of closing the large wound. The endeavor 
should be rather to produce merely a flat cicatrix. Therefore, the 
intraocular pressure should be carefully controlled, and, if it rises, an 
immediate iridectomy done. 
After-treatment.-—If extensive anterior synechia has occurred, 
an iridectomy should be performed before the patient leaves the 
hospital, in order to avoid the danger of increase in pressure and 
development of a staphyloma. The continuous application of a 
pressure-bandage is advisable to produce a flat cicatrix. A typical 
picture is seen in those patients who have suffered from a well- 
advanced serpiginous ulcer. An extensive synechia of the iris has 
been produced, either spontaneously or after Saemisch’s incision, 
with a peripheral part of the cornea still transparent. At first the 
tension is reduced, but finally becomes normal. At the seat of the 
prolapse there is formed a flat scar. Suddenly the pressure increases, 
usually with violent pains, and immediately the still soft cicatrix, 
which is often the seat of hemorrhages, protrudes in the form of a 
hump. Under such circumstances the performance of iridectomy 
is difficult, as the anterior chamber is usually obliterated, the iris 
atrophic, and the eye painful. This almost invariable result can be 
avoided if a broad iridectomy is executed in the unaffected portion 
of the cornea as soon as the anterior chamber has been established 
during the course of cicatrization of the prolapse and before tension 
rises. 
CONJUNCTIVOPLASTY 
Transplantation of a pedicled flap of conjunctiva, especially advo- 
cated by Kuhnt, is a significant advance in the treatment of large 
prolapses of the iris. 
The method is also used in the treatment of recent corneal wounds, 
with or without iris prolapse; in transplantation of the cornea, to 
retain the new tissue in proper position; in gaping incisions after 
cataract extraction; and in some types of corneal ulcers. 
Flaps after Excision of Prolapsed Iris.—After excision of a 
prolapsed iris, a clean perforated ulcer lies exposed. If the edges 
of the defect are flat and offer a large surface for adhesion to the 
conjunctival flap, the margins should be scraped with a sharp curet, CONJUNCTIVOPLASTY 
291 
to remove the epithelium that has grown over them. If the edges of 
the wound are perpendicular, the chances for fusion with the flap are 
less favorable. A flap is now made from the bulbar conjunctiva by 
first detaching with the scissors the conjunctiva at the limbus close 
to the ulcer, making a second cut parallel to the first at a distance 
almost twice as great as the width of the ulcer, and uniting the two 
by a curved incision (Fig. 199). The flap formed is undermined, 
and its base removed far enough back to render it freely movable. 
Fig. 199.—Conjunctivoplasty. Diagram showing appearances after excision of the 
prolapsed part of the iris. The ulcer in the lower half of the cornea is free from the iris, 
which shows the ordinary coloboma. To cover this defect a flap has been cut out of the 
bulbar conjunctiva. 
Fig. 200.—Diagram showing the conjunctival flap turned over the ulcer, and 
attached to the bulbar conjunctiva in such manner that the ulcer is completely covered. 
Fig. 199. 
Fig. 200. 
If the ulcer is at the edge of the cornea, the flap may arise from the 
bordering limbus; but if the loss of substance is central, it may be 
covered by a flap brought either horizontally or vertically over it. In 
the former, the detachment of the conjunctiva must be performed 
above or below, and the base of the flap lie externally or internally. 
A horizontal flap is, therefore, to be preferred, on account of the abun- 
dance of conjunctiva in the superior fold, which readily permits the 
formation of a flap, while internally and externally there is little con- 
junctiva to spare. The only objection is the possible danger of 
limiting the movements of the eyeball by shortening the conjunctival 
fold. 
After the flap has been rotated to the correct position, so that it 
well covers the loss of substance, its apex is fastened by a few fine 
silk sutures to the bulbar conjunctiva on the side opposite to that on 
which the base of the flap is attached (Fig. 200). As the conjunctiva 
often shows a tendency to curl, one or more sutures may be intro- 
duced through the lateral edges of the flap, in order to keep it well 
stretched. The wound in the bulbar conjunctiva left by excision of 
the flap may be permitted to heal by itself, especially if there is diffi- 
culty in drawing upon the surrounding membrane; or an attempt may 292 
OPTICAL IRIDECTOMY—CONJUNCTIVOPLASTY 
be made to at least partly close the defect by undermining the wound- 
edges and inserting sutures. 
After-treatment. Both eyes are bandaged for three days to insure 
retention of the flap by excluding the possibility of ocular movements. 
Before applying the dressings, the operator should assure himself that 
the flap does not shift its position during the upward rotation that 
accompanies closure of the eyelids, and, if necessary, introduce an 
additional suture to prevent this displacement. The bandage should 
be changed on the following day, as we have to deal frequently with 
excessive conjunctival and lachrymal secretion. At first the flap 
appears quite swollen, and some time may elapse before it again 
assumes the condition of normal conjunctiva. It is generally not 
necessary to remove the stitches, as they drop out of themselves in a 
few days. If the loss of substance has occurred in the middle of the 
cornea, the separation of the flap from its base can be undertaken 
when the eye has become completely free from congestion and the 
process of healing is at an end. The results of this operation are in 
many cases remarkable, but occasionally, notwithstanding closure 
of the ulceration, an atrophy of the eyeball finally sets in. Of course 
the method cannot be blamed for these bad results, as they are caused 
by the severity of the primary injury. 
Flaps in Corneal Injuries.—A double pedunculated conjunctival 
flap (Fig. 201) may be employed in peripherally located corneal 
Fig. 201.—Kuhnt’s double pedunculated conjunctival flap, a., the dotted lines 
indicate the incision through the conjunctiva, the black line in the cornea indicates the 
wound; b., the flap drawn over the wound. 
wounds in the same manner as described in the operation for cataract 
(page 217). The flap, formed by two curved incisions of the conjunc- 
tiva a short distance from and parallel with the limbus, after being 
drawn over the corneal wound, is fastened near the two attached ends 
to the conjunctiva of the eyeball. The conjunctival bridge draws 
back to its normal position after a few days. LARGE SCLERAL WOUNDS 
293 
Instead of incising the conjunctiva to form a bridge of tissue, the 
membrane may be drawn over the corneal wound, apron-like, as 
shown in Fig. 202. 
In extensive injuries de Wecker undermines the conjunctiva on all 
sides from the limbus to the insertions of the recti muscles, after 
which this movable conjunctiva is drawn completely over the cornea 
and closed in purse-string fashion by several sutures. The raw surface 
of the conjunctiva closes the defect and fuses with the edges of the 
wound. After completion of the cicatricial process, the conjunctiva 
Fig. 202.—a., conjunctiva detached only at the limbus (dotted line); b., conjunctiva 
drawn down apron-like over the wound. 
may again be detached, after which it returns to its normal position 
in all directions, with the exception of the point of fusion. A total 
detachment of the conjunctiva is not always necessary, as a partial 
separation will often supply sufficient membrane to be attached to 
the opposite limbus and cover the corneal defect. 
Large Scleral Wounds.—In wounds of the sclera with prolapse 
of portions of the ciliary body or choroid, in which there is hope of 
preserving the eye, the same rule is to be observed as in prolapse of 
the iris. The prolapsed portion which lies exposed in the wound is 
excised, but, for reasons that can readily be understood, we avoid 
drawing upon the prolapse with the forceps. The wound is closed by 
a conjunctival flap. If it is desired to introduce scleral sutures, they 
must include only the superficial layers of the sclera, so that the needle 
does not produce a perforation and thus cause a fresh injury of the 
deeper parts. Scleral sutures are usually not employed, as the pres- 
sure necessary to pass the needle through the sclera causes further pro- 
trusion of the vitreous which lies in the wound. Scleral sutures are 
advisable only if the wound gapes, in which case they will prevent 
the formation of a wide cicatrix that upon contraction would likely 
lead to detachment of the retina. Absolute rest of the patient and 
bandaging of both eyes during the first few days are requisites to pro- 
mote healing of the wound. If a large part of the ciliary body or of 
the choroid has prolapsed, the best course is to enucleate the eyeball at 294 
OPTICAL IRIDECTOMY—CONJUNCTIVOPLASTY 
once. The patient is thus relieved of a long convalescence, which 
ends with an atrophic, painful bulb that is a source of danger, and 
may cause sympathetic ophthalmia. 
OPERATIONS FOR ANTERIOR SYNECHIA 
Increased tension may occur in cases of anterior synechia, in 
which the corneal scar is not only flat but also solid, especially if a 
considerable portion rather than a small tip of the iris is adherent to 
the scar. It is difficult to give a general rule for operative interfer- 
ence in anterior synechia—a flat cicatrix being naturally implied. 
An ectatic scar should be subjected to operation under all circum- 
stances. (See page 303.) But, in our opinion, an operation is not 
required in every case of anterior synechia with flat solid cicatrix. 
Indications.—The following are considered indications for opera- 
tion: (1) If the fusion is extensive, so that a large part of the pupillary 
border is adherent to the cicatrix. (2) If signs of increased pressure 
are present even though they occur intermittently. (3) If the cica- 
trix, although originally flat, begins to yield to the intraocular pres- 
sure and protrudes. (4) If dislocation of the pupil, as a result of 
distortion of the iris, hides the pupillary opening completely behind 
the cicatrix. A drawn up pupil from a peripheral adhesion of the iris, 
or a pupil covered by a central corneal cicatrix, demands operation 
on essentially optical grounds. 
Operation is not indicated if the adhesion consists merely of a fine 
filament which unites the anterior surface of the iris with a solid 
corneal cicatrix, or if a small part of the pupillary border is attached 
to the cornea, provided the cicatrix is firm. 
If the iris has healed in an operation cicatrix, as after an iridee- 
tomy for glaucoma, and one or both sides are adherent to the wound, 
no additional interference is called for if tension is normal and the 
operative cicatrix remains flat, presenting at most a dark coloration 
of the scar due to the adhesion of the iris. 
Temporary Resection of the Cicatrix with the Trephine.— 
While we were formerly well satisfied with iridectomy in all of the 
above mentioned cases requiring operation, we now prefer a temp- 
orary resection of the cicatrix with the aid of the trephine—a method 
which was first recommended by Sachs. As the scar is solid, it does 
not require to be replaced by a piece removed from another cornea, 
as in a fistulous or ectatic cicatrix. (See page 303.) OPERATIONS FOR ANTERIOR SYNECHIA 
295 
In order to avoid the danger of delayed healing of the excised 
flap of cornea, it is only separated in a little more than half its circum- 
ference by placing the trephine obliquely upon the cornea. In this 
way an assistant may lift the flap like a lid with a sharp tenaculum, 
while through the opening thus produced the operator enters the 
anterior chamber with the forceps or a tenaculum, draws the iris 
carefully out on all sides and excises it. The base of the flap is so 
placed that the iris can be most readily reached through the opening 
produced by lifting the flap. In most cases, therefore, this base will 
lie toward the center; that is, toward the pupil. After the iris is 
completely freed, the flap is returned to its original position, in which 
it is firmly held by the pressure of the upper lid when the eye is closed. 
A light compress and bandage may be used to support the lid. By 
the use of atropin an attempt is made to retract the iris as far as 
possible from its former point of adhesion. The anterior chamber 
will be re-established on the next day, but it is advisable to keep the 
eye bandaged for at least one week. The corneal cicatrix, which 
was formerly somewhat thin and had already become slightly ectatic, 
is often observed to become flat and solid after this operation. After 
detachment of the iris from the cicatrix, the former withdraws, and 
the pupil returns to its position behind the center of the cornea. 
Therefore, by this means not only have the optical disturbances 
been remedied but also the anterior synechia is removed. When, the 
eye has become entirely free from inflammation, and healing is 
complete, the scar may be tattooed. 
The only danger in trephining the cornea lies in an injury to the 
lens. Sometimes this cannot be avoided, as, for instance, when 
the lens capsule is adherent to the scar, and the capsule is cut when the 
corneal cicatrix is incised. But injury to the lens is not so important, 
as it is usually cloudy and, in young persons, frequently shrunken. 
The most dreaded sequel occurs after the escape of the lens-substance, 
when the delicate hyaloid membrane appears in the wound, ruptures, 
and leads to prolapse of the vitreous and prevents completion of the 
operation. 
Iris Healed in an Operation Cicatrix.—Usually these synechia 
cause no trouble, but should increased tension arise, the adherent 
iris must be removed. If the attached iris followed an iridectomy 
for glaucoma, it would be a mistake to proceed immediately to the 
performance of a second iridectomy, as the latter, being carried out 296 
OPTICAL IRIDECTOMY—CONJUNCTIVOPLASTY 
interiorly, would exert an unfavorable influence upon the visual 
function. It is necessary, therefore, to remove the adhesion of the 
iris. 
One method of operation consists in making an incision with a 
lancet corresponding to the adherent side of the coloboma, and as 
near the periphery as possible. The iris is then drawn out with the 
iris-forceps and excised, after which it either spontaneously returns 
to its proper position or is replaced with a spatula. 
A much safer procedure, and one that guards against the possi- 
bility of an injury to the lens, is to make an incision in the region of 
the iris-adhesion similar to that of an anterior sclerotomy. A Graefe 
knife is introduced on one side of the adhesion, and brought out of the 
anterior chamber on the other side of the adhesion, and a scleral cut 
made as near the periphery as possible, so that the iris is thereby 
severed from its adhesion. The incision need not completely sever 
the flap, especially if a prolapse of the vitreous humor is to be feared. 
If the iris does not retract after the incision, this method also permits 
the operator to draw the membrane out with tenaculum or forceps 
and excise it to its proper position. 
Adhesions consisting merely of a fine filament joining the iris and 
cornea, or a small adhesion of the pupillary border to the cornea, 
may be divided by a needle-knife or Graefe knife. 
Period When Excision is Safe.—No definite time can be stated 
as to how long after the occurrence of the prolapse excision may be 
undertaken. The possibility of loosening the prolapsed iris with the 
conical sound pre-supposes a loose connection between the iris and 
the edges of the wound. If cicatrization has advanced too far, the 
undermining with the sound can no longer be carried out. No 
definite time can be stated. Even after two weeks adhesion between 
the prolapsed iris and the edges of the wound may be slight, so that 
their separation, though difficult, is still possible. When the cica- 
trization has already led to a firm union, so that an ectatic black 
scar is seen in place of the prolapse, the manner of the operative 
interference again depends materially upon the size of the prolapse. 
The simplest method is to avoid freeing the iris from the corneal scar 
and to perform a broad iridectomy behind the normal portion of the 
cornea. In this way the pressure is diminished, and, by simultane- 
ously applying a pressure-bandage, an attempt is made to produce a 
flat cicatrix. Although this simple procedure often leads to the de- OPERATIONS FOR ANTERIOR SYNECHIA 
297 
sired result, it fails in many cases, for the ectasis of the cicatrix 
sometimes does not disappear after iridectomy, and the eye may be 
destroyed by a renewed increase in pressure. 
For these, as well as for all other cases of anterior synechia (espe- 
cially when the cicatrix is not solid, but dimly transparent or some- 
what ectatic), modern ophthalmic surgery has proposed separation 
of the iris from the cornea, and has devised various methods for its 
accomplishment. 
When the scar is small and the prolapse the size of a fly’s head or 
slightly larger, it is best to cut off the protruding cicatrix with a lancet 
applied flat against the cornea. The opening in the cornea is usu- 
ally too small to permit the introduction of iris-forceps for the with- 
drawal and excision of the iris. The latter is better accomplished 
by means of a blunt hook. After its excision, the iris is either drawn 
back spontaneously into its proper position, or it may be pushed back 
with the blunt tenaculum, as the introduction of a spatula through 
the small opening is impossible. The small wound cicatrizes in a 
short time, and the anterior chamber is usually established on the 
following day. 
When the ectatic cicatrix is large, it is also removed with the 
lancet, and the iris is more readily excised, as it can be drawn out 
with the forceps. After this has been done, the defect is covered with 
a conjunctival flap as already described, the conjunctiva replacing 
the cicatrix. CHAPTER XIV 
OPERATIONS ON THE CORNEA—OPERATIONS FOR RETINAL 
DETACHMENT AND VITREOUS OPACITIES 
OPERATIONS ON THE CORNEA 
Cauterization and Paracentesis.—Staining with a solution of 
fluorescin facilitates the recognition by the less experienced observator 
of the extent of an eroded or ulcerated area of the cornea. In 
the cauterization of a focus of infection the cautery loop, brought to 
a white heat, is first carried along the infiltrated margin slowly pene- 
trating rather deeply into the tissues, the central area being treated 
last. As the cornea in the area of inflammation is considerably 
swollen, an unexpected perforation is not to be feared. In general 
the beginner is too timid, and is satisfied with a rather superficial 
cauterization, and as a consequence pathogenic germs in the deeper 
tissues are not destroyed. Should the cautery perforate the cornea, 
it is of minor consequence, although when it is desired to relieve the 
tension of the eye a lancet incision at the limbus is preferable, as it 
relaxes the cornea and allows the removal of the hypopyon. The 
cauterization is repeated only if a new focus of infiltration appears. 
The vapor cautery of Wessely does not destroy so much tissue as the 
thermo-cautery, and the scars are supposed to be less dense and clear 
more readily, but its action is not so thorough as the actual cautery. 
It is recognized that the cautery is not indicated in all cases of 
ulcerations of the cornea, but is only employed after the usual local 
measures have failed to check the progress of the diseased process, 
including subconjunctival injections of i—1000 corrosive sublimate 
solution, and applications of such chemical agents to the infected 
area as carbolic acid, tincture of iodin, absolute alcohol, or trichlorace- 
tic acid. The use of optochin (ethylhydrocuprein) has given excel- 
lent results in the treatment of serpiginous ulcers. 
In progressive corneal ulcers the paracentesis is frequently com- 
bined with cauterization of the ulcer. The puncture may be 
advantageous in ulcers in which a rupture is imminent, since the 
obliteration of the anterior chamber by the puncture, instead of 
298 CAUTERIZATION AND PARACENTESIS 
299 
spontaneous rupture, prevents sudden escape of the aqueous and 
prolapse of the iris. In chronic inflammation of the cornea (kera- 
titis profunda) puncture occasionally exerts a favorable influence 
on the disease process. Puncture also accelerates the absorption 
of vitreous opacities. 
Saemisch Section.—Serpiginous ulcers that have affected more 
than one-third of the cornea are not amenable to the above form of 
treatment, as the extensive destruction of the cornea in its whole 
thickness leads to perforation before completion of the cauterization. 
It is in these cases, and only in these cases, that splitting the cornea 
according to the Saemisch method is indicated. The cocainized eye 
is held with the forceps below, and the cornea is then split in the re- 
gion of the serpiginous ulcer with a Graefe knife. The knife, with the 
cutting edge directed forward, is introduced into the healthy part of 
the cornea close to one edge of the ulcer, enters the anterior chamber, 
and is brought out at the opposite edge, so that the ulcer is cut 
through (Fig. 203). The blade of the instrument must be parallel 
to the cornea, in order that the lens will not be injured. By a slow, 
sawing motion, the cornea is then split in the region of the ulcer from 
behind forward. The incision is so directed that it passes through the 
extending, yellow, infiltrated part of the border. The aqueous humor 
escapes rapidly through the incision, and the hypopyon is frequently 
forced into the wound, whence it can readily be extracted in a com- 
pact mass by a pair of forceps. 
After-treatment.—The opening into the anterior chamber must 
not be allowed to close until the ulcer has become clean and retro- 
Fig. 203.—Saemisch incision through serpiginous ulcer. 
gressive. The re-opening of the incision on the succeeding days is not 
difficult, and may be accomplished by slightly depressing one lip of 
the wound with a spatula. The splitting of the cornea does not 
always have the desired effect, and the serpiginous ulcer progresses 
further and destroys the whole cornea. However, a favorable result 
usually follows, but the operation has the disadvantage of causing 
extensive attachments between the cornea and the iris. These 
adhesions cannot be avoided, but we select the Saemisch section only 300 
OPERATIONS ON THE CORNEA 
in advanced serpiginous ulcers to preserve an eye that would probably 
otherwise be entirely ruined by infection. 
Before the patient leaves the hospital, a broad iridectomy is per- 
formed behind the transparent part of the cornea, to prevent the 
otherwise certain onset of increased pressure, which would com- 
pletely destroy the visual power and cause the patient other incon- 
veniences through the transformation of the flat cicatrix into a 
staphyloma. Serpiginous ulcers are frequently associated with 
purulent disease of the lachrymal canal, and an important part of 
the treatment of the corneal affection is the immediate removal of the 
diseased sac. 
TATTOOING THE CORNEA 
Only solid, flat scars of the cornea are suitable for tattooing. If 
there is a tendency to ectasis, or if the scar is thinned, tattooing is to 
be avoided. India-ink is the only pigment applicable for the purpose, 
although excellent results are reported in the use of colored pigments. 
These consist of finely ground colors, which are washed with water, 
alcohol, and ether to remove the oily and resinous impurities. In 
this way a sterile, impalpable powder is obtained that is non-irritat- 
ing. The pigment is introduced into the corneal scar by pricking, 
either with a cluster of needles (Fig. 204), or with a single, broad 
needle, provided with a groove for holding the coloring matter (Fig. 
Fig. 204.—Cluster of needles. 
Fig. 205.—Grooved needle. 
205). In order to produce the best results, the tattooing must 
usually be done in several sittings. Thorough cocainization is 
always necessary. To hold the eye steady, the conjunctiva should be 
grasped with slightly roughened forceps, as toothed forceps produce 
slight wounds which become impregnated with the pigment. 
Tattooing with the cluster of needles is to be preferred to that 
done with the grooved needle. The latter is better suited, however, 
for accurate definition of the border. With the cluster of needles, CONICAL CORNEA 
301 
which is put in vertically, the operator produces simultaneously a 
series of closely-placed points, and, therefore, works more rapidly. 
There is also less danger of perforating the cornea than with the 
grooved needle, which has to be applied in a slanting direction to 
prevent perforation. If the latter should accidently be produced 
and the pigment enters the anterior chamber, the latter must be 
opened with a lancet and washed out. 
Froelich’s method is an excellent procedure for imitating a beauti- 
ful, round, black pupil. It is recommended for very large and thick, 
flat scars. With a von Hippel trephine a superficial furrow is cut, 
corresponding in position and size to the pupil of the other eye. 
Then, with a lancet applied on the flat, the superficial layers of the 
cicatrix, containing epithelium and a few lamellae, are removed in the 
form of a disk. The exposed base is scarified in all directions with 
the cutting edge of the lancet and the ink is rubbed in well. In this 
way a pronounced and uniformly black pupil is produced, which 
closely resembles a true pupil. The surroundings are then tattooed 
by pricking with the cluster of needles until the desired shade is 
produced. 
CONICAL CORNEA 
Conical cornea (Keratoconous) is treated either by trephining or 
by cauterization with the galvano-cautery. 
Trephining.—The pupil is dilated with atropin, several drops of 
a 3 per cent, cocain-solution instilled, and a disk, i mm. in diameter, 
excised with the trephine from the exact summit of the cone and 
through the entire thickness of the cornea. Only a few rotations of 
the instrument will be required to penetrate the thinned cornea. As 
soon as the circular blade has cut through, the instrument is immedi- 
ately withdrawn to prevent injury of the lens. The aqueous gushes 
out, the pupil contracts, and the cornea collapses, forming small 
radiating folds around the opening. As most of the trephines in 
use have crowns larger than i mm., a special blade must be secured, 
as a larger opening than i mm. is not to be made. 
Both eyes are bandaged, and the patient put to bed. Atropin is 
to be used every five to six hours until the wound is healed and the 
anterior chamber reformed. Neglect of this course will result in 
adhesion of the iris in the opening, with the usual serious conse- 
quences of anterior synechia and increased tension. 302 
OPERATIONS ON THE CORNEA 
The anterior chamber is often restored in three or four days, 
although a week or two may elapse before closure of the wound occurs. 
Until healing is complete, the patient should remain in bed with both 
eyes bandaged. Afterward, the operated eye is bandaged for several 
months, at first gently, to prevent breaking open of the wound, but 
later more firmly to secure as flat a cicatrization as possible. Occa- 
sionally the dressings are removed for a few hours, and then, as 
firmer union takes place, applied only at night. The use of atropin 
is indicated by the ocular injection. 
The resulting scar is not perfectly round, having slightly scalloped 
edges, but is never so prominent as to require tattooing. 
The results of the operation are superior to other forms of treat- 
ment, not only in the ultimate results as to vision but in its safety. 
The smallness of the scar renders optical iridectomy unnecessary, 
while the flattened cornea restores good vision, which in the majority 
of instances is permanent. In the event of insufficient flattening, a 
second trephining may be made close to the first. Most of the dis- 
credit that the method received was due to the excision of too large 
a disk from the cornea. 
Cautery Puncture.—Cauterization of the summit of the cone is 
frequently performed. The central area is touched with the cautery 
loop brought to red heat, and, if a thorough effect is desired from one 
cauterization, perforation is made. The scars after this procedure 
are much larger and less sharply bordered than after trephining, and 
usually require subsequent tattooing and almost always optical 
iridectomy. The visual results are therefore usually far from 
satisfactory. 
CORNEAL STAPHYLOMA 
Keratectomy—Beer-de Wecker Operation.—This method is 
employed for the removal of a complete corneal staphyloma. The 
conjunctiva is detached around the limbus, as in the operation for 
enucleation, is thoroughly undermined, and a purse-string suture 
introduced, which is at first left loose. The epithelium on the limbus 
and the border of the staphyloma is then carefully denuded, in order 
to produce a raw surface to which the conjunctiva can adhere when 
drawn over it. The staphyloma is then cut away; the lower half first 
separated by the Graefe knife as in the operation for cataract, and the 
upper half with the scissors. A narrow band should remain above CORNEAL TRANSPLANTATION 
303 
and below, through which sutures are introduced but not tied. The 
lens is allowed to escape by opening the lens capsule, after which the 
sutures are rapidly drawn together to avoid loss of the vitreous 
humor. The wound in the conjunctiva is then closed by drawing 
upon the purse-string suture. 
In a recent staphyloma with thin walls an attempt may be made 
to produce a flat scar by simply splitting the staphyloma. A bow- 
shaped incision like that for cataract is so made that the flap is 
formed from the wall of the staphyloma. By retraction of the flap, 
the wound is made to gape, which effect may be increased by excising 
a narrow edge from the flap. The lens is removed by rupture of the 
anterior capsule, and a compress and bandage applied, so that a flat 
cicatrix may be produced. 
The incision of a staphyloma has only one advantage over 
enucleation, namely, that the patient is left with a freely movable 
stump upon which an artificial eye can be well fitted. On the other 
hand, the operation has the disadvantage of not guarding against 
sympathetic ophthalmia. It is, therefore, evident that enucleation 
should be preferred in all cases in which there is suspicion of sym- 
pathetic ophthalmia or in which the latter may readily develop. 
CORNEAL TRANSPLANTATION 
Fuchs was the first to recommend that the fistulous or ectatic 
cicatrix be excised with a corneal trephine, and that the defect be 
covered with a piece of cornea removed by a trephine from a freshly- 
enucleated eye. The excised portion may include the entire thickness 
of the cornea, total keratoplasty, or all but the posterior transpar- 
ent layer and Descemet’s membrane, partial keratoplasty. While the 
new piece of cornea inserted usually adheres well, it becomes cloudy 
in a short time, so that from an optical point of view the operations 
are worthless, and are only employed to replace a fistulous or ectatic 
portion of the cornea. The treatment of anterior synechia, in which 
the cicatrix is solid, has already been given (page 294). 
Total Keratoplasty.—Local anesthesia is sufficient except in rest- 
less patients. The cutting edge of the trephine, which should project 
only slightly to avoid injury of the lens capsule, is pressed lightly 
upon the cornea over the cicatrix, and the assistant presses the 
button starting the trephine. After a few rotations the instrument 
must be raised to determine the depth of the cut, and to observe 304 
OPERATIONS ON THE CORNEA 
finally if the instrument has perforated. As the scars are thin, per- 
foration often occurs with unexpected rapidity. After the aqueous 
humor has escaped, if the circumscribed piece is not cut through in 
its entire circumference, it is better, rather than re-apply the tre- 
phine, to raise the flap with forceps at its cut end and carefully sepa- 
rate it at the periphery with a lancet. This is not difficult, as a 
rather deep furrow will have been made. On the posterior wall of 
the excised piece may be seen adhering the remnants of the pigmented 
epithelium, as the excised cicatrix is nothing more than the iris which 
has undergone cicatricial change. 
Carefully avoiding the capsule of the lens, which lies exposed in 
the opening, the operator then proceeds with the forceps to draw the 
iris out a trifle on all sides, and to excise it with de Wecker scissors. 
In doing this there is the danger of producing an iridodialysis, espe- 
cially if the iris is short on one side. This is most likely to occur when 
the iris is roughly drawn out with the forceps. It is, therefore, better 
to break up the adhesions with a blunt tenaculum and thus free the 
iris, whereupon it will usually withdraw itself from the scar, or it may 
be pushed away with the spatula. 
The defect is then covered with a piece of cornea removed with 
the same trephine from a freshly-enucleated human eye. If the lens 
does not protrude it is sufficient to insert the piece without further 
fixation, care being taken to place the side covered with epithelium 
externally. When the flap is placed in the proper position, the upper 
lid is drawn down carefully over the eye, a bandage is applied to both 
eyes and not removed for two days, and the patient kept in bed. 
While the inserted piece usually remains fixed in position, it may 
be forced out into the conjunctival sac after the bandage has been 
applied. If the new disk shows no tendency to stay in place imme- 
diately after operation, which occurs if the lens or hyaloid protrude, 
it must be held in position for a few days with a conjunctival flap. 
The flap should be twice the width of the corneal defect, as one that is 
scanty tends to slip from the bulging cornea. The conjunctiva lies 
upon a surface completely covered with epithelium, so that there is no 
adhesion between the two. If the sutures have not spontaneously 
cut through, the conjunctiva may be loosened in a few days and 
returned to its normal position or excised. 
It is evident that the operation for removal of an ectatic cicatrix 
with the trephine can only be applied to scars with a maximum diam- PARTIAL KERATOPLASTY 
305 
eter of 4 mm. If a large piece is trephined from the cornea, the trans- 
planted flap will not hold, and the large opening will have to be 
covered later by a conjunctival flap. Therefore, for large ectatic scars 
there remains only the original simple method of producing a flatten- 
ing of the scar by a broad iridectomy and subsequent pressure- 
bandage. Ectatic cicatrices should be removed by operative means, 
as they not only carry with them the danger of increased pressure, but 
also afford a portal of entry for infection of the eye. 
Partial Keratoplasty.—This method has been perfected especially 
by von Hippel. It is suitable only for those cases in which the cica- 
Fig. 206.—The von Hippel corneal trephine 
tricial clouding of the cornea that is to be replaced by a transparent 
piece does not include the whole thickness of the cornea. The tre- 
phine cut should never exceed 4 mm. in diameter, and is carefully cut 
out with the aid of forceps and a lancet applied flat, the result being 
that the transparent posterior layer of the cornea lies exposed in the 
opening. A corneal segment of the same size is then excised in its 
whole thickness from a suitable freshly-enucleated human eye. The 
defect is covered with this piece. The eyes are carefully closed and 
bandaged, the bandage being changed in three days. It can be 
entirely dispensed with in nine days. The adhesion of the trans- 
planted piece usually occurs promptly, but the expectation that the 306 
DETACHMENT OF THE RETINA 
flap will remain transparent is almost never realized. A complete 
cloudiness gradually develops. 
The trephine of von Hippel (Fig. 206) contains a drum at its 
upper end, in which a clock-work arrangement is introduced. On the 
cover of the drum is placed a button, the pressure of which with the 
finger causes the crown of the trephine to be set into rapid rotation. 
This crown can be varied in height, thus regulating at will the depth 
of the incision. The trephine contains a set of crowns of varying size. 
DETACHMENT OF THE RETINA 
Operation may be considered in the serous detachment in myopic 
eyes; in some cases of retinal detachment which occasionally occurs 
in elderly persons with no other apparent disease of the eye; and in 
detachment which follows the shrinkage of isolated strands of 
connective tissue, especially after injuries. In every case of detach- 
ment the possibility that a neoplasm may be the cause of the separa- 
tion is to be considered before any surgical measures are taken. 
Detachment which follows serious diseases of the choroid and 
vitreous, especially after long-existing inflammations, is less suited 
for surgical treatment. No consideration is to be given detachment 
which follows intraocular infections from perforating injuries, with 
beginning atrophy of the eyeball, since sight is entirely lost in these 
cases. 
In many cases of high myopia the detachment occurs suddenly, 
extends rapidly, and sight is reduced to eccentric fixation; while in 
others the course is much slower, the separation remaining limited 
for a long period to the periphery, and only slowly increasing in 
extent. 
Although the detachment may occur with perfectly clear vitreous, 
the consistence of this structure is never normal in such cases, being 
either liquid or of a tough-mucoid consistency. In other instances a 
dense opacity appears with the detachment, or may even precede it. 
The tension of the eye is usually diminished, often to considerable 
degree, and the anterior chamber deep. Frequently an abnormal 
depth of the chamber has existed for some time. In other cases 
the tension is normal or nearly so, and there is no alteration in the 
depth of the anterior chamber. 
Attacks of inflammation may appear at any time in an eye with 
retinal detachment, but usually only in cases of long standing disease. INDICATIONS FOR OPERATION 
307 
There is ciliary injection, discoloration of the iris, deep anterior 
chamber, rapid formation of posterior synechia, minute opacifica- 
tions of the aqueous, and tenderness of the eyeball. Tension is often 
subnormal at the beginning, but as the inflammation progresses 
the globe frequently becomes hard. Even after the acute symptoms 
have subsided, there remains injection of the deep vessels, so that 
recurring attacks are not uncommon, and with blocking of the 
pupillary space with inflammatory exudation, followed by secondary 
glaucoma, the eye is ultimately lost. The prognosis is bad in cases 
where there is atrophy of the iris fibers, and the lens becomes 
cataractous. 
General Treatment.—At the time the detachment first appears 
the most efficacious measure is complete rest in bed. Some cases are 
favorably influenced by a compress bandage, but in others it acts 
badly. In pronounced lowering of the tension the bandage is con- 
traindicated, and is not used if the cornea becomes depressed or the 
eye sensitive. Some authorities report favorable results with sub- 
conjunctival injections of salt solutions, from 5 to 10 per cent., as 
much as 2 cm. of the fluid being used. Unless they are followed by 
severe pain, such injections may be employed. 
Indications for Operation.—If the area of the macula is included 
in the detachment, and the retina fails to become re-attached by 
conservative treatment, operation is indicated. Detachment at the 
macula not only seriously affects sight at the time, but even if the 
retina in this region becomes replaced, there is no restoration of 
function, and a large central scotoma persists. Apart from eyes 
with dense vitreous opacities or rapidly forming cataract, operation is 
indicated in many cases even though separation again occurs, since the 
return of the retina to normal position is often followed by an improve- 
ment in sight for months. In this way the operation may be repeated 
at suitable intervals, and some measure of sight preserved for years— 
much longer than if nothing had been done. 
Results.—Even though the majority of cases of retinal detach- 
ment are not greatly benefited by treatment, there has been restora- 
tion of useful vision in a few, and re-attachment of the retina in a still 
greater number, to warrant every attempt being made to relieve 
the condition. While operation may result in return of the retina 
to its normal position, it is rare that it remains fixed, so that the 
operation may have to be repeated several times. The results are 308 
DETACHMENT OF THE RETINA 
less favorable the longer the disease continues, so that early surgical 
treatment is to be recommended. 
In a certain proportion of cases the influence of operation is 
surprising, and extensive detachments disappear for a shorter or 
longer period. In others there is little if any effect, and further 
operation is therefore of no value. In general, recent detachments 
are more favorably influenced than those that have existed for some 
months. Detachments of long standing which have not been pre- 
viously treated surgically are not benefited by operation. 
The first operation usually shows the greatest benefit. Occasion- 
ally there will be re-attachment which had been treated in vain by 
conservative methods. The visual acuity improves, and the field 
returns to normal limits. Many such cases are reported as cured, 
and the method praised as an efficacious one in retinal detachment, 
but subsequent separation takes place, sometimes in a few weeks or 
months; rarely does the retina remain in place for as long as a year. 
The influence of subsequent operations is not as lasting, and they 
finally are without effect. 
Experience shows that recurrence of the detachment is not always 
at the place of the primary separation and the first operation. 
Sometimes the area of a subsequent detachment is entirely removed 
from the previous point of separation. 
Methods of Operation.—Numerous procedures have been sug- 
gested for the relief of the detachment. Deutschmann transplants 
the vitreous body of the rabbit or calf into the vitreous chamber 
of the affected eye. Birch-Hirschfeld injects into the vitreous the 
fluid withdrawn by suction from the subretinal space. These 
methods are based on the supposition that the diminution in the 
volume of the vitreous is either the exciting cause or the contributing 
factor in continuation of the detachment after withdrawal of the 
subretinal fluid. The increase in the bulk of the vitreous as obtained 
by these operations lasts but a few hours, and there is a return 
of the former condition, with the possibility of an added severe 
inflammatory irritation as a result of the operation. There is no 
possibility of furnishing any similar or equivalent substitute for the 
vitreous which has become degenerated, as, for example, in the 
myopic eye. The liquefaction of the vitreous body in such an eye is 
a recognized fact and exists in many eyes through life without a 
retinal detachment. METHODS OF OPERATION 
309 
If the ciliary body is performing its functions normally there is 
plenty of fluid always ready for the vitreous chamber. After an 
operation in which considerable of the liquid vitreous is lost, so that 
the eye is partly collapsed, a considerable quantity of fluid is substi- 
tuted in a few hours, the opening of the eye, the lowering of the ten- 
sion, and other circumstances influencing the ciliary body in such a 
way that its normal secretion is increased to make up for the fluid lost. 
The attempts therefore to relieve retinal detachment by injections 
into the vitreous chamber to increase its bulk are of limited value 
unless at the same time the ciliary body is stimulated to secrete the 
fluid needed. The subretinal fluid in detachment seems to impair 
the function of the ciliary body, and may acquire properties that lead 
to inflammation and irido-cyclitis. Removal of the liquid by scleral 
puncture not only exerts a beneficial effect on the inflammation but 
is frequently followed by the restoration to normal depth of the 
anterior chamber which had become abnormally deep, and by increase 
in the diminished tension of the globe, notwithstanding the escape 
of the subretinal fluid. 
The most important purpose of any operation for the relief of 
retinal detachment is to secure drainage of the subretinal fluid. All 
the many and somewhat complicated procedures recommended seem 
to act as puncture of the subretinal space—posterior sclerotomy; 
puncture of Deutschmann; severing of adhesion bands of the vitreous 
body; puncture of Sachs; trephining of the sclera; puncture and 
suction of Fuchs, etc. None of the methods are of positive value, 
as the cause of the detachment is not influenced by the removal of 
the subretinal fluid. 
It is a fact, however, that operations which confine themselves 
to removal of the subretinal fluid, and therefore do not touch the 
retina and the ciliary body, have exactly the same influence as those 
which go further and try to prevent recurrence of the detachment by 
the creation of cicatricial adhesion between the retina and choroid; 
or those operations which are planned to relieve supposed strands in 
the vitreous body or shrinking membranes on the surface of the 
retina. It is recognized that after injuries membranes in the vitreous 
lead to detachment of the retina, but it is the exception to find 
that the drag on the retina is due to a circumscribed strand; usually 
there is a cicatricial mass for which nothing can be done. Even when 
it is shown that a single fine band of tissue leads to the detachment 310 
DETACHMENT OF THE RETINA 
it is only exceptionally that severing of this string causes disappear- 
ance of the retinal separation. Often the condition is rendered worse 
by the dragging on the band in the attempt to sever it. As the 
operation is done under control of the ophthalmoscope, it is often 
impossible to secure a sufficiently clear view to insure success. 
The supposition that recent retinal detachment in myopic eyes 
is due to strings in the vitreous or shrinking membranes on the retina 
does not accord with experience. Sometimes after puncture a large 
boggy detachment has disappeared without the retina or vitreous 
having been touched, and remained so for months, which could not 
have happened if the detachment was caused by a shrinking mem- 
brane. In fact, scleral puncture is without effect if there are adhesion 
bands in the vitreous, as after hemorrhages or injuries. It is there- 
fore clear that operations designed to sever supposed strings and 
membranes in order to free the retina from traction are no more 
successful than simple puncture. 
.As the subretinal fluid usually flows off quickly after puncture, 
the retina in sinking into place is often penetrated by the knife point. 
This may be recognized usually by a thread of mucoid vitreous 
adhering to the blade or later by a white retinal scar seen with the 
ophthalmoscope if the puncture has been made far enough back. 
Most operators plan to puncture the retina at the time of opening the 
sclera in order to produce cicatricial adhesion between the retina and 
choroid, but these adhesions are too circumscribed to assist much in 
permanently retaining the great expanse of the retina in proper 
position. In the normal eye the retina throughout its extent is 
anchored to the pigment epithelium, with many thousands of cells 
in an intimate connection with each other. If this junction is once 
separated by atrophy of the cells of the pigment epithelium, it cannot 
be substituted by single streak-like cicatricial adhesions. Even the 
large equatorial incisions of the retina as recommended by Sachs, 
made with the intention to decrease stretching of the retina, do 
not suffice. Attempts to produce extensive adhesions by injecting 
irritating liquids (Jod) or by electrolysis of the subretinal fluid have 
failed. Equally efficacious and relatively harmless are fine-point 
cauterizations of the sclera. They are supposed to provoke foci of 
inflammation in the choroid and subsequent adhesion of the retina. 
It is probable that the subretinal fluid originates in the choroid, 
as shown by the clinical observation that extensive atrophy of the RESECTION OF THE SCLERA 
311 
choroid frequently protects the eye from retinal detachment. Based 
upon this fact, the various forms of puncture, especially if frequently 
repeated, act the same as cauterization in producing cicatricial 
atrophy of the choroid. Sachs has endeavored to secure the same 
results by cutting the ciliary blood-vessels at the posterior pole of the 
eye. 
The author has endeavored in several cases to direct the sub- 
retinal fluid beneath the choroid by exposing the sclera as in cyclodi- 
alysis, but somewhat further back from the limbus, and, after 
severing all the lamellae of the sclera, introducing a spatula through 
the wound backward between sclera and choroid, detaching the 
latter from the sclera (choriodialysis). The spatula is then carried 
forward to the region of the equator, its point turned toward the 
interior of the eye, and the choroid perforated. By a lateral move- 
ment a long oblique tear is made in the choroid, which is followed by 
a small amount of subretinal fluid in the wound. The spatula is 
quickly withdrawn before much of the fluid has escaped, as this is not 
the object of the operation. Occasionally the retina is injured by the 
tip of the spatula. The conjunctival wound is closed with a single 
suture, both eyes bandaged, and the patient put in bed for one or 
two weeks. Atropin is instilled daily. The hemorrhage of the 
choroidal wound is usually insignificant, and is a distinct advantage 
in the development of adhesions between the choroid and retina. 
After healing, the ophthalmoscope picture is that of a choroidal 
rupture. Muller’s observation that in retinal detachment fluid is 
present in the space between the choroid and sclera was confirmed 
in a few but not all of the cases. 
Resection of the Sclera (Muller’s Method).—This operation is 
designed to shorten the myopic eye by excision of a broad strip from 
the sclera, whereby the volume of the vitreous is indirectly decreased. 
The stretching of the choroid is also prevented, to which Muller 
attributes much importance as a factor in the development of the 
detachment, so that re-attachment of the retina is facilitated. The 
operation, as slightly modified by Blaskovics, is performed as follows: 
Aftev canthotomy, the conjunctiva is incised above the external 
rectus muscle, and dissected back, uncovering the muscle and sclera. 
Two sutures are inserted in the muscle, which is then divided between 
them. An ellipitical space is outlined in the sclera about 20 mm. in 
length and 10 mm. wide, from back of the muscle insertion toward 312 
DETACHMENT OF THE RETINA 
the equator, and the sclera cut through in half its thickness. The 
superficial layers of this elliptical area are removed and in the edges 
of the cut are introduced five double-armed sutures, from within 
outwards. After the sutures are turned aside, the posterior border 
of the scleral incision is completed through the entire thickness 
of the sclera, without injuring the choroid. The latter is now 
separated from the sclera with a spatula, a puncture made in the 
choroid, and the sutures tied. This brings the two edges of the sclera 
together, while the thinned area of sclera is pushed into the pocket 
between the sclera and choroid. The divided muscle is sutured 
in place, the wound in the conjunctiva closed, and the patient kept 
quiet in bed for ten days. Atropin is instilled daily. 
Puncture of the Sclera.—If the detachment involves the entire 
lower half of the retina, the puncture is made preferably in the 
Fig. 207.—Sickle-knife after Sachs. 
lower outer portion of the sclera. Should the detachment occupy 
the upper half of the globe, it is the general rule to wait until it has 
changed its situation to the lower portion before puncture is made, 
but this plan has little to recommend it, as the subretinal fluid on its 
Fig. 208.—Sickle-knife after Sachs. 
way down pushes the whole retina from the base to which it was 
previously firmly attached, and thereby facilitates recurrence and. 
greater extent of the detachment. It is not borne out by experience 
that puncture in the upper half of the eyeball is followed more fre- 
quently by hemorrhage into the interior of the globe. Several dif- 
ferent methods of making the puncture have been suggested: 
(a) The usual method is the same as used in posterior sclerotomy, 
the Graefe knife passing through conjunctiva and sclera as far back as 
possible toward the equator and in the region of the detachment. 
By slight rotation of the knife the subretinal fluid slowly escapes, 
and the retina usually falls upon the point of the knife. At the place 
of puncture the choroid becomes attached to the retina. Two punc- PUNCTURE OF THE SCLERA 
313 
tures at different points of the detachment may be made at the same 
sitting. 
(b) Instead of passing the knife directly through conjunctiva and 
sclera, a flap of conjunctiva may be dissected, and the sclera exposed 
at the point desired. 
(c) With the sickle-knife of Sachs (Figs. 207 and 208), the punc- 
ture may be made as far back as desired, even in the posterior part 
of the eye, although this portion is usually avoided, owing to the 
danger of injuring large blood-vessels and causing extensive hemor- 
Fig. 209.—Knife with double cutting edge after Deutschmann. 
rhage into the interior of the eye. The puncture is made in the 
usual way after the conjunctival flap has been elevated with a double 
hook, the capsule opened, and hemorrhage stopped. 
(d) Deutschmann employs knives with double cutting edges 
(Figs. 209 and 210). The point of the knife is entered as far back as 
Fig. 2io.—Bayonet-shaped knife after Deutschmann. 
possible on the temporal side, passes through conjunctiva, sclera, and 
choroid into the area of detachment, then into and across the subreti- 
nal space to puncture the retina and other membranes to the inner 
side, but after the counter-puncture in the sclera is made the con- 
junctiva is not perforated. The subretinal fluid is not observed to 
run out, but it undoubtedly gradually oozes through the wound, 
especially if the compress bandage is lightly applied. 
Whatever method of operation is employed, the patient must 
remain quiet in bed for at least a week, with daily instillations of 
atropin and a light compress bandage. 
The success of the operation may be determined the following day 
by ophthalmoscopic examination. If, instead of a dull gray reflex, the 
normal red color of the fundus is seen, there is promise of a successful 
result. Frequently the full effect is not seen for several days. If the 
detachment recurs, operation is postponed until all irritation has 
subsided and the detachment has become stationary. The sooner 314 
DETACHMENT OF THE RETINA 
the detachment recurs, the less favorable will be the effect of subse- 
quent operation. 
Pre-equatorial Sclerectomy (Holth).—In this operation no 
attempt is made to remove the subretinal fluid, but a trephine opening 
is made in the sclera in the lower outer portion of the eyeball, anterior 
to the equator, and the supra-choroidal space brought in communica- 
tion with Tenon’s capsule, so that the intraocular lymph may ooze out 
continuously for a period of several weeks until the opening closes. 
Thejresorptive power of the choroidal lymph spaces is in this way 
indirectly increased, and the subretinal fluid absorbed. The method 
appears to act better in detachments without a tear in the retina. 
Fig. 21 i.—Pre-equatorial sclerectomy (Holth), for detachment of the retina. The 
choroid is not injured. The opening is covered by the conjunctiva, and the sutures are 
inserted in the conjunctiva in such a position that they do not touch the scleral opening. 
Anesthesia.—The usual instillations of cocain-solution are supple- 
mented with a subconjunctival injection at the seat of operation of 
about % cm. of i per cent, cocain-adrenalin solution. 
Operation.—The lids are separated with the speculum, or the lid 
spoon may be employed to draw the lower lid from the eyeball. 
A thread is inserted close to the limbus down and out, so as to rotate 
the eyeball in the opposite direction. A horizontal incision is made 
through the conjunctiva between the inferior and external recti 
muscles, beginning io mm. from the limbus and extending backward 
io mm. Tenon’s capsule is opened, and the sclera exposed near the 
outer border of the inferior rectus. The hemorrhage is checked, the ASPIRATION OF THE VITREOUS 
315 
wound-margins held apart by small double hooks, and a 2.5 mm. 
trephine placed on the sclera, 12 mm. from the limbus, near the 
inferior rectus. In this area the sclera is on the average 0.5 mm. 
thick. In order not to injure the choroid, the crown of the trephine 
is set to cut 0.5 mm. in depth. A few rotations are sufficient to 
excise the small disc (Fig. 211). If the button still adheres to the 
sclera by a thread of tissue, it is cut off with the scissors. The con- 
junctival wound is closed by two silk-sutures, so placed that they 
do not touch the scleral opening. Both eyes are bandaged for two 
days, and the operated eye for a week, at which time the sutures are 
removed. Rest in bed for several weeks is important. 
Aspiration of the Vitreous (Zur Nedden).—This operation is 
employed for opacities in the vitreous which have not absorbed after 
all conservative forms of treatment have been tried, such as sweat 
cures, subconjunctival injections, mercurials in various forms, and 
the iodides, and where further improvement in sight cannot be ob- 
tained by the usual measures. 
Indications.—(1) Vitreous opacities remaining after traumatic 
hemorrhages. (2) Vitreous opacities the result of uveal inflamma- 
tions, but all irritation must have subsided before an attempt is made 
to remove the vitreous. The method is especially adapted for cases 
of chronic inflammation. (3) In acute infections after perforating 
injuries the sucking should be done immediately after the onset of 
the infection, and repeated at short intervals. 
Instruments.—As it is difficult to perforate the sclera with a 
needle, special needles are used with sharp points, slantingly ground. 
The thinnest needle has a diameter of 0.4 mm., the thickest, 0.9 mm. 
Fig. 212.—Needle for Zur Nedden’s method of sucking off vitreous body. 
At a distance of 1.5 cm. from the point there is a ring-shaped thicken- 
ing (Fig. 212) which prevents the needle from penetrating too deeply 
into the interior of the eye. After the liquid is withdrawn the eye 
is soft. In order to prevent a drag upon the internal structures as 
the needle is withdrawn, a special spatula (Fig. 213) is employed, 
which has a slit to be placed over the point of perforation before the 
needle is pulled out. The spatula has a plate-shaped excavation 
(Fig. 214). A complete set of 12 needles, in pairs, is supplied by 316 
OPERATION FOR VITREOUS OPACITIES 
Windier, Friedrichstrasse, Berlin, with a stand to hold the needles 
and spatula at the time of sterilization. 
The thinnest needles are used in opacities following inflamma- 
tions, as the vitreous body in these cases is liquid and readily passes 
through the small opening of the needle. In the other opacities 
Fig. 213.—Spatula for Zur Nedden’s method. (Natural size.) 
needles of 0.6 and 0.7 mm. are employed. The ordinary record glass 
syringe serves well. 
The spatula prevents the membranes of the eye, rendered soft 
by the loss of liquid, from following the traction of the needle, and 
also prevents alteration in the shape of the eye. The eye is bandaged 
for several days, but rest in bed is not necessary. In the case of 
ciliary irritation atropin is to be instilled. 
Operation.—After the usual cocainization the eye is fixed, and the 
needle enters the vitreous at a point down and out, about 6 to 7 mm. 
Fig. 214.—Spatula for Zur Nedden’s method. (Lateral view.) 
back of the limbus. If the resistance of the sclera is great, the 
Elschnig sharp-toothed forceps are used. As the forceps pull the 
eyeball forward, the conjunctiva is somewhat displaced, so that after 
the needle is withdrawn, the opening in the sclera is closed as the 
conjunctiva returns to its normal position. After the needle passes 
through the sclera, it is not carried at first deeply into the eye, since 
the sucking process proceeds more readily when the vitreous is fluid. 
In case fluid does not appear in the syringe, the needle is entered 
deeper, as occasionally the central parts of the vitreous are more 
fluid than near the periphery. The vitreous of normal consistence 
is not likely to be sucked out. After the desired quantity of fluid 
has been removed, the spatula, with the needle in the slit, is slightly 
pressed to the sclera until the needle has been withdrawn. 
Quantity of Liquid Removed.—At the first operation 0.5 ccm. may 
be removed; subsequently the quantity may be increased to 1 ccm. ASPIRATION OF THE VITREOUS 
317 
each time, i.e., one-third of the entire vitreous liquid. In inflamma- 
tions of the uvea and retina not more than 0.6 ccm. may be removed. 
The aspiration must be repeated at intervals of three weeks. 
In acute infections it may be repeated twice in one day. The point 
of perforation should be changed each time. 
Complications.—Among the complications are slight ciliary injec- 
tion, especially in cases of inflammatory vitreous opacities, for which 
atropin is to be used; difficulty in passing the needle through 
the sclera, owing to the lowered tension of the globe or dullness of the 
needle point. The use of two pairs of fixation forceps facilitates the 
puncture in reduced tension. There is no danger of retinal detach- 
ment. The wrinkling of the cornea, which may occur on account of 
softness of the ball, disappears in a few days. The tension usually 
remains subnormal for several days. 
Contraindications.—The operation is not done in instances of 
disease of the retinal vessels because of the danger of intraocular 
hemorrhage; nor if the uveal inflammation is active, since a fresh 
attack may be started, as previously mentioned. 
Action of the Operation.—(1) Mechanical removal of the vitreous 
opacities; (2) improved nutrition of the uvea; and (3) rapid supply of 
the normal protective constituents of the blood in infections by the 
new secretion of vitreous fluid. 
Results.—Occasionally the operation is followed by surprising 
improvement in the sight; frequently little influence is shown; and 
sometimes there is no effect. CHAPTER XV 
EXTRACTION OF FOREIGN BODIES FROM THE INTERIOR 
OF THE EYE 
The extraction of foreign bodies from the interior of the eye is 
usually a most delicate operation, particularly if attempted weeks or 
months after the original injury. There is no typical operative 
method that may guide the less skillful, and, as many of the most 
important structures of the eye are directly or indirectly affected in 
any form of operation, these may readily receive more injury than 
aid from the operator of limited experience. 
Diagnosis.—The means of diagnosis employed in ocular injuries 
by a foreign body comprise external examination, the ophthal- 
moscope, the sideroscope, and the Roentgen rays. 
External Examination.—In some cases one may recognize at first 
glance a perforation of the eyeball by a foreign body and determine 
the presence of the latter within the eye, but in others it may be 
difficult to find the point of entrance and to discover the foreign body 
itself. It frequently happens that a patient will complain of diminu- 
tion in visual power without known cause and with positive denial of 
any injury, while the skilled eye of the physician, warned by the 
finding of a unilateral partial or total cataract, will examine the eye 
with a magnifying glass and at once discover a positive sign of a 
previous penetrating wound in the form of a fine linear corneal 
cicatrix. 
Often a vain search is made for the cicatrix. A fine narrow 
splinter with sharp edges, penetrating the sclera at the limbus or 
through the bulbar conjunctiva, will leave behind not the slightest 
trace of a visible cicatrix. 
In general, the presence of small wounds caused by the impact of 
foreign bodies usually points to the likelihood of these bodies having 
entered the eye; while in patients showing large wounds the injury is 
caused by larger pieces which rebound and do not remain in the eye. 
For example, if, in a recent injury of the cornea in the form of a 
small perforating wound, the history is obtained that a small splinter 
318 METHODS OE EXAMINATION 
319 
had come in contact with the eye, such circumstances will allow the 
presumption that there is a foreign body within the eye. If it is not 
found lying in the anterior chamber, the search for a perforation of 
the iris, lens capsule, etc., will not be in vain. On the other hand, a 
larger piece, striking the eye with its fine point, might wound the 
cornea, iris, and lens capsule and then drop away. In this case the 
patient’s statement concerning the size of the splinter may be of 
importance. In war injuries reports concerning the details of the 
injury are defective, especially during action with heavy artillery 
or close fighting with hand grenades. Therefore, the presence of a 
foreign body cannot positively be determined by external examination 
alone, as in these war injuries foreign bodies frequently entered the 
posterior portion of the eye through the neighborhood of the orbit. 
The Ophthalmoscope.—If the media are sufficiently transparent to 
permit an ophthalmoscopic examination, the splinter may be seen in 
the vitreous or retina. An advanced cataract may render impossible 
the illumination of the eye-ground and the discovery of the foreign 
body. The lens, however, may be transparent if the perforation has 
occurred through the sclera. The diagnosis is difficult, however, 
from dense vitreous turbidity, usually greatest around a foreign 
body lodged posteriorly in the eyeball, owing to the separation of 
the retina, which occurs frequently in such injuries. An exact and 
complete diagnosis, including the localization of the splinter, is most 
readily made when the opportunity is afforded of examining the 
patient immediately after the injury. Under these conditions, even 
if the lens is pierced, it is frequently possible, in spite of beginning 
cataract turbidity, to find the splinter by means of the ophthalmo- 
scope in the vitreous or in the retina. 
The position of the foreign body does not always correspond to the 
direction indicated by the corneal wound and the opacity of the lens. 
It frequently happens that the splinter has been deprived of its 
momentum through resistance of the cornea and lens, and simply 
falls to the bottom of the vitreous chamber. On the other hand, it 
may have been projected as far as the retina without penetrating the 
latter, and may have sunk downward from the point of impact. 
It is, therefore, always advisable to examine first the fundus, espe- 
cially in the direction indicated by the corneal and lenticular wounds. 
Here there may be discovered a wound in the retina and choroid, 
appearing as a glistening, white spot (the exposed sclera), which 320 
EXTRACTION OF FOREIGN BODIES FROM THE EYE 
may even assume the form of the foreign body; or there may at least 
be seen a hemorrhage corresponding to the point of impact. 
In most cases the foreign body is a splinter of metal, which is ren- 
dered conspicuous by its metallic luster, as its outer surface reflects 
light strongly. In recent cases, air-bubbles may not infrequently be 
seen in the vitreous or around the foreign body. If a dense opacity 
of the vitreous lies in front of the foreign body, the position of the 
latter is betrayed by a conspicuous whitish luster. 
The Sideroscope—For the diagnosis of iron or steel splinters with- 
in the eye, the sideroscope is of value. It not only indicates the 
presence of small particles, but at the same time allows an incidental 
localization, manifested by a marked deviation of the magnetic 
needle upon approaching the position of the fragment. 
A negative result from the examination with the sideroscope is not 
always to be accepted as a certainty that no steel is in the eyeball or 
orbit; a slight deviation may frequently have no significance, espe- 
cially in large cities, where the magnetic needle is always in a state of 
unrest. Nor does a marked deviation of the magnetic needle always 
indicate that the splinter is within the eyeball. We have recently 
seen an illustrative case in which a patient declared that he had been 
wounded by a splinter while hammering on iron two months previ- 
ously. The splinter penetrated the lower lid about 8 mm. below the 
margin. The wound bled slightly, and it was only after the lapse 
of some time that the patient noticed a gradual diminution in the 
visual power of this eye, without having experienced any inflamma- 
tion. When seen for the first time, there was found a delicate scar 
in the skin of the lower lid about 3 mm. in length. No cicatrix could 
be found on the eye by the minutest examination, but the vision 
was about one-fourth normal. By means of the ophthalmoscope, 
floating vitreous opacities could be seen, which were fixed below and 
moved about freely in the upper part of the eyeball. Upon looking 
downward, the red reflex was lost entirely on account of increasing 
density of the opacities. As the visual field was much limited in its 
upper part, a separation of the retina in the lower part of the eye 
seemed probable. The splinter could not be seen. The patient 
was placed in front of the sideroscope, and the needle showed a 
marked deviation. This occurred with almost the same intensity 
in all positions of the eyeball, but was greatest when the eye was 
directed upward. With the large magnet even the strongest current ROENTGEN RAYS AND THE GIANT MAGNET 
321 
did not draw out the splinter, and the patient did not have the 
slightest pain. This was more remarkable, since the presence of a 
large splinter had been assumed from the size of the palpebral cica- 
trix and the deviation of the sideroscope. However, examination 
with the Roentgen rays showed that a splinter, 5 mm. long, was 
lodged in the orbit outside of the eyeball. In its course through the 
orbit the splinter either had perforated the sclera twice, or had slit 
up the envelope of the eyeball below, and had thus produced the 
intraocular changes. Finally, it is to be remembered that there are 
some forms of iron, particularly those alloyed with manganese, which 
are non-magnetic, and in these cases the sideroscope is valueless. 
Roentgen Rays.—The Roentgen rays are the most positive means 
of diagnosis, and not only indicate the presence of the foreign body, 
but accurately locate its size and position in the eyeball or the orbit. 
Only in rare instances, in which the shadow cast by a minute body is 
lost in the shadow of the bones of the skull, will the Roentgen rays 
fail to give a positive diagnosis. The rays are applicable to injuries 
from metal of all kinds, shot, and glass or stone, if the particle is not 
extremely small. 
The Giant Magnet.—The value of the sideroscope as a means of 
diagnosis has been considerably lessened since the use of the Roentgen 
rays. The operator who is not provided with means for prompt 
Roentgen-ray diagnosis must depend upon the external and oph- 
thalmoscopic examination, the history of the injury, and the employ- 
ment of the magnet in an attempt to extract a possible foreign 
body if the injury is recent. After the usual preparations are made 
for operation, and the injured eye is gradually brought toward the 
tip of the giant magnet, the patient experiences pain if there is a 
magnetic foreign body in the eyeball. This is a valuable indication 
of the presence of a splinter of iron or steel in the eye and suggests 
the possibility of its removal. In a recent injury it is rare that a 
particle of iron or steel fails to follow the attraction of the giant 
magnet, so that the negative result and the lack of pain in these 
cases usually indicates the absence of a magnetic body in the 
eye. Clinical experience has shown, however, that occasionally a 
piece of steel has entered the eye with so much force as to penetrate 
deeply in the sclera, and fails to come forward under the attraction 
of the largest magnet. It is not to be understood that the Roentgen- 
ray examination is to be omitted in any perforating wound where the 322 
EXTRACTION OF FOREIGN BODIES FROM THE EYE 
magnet has failed to indicate the presence of a foreign body in the 
eye. If, however, this means of diagnosis is not available, the evi- 
dence given by the trial of the giant magnet in a recent injury may 
usually be regarded as conclusive. 
The Haab giant magnet is now made in bell form, with the work- 
ing point in the shape of a cone of 90 degrees, so that the operator 
has a clear view of the field of operation. Four tips of different 
shapes are supplied. The magnet is mounted on a hollow cast-iron 
pillar, with a shelf to support the arms of the patient and keep 
the head steady, while at the base is a foot pedal for closing the 
circuit. 
Small Hand Magnets.—The original small Hirschberg magnet, 
operated by battery, has been generally superseded by larger and more 
powerful hand magnets. The newer-type hand magnets weigh from 
eight to twelve pounds, are operated like the Haab instrument on the 
general lighting circuit, and are extremely powerful. Points of 
different sizes and shapes are used. Owing to the difficulty of 
manipulating the Haab magnet in extracting the body, after it has 
been drawn into the anterior chamber, the operator should be sup- 
plied with one of the hand magnets. 
MAGNETIC FOREIGN BODIES 
Splinters of iron or steel are to be removed from the eye as soon 
after injury as possible, otherwise the eye, apart from the question 
of infection from the metal, gradually becomes blind from degenera- 
tion due to the action of the ocular secretions upon the metal (sidero- 
sis). Even when the steel has remained quiescent for several months, 
a sudden inflammation may arise, and the attempt to extract the 
metal must then be made under the most unfavorable circumstances 
and usually without success. 
Foreign Bodies in the Anterior Chamber and Lens.—If the wound 
is still open, the foreign body may be brought out through the 
wound, which may be enlarged if necessary, provided it is not situated 
in the pupillary area or in the ciliary region. If the entrance wound 
is close to the center of the cornea, the incision is then made at the 
limbus, which may be done with the lancet without injuring 
the iris even if the anterior chamber is empty. Usually the wound 
made by the foreign body is small, and the anterior chamber 
is restored in a few hours, so that the incision may be readily PROCEDURES IN RECENT INJURIES 
323 
made. When the wound has healed, the large point of the 
hand magnet placed between the lips of an incision made at 
the limbus will usually succeed in extracting the metal. It is of ad- 
vantage, before the anterior chamber is opened, to draw the metal, 
with the magnet point passed across the cornea, into the angle of the 
anterior chamber at the point where it is desired to make the incision 
for extraction, usually above in case an iridectomy becomes necessary. 
Occasionally the splinter may be situated where it can be picked up 
with the forceps and removed, or the closed forceps may be intro- 
duced into the chamber in contact with the metal, and, after the 
magnet is placed against the base of the forceps and the current 
turned on, the forceps are withdrawn with the metal. In this way 
the forceps act as an extension point of the magnet. 
Foreign Bodies in the Vitreous Chamber.—The sooner the 
splinter is removed from the eye the better the prognosis. The 
operation is nearly always made under local anesthesia, and after 
the pupil has been dilated. A subconjunctival injection of cocain 
maybe employed insensitive patients. When a positive diagnosis has 
not been made, sensitiveness of the ciliary body is advantageous, 
because the sensation of pain when the magnet is applied indicates 
a foreign body in the eye. Subconjunctival injections thoroughly 
anesthetize the deeper ocular structures, so that operation may be 
performed without pain even in inflamed eyes and sensitive patients. 
Procedures in Recent Injuries.—The method to be followed 
depends upon the position of the entrance wound and the size and 
shape of the body. 
A. Wound in the Cornea—Lens perforated, a. Splinter Small.— 
The metal is drawn into the anterior chamber by the giant magnet 
and then extracted through the open wound of entrance. In order 
that the metal does no harm to the eye by reason of the strong 
attractive power of the magnet, the latter is manipulated with 
extreme care. There are two means at our command to lessen the 
attractive power of the large magnet on the eye, either by employing 
a weak current so that the iron core is given but slight magnetic 
pull, or by keeping the eye at some distance from the pole of the 
magnet. The object is to use the least possible magnetic force 
necessary to draw the splinter gently around the edge of the lens, 
first behind the iris and then through the pupil into the anterior 
chamber. 324 
EXTRACTION OF FOREIGN BODIES FROM THE EYE 
Drawing the Body into the Anterior Chamber. The center of the 
cornea of the injured eye is placed opposite the pole of the magnet at a 
considerable distance and brought gradually closer, employing one- 
half of the power of the current. Strong lateral illumination allows 
exact observation so that the current may be interrupted at the 
moment the body appears behind the iris, before it has become 
drawn into this membrane. The metal should be drawn around the 
lens in its passage forward. If the current is not sufficient, its 
strength is gradually increased, and the same care exercised in 
approaching the eye to the magnet. In recent injuries the foreign 
body is soon attracted. Pain, while the eye is some distance away 
and the current of reduced strength, is an indication that the splinter 
has been drawn forward and may be in contact with the ciliary body. 
Great care is then to be taken both as to the strength of the current 
and the position of the eye, in order that the body may be brought 
into the anterior chamber and not become imbedded in the ciliary 
body. After the splinter has come forward and lies behind the iris, 
the patient is told to turn the eye in the direction in which the body 
has been shown to be situated, the current is again turned on, and 
the particle drawn from behind the iris through the pupil into the 
anterior chamber. Thus, if the iris is bulging below, the eye is 
turned down, and approached in this position to the magnet point, 
the latter close to or in contact with the eye in the region of the 
upper limbus. 
Extraction of the Body from the Anterior Chamber.—The extrac- 
tion through the open wound of entrance has been referred to. In 
the extraction of the body from the anterior chamber, the technic 
in recent injuries is essentially the same as those of longer duration. 
After the metal has been drawn into the anterior chamber it may be 
found stuck in the posterior surface of the cornea or at the bottom 
of the chamber. 
To remove the splinter an incision is made with the lancet, of 
sufficient size so that an instrument, such as forceps or the tip of a 
small magnet, may readily be introduced without compressing the 
iris or cornea, in the event that the magnet point at the edges of 
the wound fails to extract the body. Care must be taken not to 
allow the splinter to disappear behind the iris, either by falling 
downward or by being pushed upward behind the pupil by the 
use of an instrument. In order to bring again to view the foreign EXTRACTION FROM THE VITREOUS 
325 
body, recourse must usually be had to the magnet, especially if 
a minute splinter has disappeared below into the bottom of the 
chamber. The iris is to be excised only if severely injured by the 
accident, or, as rarely occurs, it has been badly contused during 
the operation. If the foreign body has perforated the lens and the 
wound in the capsule becomes closed by the iris, the opacity in the 
lens may remain slight and stationary. In this case that part of 
the iris which covers the wound in the capsule should be carefully 
avoided during the operation. 
Should there be difficulty in bringing the foreign body which is 
lying back of the iris through the pupil into the anterior chamber, or 
if the pull of the magnet seems to tear the iris or detach it from its 
insertion, the magnet is put aside, and an incision made at the limbus 
with the lancet in the situation of the foreign body. If the iris does 
not prolapse spontaneously, it is drawn out by a blunt hook inserted 
to the pupillary margin. The posterior surface of the iris is then 
exposed in the wound and the foreign body may be grasped with 
forceps or disengaged with the hand magnet. The iris is then care- 
fully replaced. 
b. Large Splinter, Especially if Irregular in Shape.—A large splinter 
must be extracted with the hand magnet through an incision in the 
sclera. The giant magnet exerts so great a traction force that the 
particle comes forward rapidly, with possible injury of the ocular 
membranes. 
Extraction of a Foreign Body from the Vitreous Chamber through 
a Meridional Incision in the Sclera.—Local anesthesia is sufficient 
except in restless, nervous patients or in eyes markedly inflamed. 
The eye is brought in the desired position for the scleral incision by 
a thread inserted at the limbus. The conjunctiva is dissected up, 
exposing the sclera, and a meridional incision made, 5 mm. in length, 
with the Graefe knife, according to the rules given for posterior 
sclerotomy. The situation of the incision depends upon the position 
of the metal, but the closer the opening is made to the foreign body 
the more certain the action of the magnet and the less the distance 
of the passage of the splinter through the vitreous. In rare instances 
the foreign body appears in the wound after the scleral incision is 
completed, carried there by the intraocular fluid as it escapes from 
the eye. 326 
EXTRACTION OF FOREIGN BODIES FROM THE EYE 
After the sclera has been incised, an assistant holds the wound 
margins apart with fine non-magnetic double hooks. Any pressure 
on the eye is avoided, otherwise the vitreous will bulge forward. 
The large point of the hand magnet is now brought to the scleral 
wound and the current turned on. If the body comes to the scleral 
opening without passing through it, the magnet is moved slightly 
from side to side to disengage the particle. Occasionally the splinter 
after it has passed into the scleral wound may be picked up with 
non-magnetic forceps. Care must be taken that the body is not 
stripped off the magnet point. Frequently several attempts must 
be made before the foreign body comes forward. If the splinter is 
not secured with the magnet at the opening in the sclera, and fails 
to come forward with the giant magnet, one of the longer straight or 
curved tips of the hand magnet may be introduced to the previously- 
determined situation of the foreign body. After extraction of the 
metal, the conjunctiva is sutured over the opening in the sclera, and 
the patient put in bed, where he remains for five or six days. If no 
complications arise, he may leave the hospital in about two weeks. 
B. Point of Entrance in the Limits of the Anterior Chamber and 
in the Area of the Ciliary Body: Lens Uninjured.—If the entrance 
wound of the foreign body is in the region of the ciliary body, extrac- 
tion is made through a meridional scleral incision, even if the original 
wound is open. An attempt to remove the metal through the wound, 
which could not be lengthened if found necessary, would result in 
serious injury to the ciliary body; nor is the anterior route advisable, 
on account of possible injury to the clear lens. 
C. Wound within the Region of the Vitreous Chamber: Lens 
Uninjured.—Splinters of irregular shape are likely to injure the lens 
if extracted through the anterior chamber, so that the method 
previously mentioned of removal through a scleral incision is to be 
followed. 
Infection.—In recent injuries with signs of purulent infection the 
extraction of the foreign body does not check the inflammatory 
process. The pathogenic germs have spread out in the vitreous 
body, and the suppuration progresses, the natural protective powers 
of the eye not being sufficient to overcome it. Active treatment by 
atropin, dionin, subconjunctival injections of bichlorid or oxycya- 
nid of mercury, and intramuscular injections of milk or other protein 
may be continued, but are often unavailing. PROCEDURES IN OLD INJURIES 
327 
Procedures in Old Injuries.—When a foreign body has remained 
in the eye for a considerable time, it is usually of small size. A large 
splinter of iron soon leads to degenerate changes that cause loss of 
vision and shrinking of the eye, with more or less violent symptoms 
of inflammation, and enucleation is required. The condition of the 
lens in these old cases of retained foreign body determines which 
method of extraction is to be tried. 
a. Lens Opaque.—An attempt is to be made to draw the splinter 
into the anterior chamber with the giant magnet by the method 
previously described. If the metal is loose in the vitreous, it will 
come forward with the magnet point some distance from the cornea, 
as in recent injuries. Most frequently, however, the splinter is 
imbedded and covered with adhesions, so that the point of the magnet 
must be placed in contact with the center of the cornea, and the 
current repeatedly interrupted, and again used with full strength, 
before the metal is loosened. Often the body is only brought for- 
ward after the patient has been subjected to the magnet repeatedly 
and each time for a longer period. The difficulties are greater if the 
splinter is of small size and has undergone chemical changes. 
If the metal fails to appear behind the iris, the magnet point 
may be applied far back in the region of the equator in the hope of 
loosening the splinter from its adhesions. This insures that the 
metal, if detached, does not become imbedded in the ciliary body under 
the strong pull of the magnet. 
If all attempts to extract the splinter through the route of the 
anterior chamber fail, the tip of the magnet may be placed at an 
incision in the sclera, as near as possible to the position of the metal 
as determined by the Roentgen rays. 
b. Lens Transparent.—Extraction is attempted through a scleral 
incision, as in recent injuries. Unless there is clouding of the vitreous 
the position of the metal may be determined by the ophthalmoscope. 
Even the giant magnet does not succeed in many instances in remov- 
ing a small foreign body which has remained in an eye for a con- 
siderable time, owing to the connective tissue with which it is firmly 
covered. 
Prognosis.—Under the most favorable circumstances of prompt 
extraction of foreign bodies from the posterior segment of the eye, 
even with no evidence of infection, few individuals secure useful 
vision in the injured eye. The greater the size of the splinter, 328 
EXTRACTION OF FOREIGN BODIES FROM THE EYE 
the more anatomical changes have been produced. With healing of 
the wound, cicatricial tissue develops, with retinal detachment and 
complete loss of sight; or a low-grade iridocyclitis appears after many 
weeks, and leads to blindness and possible inflammation of the other 
eye. The patient should remain under observation for a long time. 
Splinters of iron situated in the anterior chamber, iris, or lens 
give a better prognosis than those that lodge in the posterior segment 
of the eye. The smaller the splinter the better the final function 
of the eye. 
NON-MAGNETIC FOREIGN BODIES 
Penetrating wounds of- the eyeball are often made by particles 
of copper from exploding percussion caps, pieces of wood or stone, 
splinters of glass, birdshot, and by stone projected by the explosion 
of shells in war time. Prognosis depends largely upon the prompt- 
ness with which the body is removed. If a long period has elapsed 
since the injury, the body may become covered with exudate, and, 
even though extraction may have been performed smoothly, separa- 
tion of the retina or chronic iridocyclitis may follow, usually necessi- 
tating enucleation of the eye. 
Bodies in the Anterior Segment of the Eye.—Non-magnetic 
bodies that lodge in the anterior section of the eye, may in exceptional 
cases be extracted through the original wound in the cornea, after its 
enlargement by means of scissors. Only peripheral wounds, however, 
are suitable for this procedure. Wounds near the center of the 
cornea if similarly treated would later produce still greater distur- 
bance of vision through the larger cicatrix resulting from the incision, 
and it is, therefore, the best procedure to make a lancet incision else- 
where of sufficient size to permit the introduction of forceps. This 
incision may be difficult if the wound produced by the foreign body 
has not yet closed, permitting escape of the aqueous and shallowing 
of the anterior chamber. But even then incision can be made between 
the cornea and the iris without wounding the latter, especially if a 
Graefe knife is used and is slowly introduced between both mem- 
branes. If the splinter in the anterior chamber is large and warped, 
care must be taken during its withdrawal not to wound the iris or 
capsule of the lens. The incision into the anterior chamber is made 
below or in the lower outer portion of the cornea, from which direc- 
tions instruments can be most readily introduced into the eye. NON-MAGNETIC FOREIGN BODIES 
329 
Bodies in the Posterior Segment of the Eye.—The extraction of 
non-magnetic foreign bodies from the vitreous chamber is a compli- 
cated procedure, even after accurate localization by the Roentgen 
rays. Quite frequently substances like copper and grains of shot fall 
to the bottom of the chamber, where they often become fixed by 
exudate. Bodies that lie to the temporal side and below are more 
readily secured than if situated in other portions of the vitreous. 
The operative procedure is as follows: After dissecting up a flap of 
conjunctiva and uncovering the sclera, a meridional opening, at 
least 6 to 8 mm. long, is made in the neighborhood of the foreign 
body, the cut extending through the sclera into the vitreous. With 
double tenacula the assistant raises and separates the edges of the 
wound, in order to facilitate an examination of the interior of the 
eye. During this procedure the loss of vitreous can readily be 
avoided. It is best to have the patient in a condition of profound 
anesthesia. 
If the incision corresponds with the position of the foreign body, 
the latter may appear in the wound and can be removed with forceps. 
But if not, the attempt to find it in the vitreous chamber is usually 
hopeless. The immediate neighborhood of the wound must be 
carefully explored with the iris-forceps, in the hope of locating the 
foreign body. Occasionally, the use of Sachs’ lamp will be of 
material assistance in the operation. If the lamp is placed by an 
assistant laterally against the cornea, without exerting pressure on 
the eye, the open incision and the whole vitreous space is illuminated 
and transparent, so that in fortunate cases the foreign body is 
recognized as a dark structure, and can be grasped and withdrawn 
with the forceps. After the extraction a suture may be entered 
through the superficial layers of the sclera if the wound gapes, but 
usually the stitching of the conjunctival flap over the incision will 
suffice. The patient should be kept in bed for several days. The 
prognosis even in successful cases is bad on account of detachment 
of the retina. 
In injuries that are not recent the difficulties of extraction are 
greater. Of the different foreign bodies that enter the eye copper 
splinters are least well borne, and the attempt to remove them should 
be made in every case, except, if a foreign body is securely lodged 
without signs of irritation or inflammation, the operation should be 330 
EXTRACTION OF FOREIGN BODIES FROM THE EYE 
avoided on account of its unfavorable prognosis, and only under- 
taken if threatening phenomena arise. 
Failure to Extract Body.—If the attempt of extraction of the 
foreign body has failed, it is best to proceed at once to the enuclea- 
tion. The consent of the patient to this operation should be obtained 
beforehand, telling him that the other procedure is merely an attempt 
to save the eye through search for and extraction of the foreign body. 
Non-magnetic foreign bodies situated in the neighborhood of the 
macula give no hope of extraction with preservation of the eye. CHAPTER XVI 
MINOR OPHTHALMIC OPERATIONS 
SUBCONJUNCTIVAL INJECTIONS—PTERYGIUM—OPERATIVE TREATMENT 
OF TRACHOMA—CHALAZION—THE OPHTHALMIC ASSISTANT- 
ANESTHESIA 
Everting the Upper Lid with Groenholm Spoon.—This instru- 
ment (Fig. 215), modeled after the Desmarres elevator, permits 
eversion and fixation of the upper lid with one hand, and exposure of 
the upper conjunctival fold. 
The patient is directed to look downward, the lashes are grasped 
between the thumb and forefinger, and the convex rim and surface 
of the spoon is applied to the skin of the lid back of the upper border 
of the tarsus (Fig. 216). The spoon is pressed backward as the lid 
Fig. 215.—Groenholm spoon. 
is everted over its convex rim. The handle of the spoon is now 
turned toward the forehead, and the lid stretched over the spoon, 
the rim of which firmly holds the lid in place. The entire surface of the 
Fig. 2 i6.—Spoon applied to the surface of the lid, 
331 332 
MINOR OPHTHALMIC OPERATIONS 
tarsus as well as the fornix (Fig. 217) is exposed and spread upon the 
spoon. The spoons are of various shapes and sizes to be adaptable 
to all lids. The rim of the spoon should be straight and not sharp, 
and its surface only slightly curved. If the lid should slide off the 
spoon, it may be still held in place with the thumb, while the middle 
and index fingers support the spoon handle. 
The employment of the spoon permits the surgeon to have one 
hand free for operation, exposes the conjunctival fold, and smoothes 
outfall recesses, so that treatment may be readily made. 
Chalazion.—Local anesthesia, with several drops of a 3 per cent, 
solution of cocain in the conjunctival culdesac, is supplemented by 
the injection of several drops of a 1 per cent, cocain-adrenalin solu- 
tion through the conjunctiva into the cavity of the chalazion or 
through the skin of the lid in the neighborhood of the swelling. 
Incision.—If the chalazion is in the upper lid, the lid is everted, 
and the tarsus grasped between the thumb and index finger; if in 
the lower lid, the eye is directed upward as the lid is drawn away 
from the eyeball. Many forms of forceps have been devised, but 
they are unnecessary and cause more pain when the lids are com- 
pressed between blades of the forceps than the operation itself. The 
incision into the cavity is made with a small pointed scalpel. If 
the tarsus on the conjunctival side is only slightly altered, the incision 
is made parallel to the Meibomian glands, that is, vertical, but if 
the contents of the chalazion bulge through the softened and thinned 
tarsus, the incision is made transversely. The incision parallel 
to the lid border has the advantage that the knife cannot penetrate 
the margin of the lid if a nervous patient should unexpectedly move 
Fig. 217.—Lid everted over the spoon SUBCONJUNCTIVAL INJECTIONS 
333 
the head. Where the contents cannot be well evacuated, a cross 
incision may be made. After the incision the contents are squeezed 
out with the fingers. The remnants, which are adherent to the 
inner surface of the cavity, are scraped out with a small sharp spoon. 
The hemorrhage soon ceases. No bandage is required. Occasion- 
ally the chalazion projects entirely from the anterior portion of the 
tarsus, so that it may be more readily dissected out through a hori- 
zontal incision in the skin surface. 
SUBCONJUNCTIVAL INJECTIONS 
Subconjunctival injections of salt-solution or weak solutions of 
bichlorid of mercury or cyanid of mercury are employed in both 
external and internal ocular affections. 
Injections of Salt-solution.—These are indicated in (i) cloudi- 
ness of the vitreous, whether of inflammatory nature or produced 
by hemorrhages. The more recent the affection, the more favorable 
their influence. (2) In retinal detachment. The result is only tran- 
sitory. (3) In choroiditis, especially in myopic eyes, and in hemor- 
rhages in the retina. (4) In deep keratitis, to promote absorption of 
the corneal infiltration. Old corneal cloudiness is little influenced by 
the injections. 
Injections of Solutions of Mercury.—These are employed in 
(1) rapidly progressive corneal infiltration and ulceration, especially 
scrofulous ulcers, infected corneal wounds, and incipient serpiginous 
ulcers; (2) commencing infections of the interior of the eye, either 
after injury or following operation. 
The Method of Injection.—After local anesthesia with a 3 per 
cent, solution of cocain, the lower lid is drawn away from the globe 
with one hand, while the other hand, holding the syringe horizontally 
and nearly parallel with the surface of the sclera, enters the needle 
beneath the conjunctiva, midway between the limbus and the lower 
conjunctival fold. If the fluid is injected close to the limbus, the 
violent detachment of the closely adherent conjunctiva causes severe 
pain and occasionally stippling of the corneal epithelium from circu- 
latory disturbances. The injection may be made at any point around 
the globe, and the desired quantity of solution slowly introduced. 
The patients complain of slight discomfort after the injection, but 
intense pain of long duration is rare. Adrenalin may be dropped in 
the conjunctival sac prior to the stronger injections. 334 
MINOR OPHTHALMIC OPERATIONS 
The injection fluid consists of a io per cent, solution of common 
salt, a i-iooo solution of bichlorid of mercury, or 1-5000 solution 
of cyanid of mercury. A 1 per cent, solution of cocain is added, with 
or without adrenalin. The quantity of the salt-solution injected 
equals the entire contents of a Pravaz syringe (1 c.c.). Immediately 
following the injection, a large conjunctival bleb forms, which is 
distributed by slight massage. No more than or c.c. of the 
mercury solutions should be injected, otherwise necrosis of the tissues 
and vessels would ensue, with possible corneal complications. The 
effect of small injections is to cause a moderate irritation of the con- 
junctiva, with more active exchange of fluids between the cornea 
and its adjacent tissues. Their value therefore depends more upon 
increased tissue metamorphosis than the antiseptic influence of the 
minimal quantity of the mercury injected. The injection is. repeated 
after the chemosis has subsided and the disease shows no signs of 
distinct improvement. The second entrance of the needle should be 
some distance from the first, even though the corneal disease is much 
farther removed. As many as four or five injections may be given 
if the disease has been favorably influenced. 
The injections are often useful in scrofulous ulcerations of the cor- 
nea, but frequently fail in serpent ulcer, particularly if the ulcer has 
passed the incipient stage. 
No complications occur from properly-given injections, although 
the injury of a large conjunctival vessel may cause a subconjunctival 
hemorrhage. Deep injection of salt-solution in Tenon’s capsule, a 
procedure employed in the treatment of retinal detachment, may 
cause transitory diplopia with slight exophthalmos. 
OPERATIVE TREATMENT OF PTERYGIUM 
Operations for pterygium consist of inversion, excision, or trans- 
plantation. Cauterization of the apex of the growth and the opera- 
tion of ligation are inferior methods of treatment, and have few advo- 
cates. Local anesthesia is used in all cases. 
Inversion.—This is a simple and at the same time a most reliable 
method. After well cocainizing the eye, the lids are opened with a 
spring-speculum, and the patient is told to look toward the side 
opposite to the pterygium. The operator grasps the neck of the 
pterygium with toothed-forceps, stretches it somewhat, and applies a 
lancet flat against the cornea completely separating the head (a, OPERATIVE TREATMENT OF PTERYGIUM 
335 
Fig. 218) from the corneal tissue, with which it is firmly united. 
This peeling off must be done carefully and thoroughly. When the 
head is once free, the remaining loosely connected portion of the 
growth is separated as far as the border of the cornea and for a short 
distance on the sclera. The margins of the pterygium at the apex of 
the loosened conjunctiva are excised with the scissors, and the 
pterygium with its apex (a) turned inward so that its raw surface is 
directed forward and its two borders (ab, ac) diverge toward the 
cornea (Fig. 219). By two or three suitable sutures the borders are 
now united, taking care that no open wound remains at the limbus. 
The first suture is therefore introduced vertically in the neighborhood 
of the limbus, including with the needle a few superficial fibers of 
Fig. 218.—Inversion of 
the pterygium. 
Fig. 219.—Inversion of 
the pterygium. Sutures in 
position. 
Fig. 220.—Arlt’s 
method of operation 
for pterygium. 
the sclera between the two edges. A projection is formed on the 
conjunctiva by the transplanted pterygium, which in a short time 
completely disappears. 
Excision (Arlt).-—This method is also used frequently. The 
pterygium is held with toothed forceps at its neck, where it can be 
slightly lifted from the underlying part. The separation is the same 
as previously described. While none of the advancing head should 
be left on the cornea, no normal corneal layers should be removed, as 
this would produce a more extensive scar. After separation of the 
pterygium, two convergent incisions (c b, b d) are made in its body 
(Fig. 220). A rhomboidal piece is thus excised, consisting of the 
head and part of the body. The conjunctival opening is closed by 
two sutures which are introduced in a vertical position. Unless the 
wound is entirely covered by the conjunctiva, the growth will be 
drawn on the cornea by cicatricial tissue. The wound in the cornea 
heals by cicatrization and leaves a permanent opacity. 336 
MINOR OPHTHALMIC OPERATIONS 
Transplantation (McReynolds).—This is a modification of the 
Desmarres operation. The separation of the pterygium from 
the cornea is performed in the manner previously described. While 
the fixation forceps still hold the neck of the growth, a pair of slender, 
straight scissors divides the conjunctival and subconjunctival tissue 
along the lower margin only of the pterygium, commencing at its neck 
and extending toward the canthus, a distance of 34 to 34 inch. The 
body of the growth is now separated from the sclera with the blunt 
Fig. 22i.—Transplantation. An incision has been made along the lower border of 
the pterygium, and the needles passed through the head of the growth. 
points of the closed scissors, and the conjunctiva below the oblique 
incision undermined well into the lower culdesac with a few cuts of 
the scissors. Small curved needles, double-armed with black silk, 
are passed through the apex of the pterygium from without inward 
and separated from each other by a sufficient amount of the tissue 
to secure a firm hold (Fig. 221). These needles are carried downward 
through the lower conjunctival incision, and emerge in the lower 
fornix about inch from each other. The forceps now lift the 
loosened lower segment of conjunctiva, and with traction upon the 
free ends of the thread the pterygium glides beneath the loosened 
conjunctiva (Fig. 222). The threads are then tied and cut off. 
It is important that the upper border of the pterygium should not 
be incised, otherwise there will be a denuded space after the growth 
has been drawn into the inferior fornix. If the growth is not sepa- OPERATIVE TREATMENT OF TRACHOMA 
337 
rated at its upper portion from the conjunctiva, the elasticity of the 
latter is such that when the downward traction is exerted the mem- 
brane thins out and is smoothly applied to the sclera over the former 
site of the body of the pterygium, and the margin of the conjunctiva 
corresponds accurately to the corneo-scleral junction. Since the 
sclera is then covered by non-vascular conjunctiva, there is no ten- 
Fig. 222.—Transplantation. The pterygium has been drawn down beneath the con- 
junctiva in the lower culdesac, and the conjunctiva attached to the upper border covers 
the former site of the growth. 
dency to the formation of new blood-vessels, with thickening of the 
tissue and return of the growth. In a short time the corneal wound 
heals and the thin conjunctival tissue becomes adherent to the sclera. 
In two days the stitch is to be removed, and the pterygium will be 
found firmly adherent to the sclera and hidden by the loosened lower 
segment of the conjunctiva. If the head of the pterygium is large, it 
should be cut off before the growth is drawn down into the con- 
junctival pocket. 
OPERATIVE TREATMENT OF TRACHOMA 
The surgical treatment of trachoma comprises (i) the removal of 
the granulations by expression with the Knapp roller-forceps or the 
Kuhnt expressor; (2) curetment or scarification of the granules, 
followed by rubbing with strong solutions of bichlorid of mercury 
(Grattage); (3) excision of the upper transitional fold; and (4) 
excision of the tarsus. 338 
MINOR OPHTHALMIC OPERATIONS 
Expression.—This operation is performed with the Knapp roller- 
forceps or the Kuhnt expressor. Anesthesia is secured by several 
instillations of a 3 per cent, solution of cocain, followed by a subcon- 
junctival injection of a 1 per cent, solution beneath that part of the 
conjunctiva where expression is to be commenced. The upper lid is 
everted, so as to gain access to the conjunctival fold. Before the for- 
ceps are applied, the conjunctiva over the granules is superficially 
scarified to permit their contents to be easily expressed. 
Knapp’s Roller-forceps.—One end of the roller-forceps (Fig. 223) 
is introduced between the conjunctiva of the eyeball and the lid, and 
Fig. 223.—Knapp’s roller-forceps. 
the other placed upon the everted surface of the tarsus. The two 
arms of the forceps are pressed together forcibly, and drawn slowly 
along the conjunctiva, and the granular material squeezed out as the 
ridged rollers pass over the fold of the membrane between the two 
blades. The traction should not be made forcibly, or lacerations of 
the conjunctiva with fresh scar-formation will be produced. The 
more carefully the operation is done, the less painful will it be and the 
less injurious to the conjunctiva. The considerable bleeding which 
follows is combated by active sponging with a weak bichlorid solution. 
In a similar manner the lower lid is freed of its granulations. 
With the Knapp roller it is more difficult to strip the semilunar fold, 
and especially to squeeze out isolated granulations, without including 
and compressing the surrounding conjunctiva. For these cases it is 
best to employ small forceps, the narrow branches of which can 
readily grasp and express isolated granulations. If a group of granu- 
lations is found on a sharply circumscribed area of the upper fold or 
elsewhere, it may be excised, together with the underlying conjunc- 
tiva. In order to extract the granulations from the tarsal conjunctiva, 
the tarsus itself must be seized between the branches of the roller- 
forceps. 
Kuhnt’s Expressor.—This forceps-like instrument (Fig. 224) ends 
in two plates, the perforations in which are not opposite to each other EXCISION OF THE UPPER TRANSITIONAL FOLD 
339 
when the two plates come together. Its advantage lies in the avoid- 
ance of lacerations of the conjunctiva which occasionally follow the use 
of the roller-forceps. The instrument expresses the granulations with- 
out traction, and is especially recommended by Kuhnt for advanced, 
felty trachoma, in which the conjunctiva of the transitional fold is 
easily lacerated and wounded by rolling, followed by a marked 
Fig. 224.—Kuhnt’s expressor. 
contraction of the conjunctival sac. With the Kuhnt expressor this 
is avoided, as the granulations are pressed out of their beds like 
comedones. 
After-treatment.—Immediately after operation, cold compresses 
are to be constantly applied for several hours. Each day the lids are 
everted, and the grayish exudate wiped off, and, as soon as the swell- 
ing has subsided, applications of a 2 per cent, nitrate of silver solution 
are resumed. 
Grattage.—Deep scarifications of the trachomatous tissue, with 
subsequent vigorous scrubbing of the conjunctiva with the ordinary 
tooth brush and bichlorid solution, are recommended and followed by 
some operators. Severe measures of this character are not followed 
in our clinic, as they are likely to result in destruction of normal struc- 
tures and are particularly liable to the formation of adhesions of the 
retrotarsal folds. 
Excision of the Upper Transitional Fold (Kuhnt).—If the tracho- 
matous infiltration is restricted to the upper transitional fold, and 
the disease has failed to be relieved by medicinal treatment, excis- 
ion may be made as suggested by Kuhnt. Cocain is applied locally 
and by injection, the lid is everted over a spoon, and the patient 
directed to look downward, so that the transitional fold is spread out. 
The thickened and granular fold is sharply defined from the normal 
conjunctiva, and incision is made in the healthy region in the entire 
length of the conjunctiva from within outward. The bulbar 
conjunctiva retracts and the incision gapes, and becomes somewhat 340 
MINOR OPHTHALMIC OPERATIONS 
undermined. Sutures are at once inserted close to the incision of the 
conjunctiva. The second incision is carried along the margin of the 
affected part near the upper tarsal border. The circumscribed area is 
then carefully dissected out with scissors without injuring Muller’s 
muscle, which lies immediately beneath. The threads are now 
carried over the corresponding points of the tarsus. In a few days 
the wound heals. 
Extirpation of the Tarsus.—This operation is indicated, according 
to Kuhnt, in marked cicatrization of the conjunctiva with thick- 
ened and curved tarsus, and especially in obstinate pannus; in entro- 
pion with trichiasis; and in ptosis due to trachoma. After the lid is 
everted, the margin is seized with strong hook-forceps, and a horn 
plate is inserted beneath the skin surface of the lid, putting the carti- 
lage on the stretch. Incision is made parallel to and 2Y2 mm. from 
the lid-margin, without injuring the pretarsal conjunctiva or the 
orbicularis muscle, and the conjunctiva dissected loose from the tar- 
sus. As in this stage of trachoma the normal connection between 
the conjunctiva and tarsus no longer exists, the conjunctiva imme- 
diately retracts and the tarsus is separated in its anterior surface from 
the pretarsal connective-tissue as far as its upper margin. If the 
sharp edge of the knife is directed toward the cartilage, there is no 
danger of cutting through the conjunctiva. Kuhnt separates the 
entire tarsus from the levator tendon, but we follow the suggestion 
of Lyritza and allow a small strip of the tarsus to remain in order to 
exclude the possibility of ptosis. The wound is sutured with fine silk 
threads, although this is not absolutely necessary. If the conjunc- 
tiva is greatly shrunken, transplantation of mucous membrane from 
the lip to the surface of the wound is of value. 
This operation not only relieves entropion and trichiasis, but 
exerts an excellent influence upon pannus. In order to prevent the 
ptosis, double-armed needles should be carried through the conjunc- 
tiva and levator tendon and passed down along the anterior surface 
of the remaining tarsal margin and brought out through the skin 
above the cilia and knotted over a bead. 
THE OPHTHALMIC ASSISTANT 
In order to obtain free access to the eye with the instruments 
during operations, the lids must be adequately opened. In those 
operations in which the eyeball is not cut into or is incised only to a THE OPHTHALMIC ASSISTANT 
341 
slight extent, we employ the spring-speculum. It is therefore used 
in the operation for strabismus, pterygium, discissions, puncture of 
the anterior chamber, etc. On the other hand, we dispense with the 
use of the speculum in iridectomy for glaucoma and in cataract opera- 
tions. Even those operators who regularly use the lid speculum 
designate it as “an instrument dangerous to the eye, but indispensable” 
(Terrien). The first attribute is correct, but not the second. The 
lid speculum will cause no injury to the patient who is quiet and who 
does not twitch, especially if the assistant holds it carefully in his 
hand and directs it so that there is no pressure exerted on the eye. 
In any case, the lid speculum often becomes a great hindrance; indeed, 
with a small palpebral fissure it may render impossible, for example, 
an upward incision. The injury produced by introduction of the lid 
speculum may even amount to a catastrophe if the patient strains, 
the wound begins to gape, and the vitreous humor presents itself. 
In addition, it may then become difficult to free the lids from the 
instrument. In Muller’s lid speculum, the branches are turned 
around by closure of the speculum so that the lids free themselves. 
If the operator can command the services of even a half-trained assis- 
tant, this is certainly to be preferred to the ordinary lid speculum. 
The work of the assistant consists in separating the fids and hold- 
ing the palpebral fissure open only during the short periods that the 
operator works on the eye. In the intervals, while the instruments 
are being changed, the eye washed out, etc., the lids are released so 
that they cover the eye. 
In opening the palpebral fissure (seepage 180), the assistant applies 
the thumb of the right hand to the edge of the upper lid, raises it and 
draws the lower lid down with a finger of the left hand laid on its edge. 
The upper lid is at the same time somewhat drawn away from the 
globe, so that its border does not enter the wound if the eye should be 
suddenly rotated upward or if the lid should suddenly slip. The 
lower lid should be drawn downward in such manner that it does not 
roll outward. The extent of separation of the lids depends upon the 
operative procedure to be undertaken. 
The Assistant during Cataract Operation.—The work of the 
assistant during the extraction of cataract is detailed as follows: 
The Incision.—The palpebral fissure is held open as above de- 
scribed, and, after the operator has completed the incision, the assis- 
tant draws the external canthus somewhat downward, and allows the MINOR OPHTHALMIC OPERATIONS 
342 
upper lid to slide down at a slight distance from the cornea, so that 
the wound does not gape. The lower lid must not be released until 
the upper lid covers the wound. 
The Iridectomy.—The palpebral fissure is opened as before, and 
the assistant need only see that the finger which holds the upper lid is 
not placed in the way of the operator. (See Fig. 123, page 186.) 
Fig. 225.—Assistance. The operator grasps the upper lid by its cilia, draws it 
slightly away from the eyeball, and guides it downward over the wound, while the spoon 
is inserted under the lid to keep it away from the surface of the globe. 
As the operator must introduce the forceps into the wound from 
above, the assistant places his finger on the lid either on the nasal 
or temporal side. 
Opening the Capsule.—The operator raises the upper lid with his 
left hand. The assistant holds the lower lid with one hand, and at 
the same time takes a Daviel spoon in the other hand, which is held 
against the border of the upper lid. If the lid should slip through the 
fault of the operator or from the twitching of the patient, it will fall 
upon the spoon, and will thus slide over the wound without turning 
the latter back. At the critical moment the operator can help him- 
self without much chance of failure by slipping the rapidly closed 
capsule forceps under the upper lid and thus drawing it down. 
Figure 225 shows how the operator himself may draw down the lid 
by its cilia, while the spoon in the assistant’s hand is ready to slip 
under the lid and hold it away from the eye. 
Control of the lower lid always requires great care. Even though 
the patient twitches but slightly, the lower lid should never remain 
without fixation after the upper lid is raised. If the lower lid is left 
free, and the patient makes it tense through innervation of the palpe- THE OPHTHALMIC ASSISTANT 
343 
bral muscle, the lid will be pressed against the globe and will cause 
the wound to gape. It is possible for the vitreous humor to be 
expressed in this way. 
If the operator contemplates removing the lens in its capsule, on 
account of thickening of the latter, he should allow the assistant to 
hold both lids, so that he himself may take in his left hand the spatula 
with which the scleral edge of the wound is somewhat depressed to 
favor the escape of the lens. 
Expression of the Cataract.—The operator, while raising the up- 
per lid with either hand, performs with the lower lid the massage- 
movements that have been described for expressing the lens. The 
assistant holds the Daviel spoon, prepared to introduce it under the 
upper lid, if necessary, and to extract the lens when it protrudes to 
the extent of one-half. In performing this latter act, the spoon is 
placed against the equator of the lens and thus lifts it out. 
Reposition of the Iris.—The operator raises the upper lid and the 
assistant holds the lower. If the patient is quiet and does not twitch 
the lids the assistant’s task is an easy one. Of course, the assistant 
must never press the lids against the eye. In protruding eyes the 
opening of the lids requires special care. The lids must not be 
pushed far backward, but must be opened merely enough for the 
requirements of the operator. The work of the assistant is much 
more difficult in the case of a patient who strains. But it is just in 
such cases that the value of a good assistant is fully appreciated. 
Skillful separation of the lids in the correct manner and at the right 
time often prevents the otherwise certain prolapse of the vitreous. 
During Complications.—In unruly patients it may be quite im- 
possible to proceed in the manner described. The upper lid must 
then be elevated by inserting a Desmarres elevator. All pressure on 
the eye, however, must be carefully avoided. This elevator is per- 
mitted to remain in place during the whole operation, while the lower 
lid must also be fixed at the same time, for reasons that have been 
mentioned. The only disadvantage of the elevator is that it stands 
in the way of instruments that are to be introduced from above. 
The spring-speculum, however, must never be used in restless 
patients. 
If a prolapse of the vitreous occurs, the lids must not be aimlessly 
released, as is often done by frightened assistants. On the contrary, 
the upper lid still firmly held must be cautiously lowered over the 344 
MINOR OPHTHALMIC OPERATIONS 
gaping wound, while the operator inserts under the lid for its guid- 
ance the instrument which he happens to have in his hand. This 
may be a closed pair of de Wecker scissors, the capsule forceps, the 
spatula, the spoon, or even the handle of the Graefe knife. The 
lower lid may be released by the assistant only after the upper lid 
has covered the wound, otherwise the patient will raise the flap still 
further with his lower lid, and will thus express the vitreous. In 
patients who are known beforehand to be restless and likely to 
twitch, the opening of the lids may be materially facilitated by 
performing an extensive canthotomy immediately before the 
operation. 
Fixation of the Eyeball.—Occasionally the assistant must hold 
the eye with fixation forceps. As repeatedly stated, fixation is only 
employed in cataract operation while the incision is being made. In 
non-congested and well-cocainized eyes, iridectomy is usually accom- 
panied by so little pain that the patients are perfectly quiet during 
its performance. After opening the eyeball by a long incision, the 
use of fixation forceps, even with the greatest care, causes a gaping 
of the wound. The fixation forceps should only be employed when 
absolutely necessary. Especially in the cataract operation their 
use can only be forced by unreasonable patients. In such cases the 
assistant applies the forceps to the limbus exactly at the lower edge 
of the cornea, and draws the eye slightly down. The forceps also 
keep the lower lid away from the globe. The iridectomy may under 
these circumstances become difficult. 
If the upper lid is held up by the Desmarres elevator, the eyeball 
must be carefully drawn downward a little with the forceps; other- 
wise, it may be impossible in the small space to draw out the iris with 
the forceps. On the other hand, it may be easier to slip into the 
anterior chamber from the side with a properly bent, blunt tenacu- 
lum, and thus draw out and excise a fold of iris from the pupillary 
border. Likewise, the opening of the anterior lens capsule must 
then be performed with a sharp tenaculum that has been bent in the 
required direction. 
In certain cases the eye must be held with the forceps in order that 
operation may be safely done, and this course is followed regularly in 
excision of a prolapsed iris in an inflamed eye. During reposition of 
the iris it may be necessary to draw the eye downward with the for- 
ceps, because the patient will not voluntarily look in the desired direc- THE OPHTHALMIC ASSISTANT 
345 
tion. In this case it is best for the operator himself to hold the eye 
in the required position. 
As already mentioned, the eye must be fixed in all procedures with 
cutting or puncturing instruments, as during the cataract incision, 
during discission, etc. Occasionally an exception can be made in 
very quiet patients who will turn their eyes as required. For 
example, if the conjunctiva tears away during the incision, and the 
patient looks in the right direction, there is no objection to completing 
the incision without further fixation. Discission, the incision in 
linear extraction, or a puncture, may exceptionally be performed 
without fixation. 
Position of the Operator’s Fingers.—The support of the operator’s 
hand must always be at a safe point. The fourth finger of the hand 
therefore usually rests in a suitable position on the head of the 
patient. In incisions from the external side the operator’s hand is 
supported on the temple or malar bone. In incisions from below, the 
hand is supported on the cheek; and in incisions from above, on the 
forehead. The operator is not then taken unawares by an unexpected 
movement of the patient’s head. The incision directed downward is 
the more readily accomplished because every patient shows a ten- 
dency to avoid the instrument by an upward movement of the eye, 
and it is usually much easier to look upward than downward. 
It was formerly repeatedly recommended to perform all ophthal- 
mic operations, including cataract extraction, by the inferior incision, 
and in fact, special methods were devised for this purpose, but, as 
iridectomy must be performed in most cases, operators soon adhered 
to the upward cut. In fact, in the establishment of a broad coloboma 
for glaucoma, it is of importance that the coloboma be covered by the 
upper lid. The lower operations are therefore limited to those cases 
in which it is known beforehand that a coloboma will not be neces- 
sary, such as puncture of the cornea, linear extraction, and similar 
operations. There are, however, certain cases which are especially 
suitable for the inferior operation. In cataract patients an accom- 
panying ptosis may cause the pupillary region to be covered by the 
upper lid, an amyotrophic ptosis being not uncommon in old persons. 
This is an indication for the inferior operation, with a narrow colo- 
boma which avoids the periphery of the iris. 
Auxiliary minor assistance may be serviceable during an opera- 
tion. It is the duty of the assistant to remove the blood from the 346 
MINOR OPHTHALMIC OPERATIONS 
conjunctival sac by sponging. The sponges consist of small pledgets 
of cotton, which are kept in sterilized physiologic saline solution, and 
are wrell squeezed out and one end is formed into a point. This end 
is inserted into the internal angle of the eye so that it absorbs the 
blood from the point outward; or the end may be drawn from the 
internal angle outward along the inferior transitional fold, taking 
the blood with it. Direct sponging of the operation wound in the eye 
is to be avoided as much as possible. With marked hemorrhage into 
the anterior chamber it will serve the purpose very well if the assistant 
strokes the blood out of the anterior chamber, while the operator 
stands ready with the instrument to perform rapidly the next opera- 
tion (iridectomy or opening of the capsule) as soon as he can obtain 
a clear view of the chamber. 
If the conjunctival flap should get in the way of the operator, the 
assistant should turn it back with a spatula. He should stroke the 
iris back into its place if, during an extraction without iridectomy, 
the border of the pupil should become stretched against the lens as it 
makes its exit. Occasionally it may be necessary for the assistant to 
cut off the iris with the de Wecker scissors, if the operator, for exam- 
ple, in the excision of a prolapsed iris, holds and directs the eye with 
one hand while the other hand draws out the iris. 
ANESTHESIA 
In all ophthalmic operations there is an advantage in being able 
to operate under local anesthesia. We use it on the most extensive 
scale, and endeavor to make it suffice wherever possible in the place 
of general anesthesia. In most operations on the eyeball itself, the 
co-operation of the patient in bringing the eye into the proper posi- 
tion will make the procedure much less difficult and will render 
unnecessary the dangerous fixation of the eye during many opera- 
tions. General anesthesia not only robs us of this factor, which is 
important for the faultless accomplishment of many operations, but 
also draws in its train another series of baneful influences which are 
important in patients subjected to any eye operation. Among these 
latter may by mentioned the dulled consciousness, the restlessness of 
the patient upon awakening, and often violent vomiting. 
General anesthesia is therefore confined to the following cases: 
i. Children who do not possess sufficient intelligence to keep 
quiet and conduct themselves sensibly. ANESTHESIA 
347 
2. Extensive operations in the orbit and on the lids, especially 
if the parts subjected to operation are sensitive on account of inflam- 
matory conditions, such as exenteration, enucleation of inflamed eyes, 
extensive plastic operations, and similar procedures. 
3. Severe operations on the eye itself, if local anesthesia is refused 
(especially in inflammatory glaucoma, excision of prolapsed iris in 
marked inflammatory conditions, etc.) or if the patient is not suitable 
for local anesthesia on account of other circumstances, such as pro- 
nounced blepharospasm, dementia, great irritability, etc. 
Local Anesthesia.—Even in some of the cases above mentioned, 
complete anesthesia may be secured either by local injections or by 
deep injections in the neighborhood of the nerves which supply the 
operative field, employing the methods previously described. 
Cocain anesthesia in operations on the eye itself is usually effected 
by a 3 per cent, solution, which is dropped into the eye several times 
during a period of ten minutes. The eye must be kept closed during 
this process of cocainization. If it remain open, the cocain may 
readily produce a dryness of the cornea with epithelial changes, which 
may not only impede the operation on account of cloudiness of the 
cornea, but may also cause the patient pain after the operation. If 
the eye is injected, a few drops of adrenalin solution should be in- 
stilled in the eye. The last application should be made just before 
the operation, as the constriction of the vessels caused by the adrena- 
lin soon disappears and is replaced by a vascular relaxation which 
might cause considerable bleeding during the operation. 
The advantages of cocain surpass those of all its substitutes. Its 
constricting influence on the vessels is an excellent property, which 
is of great value in every operation. The dilatation of the pupil 
which it causes is undesirable only in glaucoma operations, but can 
usually be prevented by a preceding instillation of eserin. Recently 
we have substituted for cocain in these cases a 3 per cent, solution of 
alypin, which must be supplemented by adrenalin, as it does not 
possess any vaso-constrictor properties. We also prefer alypin for 
sounding, for extraction of foreign bodies from the surface of the 
cornea, etc., as it does not cause the patient the inconvenience of 
pupillary dilatation. 
To produce a more profound anesthesia of the deeper parts of the 
eye, we drop some cocain-solution into the anterior chamber after it 
is opened in cases in which manipulation of the iris will presumably 348 
MINOR OPHTHALMIC OPERATIONS 
be painful, as in inflamed eyes. For this purpose only a sterilized 
solution should be used. 
The sensitiveness of the iris may be considerably diminished by 
the injection of a 3 per cent, solution of cocain beneath the conjunc- 
tiva, and this procedure is of value in excision of iris prolapse, extrac- 
tion of foreign bodies from the interior of the eye, in cyclodialysis, 
and similar operations. The edema produced by the injection, 
however, is likely to interfere with the proper execution of the incision 
in operations like glaucoma. 
Injections of Cocain and Adrenalin.—For operations on the 
eyelids, ocular muscles, and extirpation of the tear-sac an injection 
of a 1 per cent, cocain-solution will usually suffice. The addition of 
adrenalin, one or two parts to eight or nine parts of the cocain-solu- 
tion will reduce the bleeding to a minimum. The quantity of adren- 
alin (j/fo to %o c.c.) it, never followed by bad results. In elderly 
people not more than }{0 c.c. of adrenalin is to be used. More 
accurate directions have been given in the description of the various 
operations, so that the best effect can be produced with the least 
quantity. Aimless injection in one place with neglect of other parts 
of the operative field will not produce the desired result. The dose of 
cocain which we employ in most operations is a minimal one, amount- 
ing at most to one Pravaz syringeful (0.01 gm. cocain), so that poison- 
ing need not be feared in the most sensitive individual. 
On account of the marked efficiency of cocain as an anesthetic 
agent, only a small quantity of the solution is required, so that the 
normal relations of the parts are not disturbed. This is of great 
importance in many operations, especially in extirpation of the tear- 
sac. Where disturbance of the relation of the tissues is not important, 
the quantity of solution injected need not be considered. 
Injections of Novocain and Adrenalin.—In some operations, when 
a large amount of fluid is to be injected, it is preferable to employ 
novocain in the strength of 1 or 2 per cent. Adrenalin is added, 
one or two parts (1-1000 solution) to each eight or nine parts of the 
novocain solution. In enucleation the exophthalmos produced by 
the accumulated fluid behind the eye contributes to the anesthesia 
and facilitates the operation. 
Scopolamin-morphia Narcosis.—In place of general chloro- 
form or ether narcosis, the general anesthesia with scopolamin and 
morphia is recommended, carried out according to the following pre- BANDAGING AFTER OPERATIONS ON THE EYE 
349 
scription. These solutions should be freshly prepared each time: 
$ 
Scopolamin. hydrobromat, o.oi 
Aq. destillat 30.0 
Morphin. hydrochlorat, 0.075 
Aq. destillat 9.0 
Three hours before the operation 1 c.c. of each solution is injected 
under the skin of the upper arm, first injecting one solution, and then, 
without withdrawing the needle, making the other injection in the 
same place, but in another direction. After these injections the 
patient will become somnolent, quiet, and so insensible of pain that 
the operation can often be performed in this stage with the aid of 
simultaneous cocainization of the eye. If the desired effect is not 
obtained, the same dose of each solution must again be injected fifteen 
minutes before the operation. The patient then can be subjected to 
the operation in a completely relaxed condition, if at the same time 
the eye is made insensible by cocain. The advantage of this method 
is that the patient sleeps quietly for several hours after the operation, 
does not vomit, and exhibits no restlessness upon awakening. More- 
over, after carrying out these methods, if a general narcosis is in- 
dicated, it can be rapidly produced by a few drops of ether or 
chloroform. 
Bandaging after Operations on the Eye.—We employ the Fuchs 
lattice in men, and the Snellen cup in women, the cup being attached 
by strips of adhesive. The latter is not advisable for men, because 
the plaster will not adhere to the bearded skin. In children and rest- 
less patients bandages are applied, and with the aid of starch a stiff 
dressing is produced, which will also sufficiently protect the eye 
against careless contact. The application of pressure-bandages has 
been described in connection with the operations in which they are 
indicated. INDEX 
Abduction in strabismus, 144 
Abscess, lachrymal, 2 
rupture of, 20 
Abscission of cornea, 160, 302 
Actual cautery, in corneal ulcers, 298 
in enucleation, 159 
Adduction in strabismus, 144 
Adrenalin, injections of, 348 
in chalazion, 332 
in ectropion, 41 
in entropion and trichiasis, 86 
in enucleation, 149 
in glaucoma operations, 243, 271 
in iridectomy, 250 
in operations on cornea, 314 
in operations on lachrymal apparatus, 
3 
in operations on orbit, 167 
in optico-ciliary neurotomy, 163 
in tenotomy, 120 
Advancement, 132, 143, 146 
conjunctival fixation of muscle, 137 
fixation of muscle to limbus, 134 
in convergent strabismus, 132 
in divergent strabismus, 146 
in heterophoria, 147 
of rectus externus, 132 
of rectus internus, 146 
preferable to tenotomy, 144 
with tenotomy, 143, 146 
After-cataract, 231 
Alypin, 347 
in iridectomy for glaucoma, 242 
in tattooing cornea, 286 
Anagnostakis-Hotz operation, 86 
Anatomy of lachrymal sac, 1 
anterior portion of orbit, 113 
Anel’s syringe, 27, 33 
Anesthesia, 346 
ganglion, 150 
infiltration, 3, 347 
in canthotomy, 101 
in enucleation, 149 
in glaucoma operations, 242 
in lachrymal probing, 27 
Anesthesia, in orbital operations, 167 
in strabismus operations, 138 
local, 149, 347 
of lachrymal apparatus, 3 
scopolamin-morphin, 151, 242, 348 
Seidel posterior orbital, 152, 167 
Siegrist, 149 
Ankyloblepharon, canthoplasty for, 101 
Annular synechia, operation for, 278 
Anterior chamber, angle of, 242 
blood in, 219 
foreign bodies in, 322 
growth of epithelium into, 225 
in cataract extraction, 215 
in cyclodialysis, 269 
irrigation of, 190 
lachrymal crest, 1, 21 
resection of, 35 
lens capsule, incision of, 226 
sclerotomy, 253 
synechia, extensive iridectomy in, 290 
glaucoma following, 252 
operations for, 252, 294 
Sachs’ operation, 294 
Aqueous, escape of, during discission, 230 
Arlt median tarsorrhaphy, no 
operation for pterygium, 335 
for trichiasis, 96 
Aspiration of vitreous, 315 
Assistant, duties of, 340 
Axenfeld method of excision of palpebral 
lachrymal gland, 2 5 
method of exenteration of orbital 
cavity, 164 
Bandaging after operation, 349 
of fixing eye in strabismus, 138 
Barraquer operation of enucleation, 161 
Basedow’s disease, tarsorrhaphy for, 104 
Beer-de Wecker operation for staphyloma, 
302 
Bichlorid of mercury, subconjunctival 
injections of, 222, 333 
Bielschowsky, method, in squint opera- 
tion, 144 
351 352 
INDEX 
Blaskovics, method of resection of sclera, 
311 
Blennorrhea, canthotomy for, 100 
lachrymal probing for, 26 
Blepharitis, cicatricial ectropion following, 
Si 
Blepharophimosis, canthoplasty for, 101 
Blepharoplasty, 49 
Blepharospasm, canthotomy for, 100 
Bone flap resection of orbital wall, 169 
Bowman’s operation of discission, 232 
Bruhn’s apparatus, 81 
Btidinger’s operation, 65 
Buphthalmos, canthotomy for, xoo 
Burns, followed by ectropion, 50 
closure of palpebral fissure for, in 
Canaliculi, cutting of, in sac operation, 
12 
suturing of, 34 
in old injuries, 34 
Canaliculus, 27 
dilatation of, 28 
knife, Weber’s, 30 
slitting the, 29 
superior, probing through, 33 
Canthal ligament, internal, 5, 8 
Canthoplasty, 101 
1 Kuhnt operation for, 102 
Canthotomy, 100 
indications for, 100 
in exenteration of orbit, 100, 164 
in operations on orbit, 165 
Capsule forceps, 187 
injury of, 251 
Capsulotomy, 186, 207, 232 
Caries of orbital margin, 51 
Carlsbad needles, 54 
Caruncle, retraction of, after tenotomy, 
131 
Cataract, 175, 226 
after, 231 
akineses, 178 
anterior chamber in extraction, 215 
artificial ripening of, 177 
binocular, 176 
black, 209 
capsular, 231 
central, 177, 284 
Chandler operation, 198 
complicated, 199, 208 
Cataract, congenital, 228 
couching for, 217 
diabetic, 196 
discission for, 226, 235 
extraction of senile, 175 
accidents and errors during opera- 
tion, 199 
backward displacement of lens, 
216 
collapse of cornea, 216 
dislocation of lens, 209 
errors in making incision, 200 
expulsive hemorrhage, 216 
fixation of eyeball, 199 
in expression of the cataract, 208 
in iridectomy, 206 
in opening the capsule, 207 
prolapse of the vitreous, 210 
complications during healing, 218 
blood in anterior chamber, 219 
cloudiness of cornea, 219 
delayed closure of wound, 218 
detachment of retina, 225 
eversion of corneal flap, 219 
increased tension, 224 
infection, 221 
iridocyclitis, 223 
lens particles in pupil, 219 
pain, 220 
post-operative delirium, 220 
prolapsed iris, 218 
rupture of wound, 221 
secondary infection, 224 
duties of the assistant, 341 
Kalt suture, 217 
Kuhnt conjunctival flap, 217 
method of Wenzel, 207 
position of the patient, 175 
preliminary iridectomy, 177 
preparation of eye, 178 
preparation of patient, 178 
sterilization of hands and instru- 
ments, 179 
with iridectomy, 180 
with peripheral iridectomy, 198 
with round pupil, 197 
following iridectomy for glaucoma, 
251 
glaucoma, after extraction, 224, 231 
hard, 177 
hemorrhage during extraction, 216 INDEX 
353 
Cataract, Hess operation, 198 
hypermature, 177 
immature, 177 
in children, discission for, 228 
iridectomy in, 185, 206 
knife, Graefe, 182 
light-field in, 175 
linear extraction for, 237 
mature, treatment, 177 
membraneous, 232 
monocular, treatment, 177 
Morgagnian, 209 
needle operation for, 226 
nuclear, 283 
optical iridectomy, 283 
overripeness of, 177, 209 
perinuclear, 283 
Pfliiger operation, 198 
ripe, 177 
ripening of, artificial, 177 
secondary, 231 
discission of, 232 
iridotomy, 233 
senile, 175 
simple extraction, 180 
soft, 228, 237 
discission of, 228 
linear extraction for, 237 
traumatic, 237 
unripe, 177 
Cautery puncture in conical cornea, 302 
Celluloid plate in symblepharon, 80 
Celsus, formation of skin-flap after, 60 
Chandler’s method of cataract extraction, 
198 
Children, occlusion of lachrymal duct, 33 
Chisel, delicate, with oblique cutting edge, 
171 
Choked disc, Muller’s operation for, 173 
Choriodialysis in retinal detachment, 311 
Choroid, detachment of, in cyclodialysis, 
269 
prolapse of, in scleral wounds, 293 
Cicatricial ectropion, 49 
blepharitis following, 51 
correction of, 49 
eczema following, 51 
from caries, 50 
from extensive burns, 50 
in recent injuries, 49 
covering the wound, 50 
23 
Cicatricial ectropion, epidermal inlays, 55 
hemorrhage, 52 
non-pedicled skin-flaps, 51 
pedicled skin-flaps, 56 
releasing the lid, 50 
use of sutures, 51 
V-Y operation, 51 
prevention of, 49 
war wounds, 49 
Cicatrix after iris prolapse, 294 
fistulous, corneal transplantation for, 
303 
Cilia forceps, 98 
inversion of, 82 
Ciliary body, foreign body wound in, 326 
injury of, in cyclodialysis, 272 
prolapse of, in scleral wounds, 293 
Cocain, anesthesia, 347 
ganglion anesthesia with, 150 
in enucleation, 149 
in operations upon the lachrymal 
apparatus, 3 
in probing lachrymo-nasal duct, 27 
in strabismus operations, 138 
Coloboma of lid, old, 71 
Kuhnt method, 7T 
Pflugk method, 7r 
recent, 69 
Landolt method, 71 
Lindner method, 70 
Congenital cataract, discission for, 228 
ptosis, 112 
Conical cornea, 301 
cautery puncture, 302 
trephining of, 301 
probe, 28, 34 
Conjunctiva, rabbit’s, transplantation of, 
77 
tearing of, during cataract extrac- 
tion, 199 
transplantation of, de Wecker’s 
method, 293 
Conjunctival flaps, in corneal trans- 
plantation, 304 
in extraction operation, 185 
in iris prolapse, 290 
in large scleral wounds, 293 
in symblepharon, 76 
sac, sterilization of, 178 
Conjunctivitis, granular, 339 
expression for, 338 354 
INDEX 
Conjunctivitis, extirpation of tarsus, 340 
grattage in, 339 
Conjunctivoplasty, 290 
in corneal injuries, 292 
in large scleral wounds, 293 
in prolapse of iris, 290 
Convergent strabismus, 138 
Cornea, abscission of, 160, 302 
cauterization of, 298 
central opacity of, 284 
cloudiness of, 219 
collapse of, 216 
conical, 301 
discission through, 226 
infection of, 220 
injuries of, 292 
operations on, 298 
paracentesis of, 276, 298 
purulent infiltration of, 221 
Saemisch section, 299 
sloughing ulcer of, 298 
splitting of, 299 
staphyloma of, 302 
tattooing of, 285, 300 
Froelich’s method, 301 
transplantation of, 303 
trephining of, 294, 301 
ulcers of, 298 
wounds of, conjunctival flaps for, 292 
with iris prolapse, 289 
Corneal erosion in excision of sac, 6, 17 
puncture, 298 
staphyloma, operation for, 302 
transplantation, 303 
partial, 305 
total, 303 
trephine, 306 
trephining, 294, 305 
ulcers, 298 
after Motais operation, 128 
Corrosive sublimate, subconjunctival, in- 
jections of, 333 
Cortical substance, removal of, 190, 198 
Couching cataract, 217 
Counteracting sutures in tenotomy, 142 
Counter-puncture in extraction operation, 
183, 200 
Crest, anterior lachrymal, 1, 21, 35 
Crystalline lens. See Lens. 
Cureting naso-lachrymal duct, 16 
Cyanid of mercury, subconjunctival in- 
jection of, 333 
Cyclodialysis (Heine), 269 
complications of, 272 
indications for, 269 
results of, 273 
Cyst of iris, 278 
Cystoid cicatrix, operation for 303 
Cystotome, 190 
Dacryocystitis, acute, 21 
chronic, 21 
fistulous, 21 
Dacryocysto-Rhinostomia, Toti, 34 
David’s spoon in cataract operation, 180, 
192, 342 
Deep fascia in excision of lachrymal sac, 8 
Dental compound, use of in epidermal 
inlays, 55 
Descemet’s membrane, detachment of, 
273 
Desmarres elevator, 215 
Detachment of conjunctiva in enuclea- 
tion, 154 
of Descemet’s membrane, 273 
of retina, 306 
following prolapse of vitreous, 216 
indications for operation, 307 
in myopia, 306 
operations for, 308 
choriodialysis, 311 
Jod method, 310 
pre-equatorial sclerectomy, 314 
posterior sclerotomy, 309 
puncture of sclera, 312 
Deutschmann knife, bayonet, 313 
double cutting edge, 313 
method in scleral puncture, 313 
De Vincentiis’ operation, 274 
De Wecker’s anterior sclerotomy, 253 
excision of lachrymal gland, 23 
operation for staphyloma, 302 
pince-ciseaux, 185 
transplantation of the conjunctiva, 
293 
Diabetic cataract, 196 
Dieffenbach’s blepharoplasty, 64 
Dilaceration of secondary cataract, 232 
Dilatation of the canaliculus, 28 
of the lachrymal sac, 22 
Dionin, 222, 223 
Discission, 226 
Bowman’s, with two needles, 232 
escape of aqueous in, 230 INDEX 
355 
Discission, for congenital cataract, 228 
for high myopia, 229 
for secondary cataract, 231 
glaucoma after, 231 
infection after, 231 
needle, 226 
of a transparent lens, 229 
prolapse of vitreous in, 231 
through cornea, 226 
through sclera, 235 
with two needles, 232 
Disk, movable stenopaic, 284 
Dislocation of lens, 216, 252, 277 
Divergent strabismus, 145 
Ducts, lachrymal, 12 
naso-lachrymal, cureting, 16 
probing, 31 
Duties of ophthalmic assistant, 340 
Ear cartilage, use of flaps from, 65 
in coloboma, 72 
Knapp method, 67 
Kuhnt method, 67 
for tarsus and conjunctiva, 68 
Ectasia of sclera as cause of secondary 
glaucoma, 277 
as contraindication for advancement, 
137 
enucleation for, 148 
Ectropion, 38 
acute, 38 
chronic, 49 
cicatricial, 49 
correction of, 49 
following fistulous dacryocystitis, 22 
from caries, 50 
from extensive burns, 50, in 
from war wounds, 49 
paralytic, 48, 104, in 
prevention of, after burns, in 
senile, 39 
spasmodic, 38 
spastic, 38 
Eczema, cicatricial ectropion following, 51 
Edema of lids, canthotomy for, 100 
Electric saw, 171 
Electrolytic epilation for trichiasis, 98 
Electromagnet, 321 
Elevator, Desmarres, 215 
Elliot operation for glaucoma, 262 
Elschnig method of suturing canaliculi, 34 
of tarsorrhaphy, 107 
Entropion, 82 
excision of skin, 84 
Gaillard suture, 85 
Graefe operation, 85 
senile, 82 
spasmodic, 82 
spastic, 82 
use of plaster strips, 83 
Enucleation, 148, 153 
abscission of cornea, 160, 302 
complications of, 158 
for foreign bodies, 330 
ganglion anesthesia, 150 
in iridocyclitis, 223 
in panophthalmitis, 149, 223 
in prolapse of ciliary body, 293 
indications for, 148 
orbital hemorrhage in, r 59 
perforation of sclera in, 159 
posterior orbital injection, 152 
resection of optic nerve in, 160, 162 
Siegrist anesthesia, 149 
substitute operations, 160 
with implantation of artificial globe, 
161 
of cartilage, 161 
of fat, 161 
Epidermal inlays in cicatricial ectropion, 
55 
Epilation in trichiasis, 98 
Eserin in glaucoma operations, 257 
in iridectomy for glaucoma, 242 
Ethmoid cells, resection of, 36 
Ethylhydrocuprein in ulcers, 298 
Eversbusch operation for ptosis, 113 
indications for, 114 
results of, 118 
Eversion of eyelid, 38 
Evisceration of eyeball, 160 
during panophthalmitis, 149, 160 
with insertion of artificial vitreous, 
160 
Excision, for pterygium, 335 
for senile ectropion, 40 
of corneal cicatrix, 303 
of iris, after prolapse, 287 
of lachrymal sac, 1 
of lid-margin, for new-growths, 73 
of palpebral lachrymal gland, 23 356 
INDEX 
Excision, of skin, in entropion, 84 
of tarsus, in ectropion, 43 
Exenteration of orbital cavity, 164, 166 
canthotomy for, 100 
Exophoria, 147 
Exophthalmic goiter, tarsorrhaphy for, 
104 
Exophthalmos following tenotomy, 131 
Expression of cataract, 190, 208 
of trachoma granules, 338 
Expressor, Kuhnt’s, 338 
Expulsive hemorrhage in extraction, 216 
in iridectomy for glaucoma, 251 
External rectus, advancement of, 132 
tenotomy of, 131 
tarsorrhaphy, 105 
Extirpation of lachrymal gland, 23 
of lachrymal sac, 1 
of tarsus for trachoma, 340 
Extraction of cataract, 173 
of foreign bodies, 318 
of non-magnetic bodies, 328 
Eye, extraction of foreign bodies from, 318 
preparation of, for cataract extrac- 
tion, 178 
speculum, use of, 341 
Eyeball, collapse of, 215 
enucleation of, 148, 153 
evisceration of, 160 
foreign bodies in, 318 
Mules’ operation, 160 
optico-ciliary neurotomy, 162 
rupture of, 148 
steel in, 318 
wounds of, 318 
Eyebrows and lashes, restoration of, 68 
Eyelid, blepharoplasty, 64 
Biidinger operation, 65 
chalazion, 332 
Dieffenbach operation, 64 
eversion of, 38 
everting with Groenholm spoon, 321 
Fricke operation, 63 
inversion of, 82 
Kuhnt automargino-plastic opera- 
tion, 73 
lacerations of, 49 
new-growths, excision of, 74 
old coloboma, 71 
plastic operations with pedicled flaps, 
56 
Eyelid, recent coloboma of, 69 
restoration of, 64 
tearing from its insertion, 72 
Thiersch graft, 58, 63 
Wolfe graft, 63 
wounds following war injuries, 51 
Eye-muscles, operations on, 129 
Fascia, in excision of lachrymal sac, 6, 8,16 
tarso-orbital, 25, 67 
Fat, implantation of in Tenon’s capsule, 
161 
Fergus operation for glaucoma, 262 
Filtration scar after sclerectomy, 262 
Fistula of lachrymal gland, 33 
of lachrymal sac, 19 
Fistulous cicatrix of cornea, 303 
Fixation forceps, 179 
Flap, bone, in resection of orbital wall, 169 
conjunctival, in corneal transplanta- 
tion, 304 
in extraction operation, 185 
in injuries, 292 
in iris prolapse, 290 
in symblepharon, 76 
non-pedicled, 51 
pedicled, 56 
skin-graft, 50 
Flarer operation for trichiasis, 95 
Forceps, capsule, 187, 188 
cilia, 98 
fixation, 179 
Hess, 198 
iris, 185 
Knapp’s roller, 338 
Foreign bodies in eyeball, 318 
diagnosis of, 318 
extraction of, 322 
magnetic, 322 
non-magnetic, 328 
procedures in old injuries, 327 
Fricke operation on eyelids, 63 
excision of lachrymal gland, 26 
Froelich’s method of tattooing the cornea, 
301 
Frost-Lang operation, 161 
Fuchs’ keratoplasty, 303 
lattice bandage, 84, 196 
method for retinal detachment, 309 
method of tarsorrhaphy, 105 
treatment to avert expulsive hemor- 
rhage, 217 INDEX 
357 
Gaillard’s suture for entropion, 85 
Galvanocautery. See Actual Cautery. 
Ganglion anesthesia, 150 
Giant magnet, 321 
Gland, palpebral lachrymal, excision of, 
23 
Glass ball in total symblepharon, 80 
prothesis in symblepharon, 76 
shell eyes, 81 
Glasses in strabismus, 137 
Glaucoma, 242 
absolute, 162, 252 
optico-ciliary neurotomy in, 162 
acute, 242 
after cataract extraction, 224 
after discission, 231 
anterior sclerotomy, 253 
chronic, 253 
cyclodialysis in, 269 
de Vincentiis’s operation, 274 
due to anterior synechia, 252, 270, 
294 
due to growth of epithelium into 
anterior chamber, 225 
Elliot operation, 262 
Fergus operation, 262 
hemorrhagic, 251, 270 
incision with Graefe knife, 246 
with keratome, 243 
inflammatory, 242 
intraocular tension, determination of, 
279 
iridectomy for, 242 
expulsive hemorrhage after, 251 
for secondary glaucoma, 277 
indications for, 242 
iridodialysis after, 249 
prolapse of vitreous, 252 
spontaneous rupture of lens cap- 
sule, 251 
iridoencleisis, 257 
irido-sclerectomy, 258 
malignant, 270 
non-inflammatory, 253 
posterior sclerotomy, 267 
primary, 242 
scleral puncture in, 267 
sclerectomy and irido-sclerectomy, 
258 
sclero-corneal trephining, 262 
complications, 266 
Glaucoma, sclero-corneal trephining/in- 
dications, 263 
sclerotomy, 253, 267 
secondary, 270, 275 
iridectomy in, 277 
simple, 257 
Graefe. See von Graefe. 
Granular lids, 337 
Grattage, 339 
Groenholm spoon for everting lid, 331 
Haab’s giant magnet, 322 
Haitz method in total symblepharon, 79 
Heine’s cyclodialysis, 269 
Hemorrhage after cataract extraction, 216 
after iridotomy, 234 
after tenotomy, 131 
during iridectomy for glaucoma, 250 
expulsive, in cataract extraction, 216 
in iridectomy for glaucoma, 251 
in cyclodialysis, 272 
in enucleation of eyeball, 159 
in non-pedicled skin-flap operations, 
52 
Henning, prothesis of, 165 
Hernia lentis, 251 
Hess iris forceps, 198 
method of cataract extraction, 198 
operation for ptosis, 118 
contraindications, 123 
indications, 118 
results of, 122 
Hirschberg electromagnet, 322 
method of restoration of eyebrows 
and lashes, 68 
Hollow probes, 33 
Holth, iridoencleisis, 257 
pre-equatorial sclerectomy, 314 
Hook, blunt, in iridectomy for cataract, 
206 
in operations on orbit, 166, 172 
straight strabismus, 132 
Hooks in excision of lachrymal sac, 17 
Hotz-Anagnostakis operation, 86 
Implantation of artificial globe after 
enucleation, 161 
of cartilage after enucleation, 161 
of fat after enucleation, 161 
India-ink in tattooing of cornea, 300 
Infection following cataract extraction, 221 358 
INDEX 
Infection following discission, 231 
Infiltration anesthesia, 3, 149, 347 
solution, 3, 348 
Injection of cocain in enucleation, 149 
ganglion anesthesia, 150 
intramuscular, of protein, 222, 326 
subconjunctival, 298, 333 
in serpiginous ulcer, 298 
Injuries by foreign bodies, 318 
old, procedures in, 327 
recent, cicatricial ectropion following, 
49 
Injury to lachrymal canaliculus during 
dilatation, 28 
sac during excision, 19 
lens capsule in iridectomy, 251 
in trephining the cornea, 295 
Ink, India, in tattooing of cornea, 300 
Inlays, epidermal in cicatricial ectropion, 
55 
Instruments, sterilization of, 179 
Intermarginal incision, 40 
Internal canthal ligament, 5, 8 
palpebral ligament, x, 7 
rectus, advancement of, 146 
tenotomy of, 129, 146 
tarsorrhaphy, 109 
Intraocular tension, determination of, 
279 
Iridectomy after serpiginous ulcer, 300 
after wounds of globe, 287 
complications of, 206 
extraction of cataract with, 180 
extraction of cataract without, 197 
extraction of cataract with periph- 
eral, 198 
for nuclear cataract, 283 
hemorrhage during cataract extrac- 
tion, 216 
in glaucoma, 242, 277 
cataract following, 251 
expulsive hemorrhage in, 251 
hemorrhage during, 250 
indications for, 242 
iridodialysis after incision for, 249 
prolapse of vitreous in, 252 
spontaneous rupture of lens cap- 
sule, 251 
subluxation of lens, 252 
method of Wenzel, 207 
optical, 283 
Iridectomy, peripheral, in cataract extrac- 
tion, 198 
preliminary, in cataract extraction, 
177 
Iridocyclitis, after cataract extraction, 
223 
Iridodialysis, after incision for iridectomy, 
249, 256 
in cyclodialysis, 273 
Iridoencleisis (Holth) for simple glau- 
coma, 257 
Irido-sclerectomy, 258 
Iridotomy, hemorrhage after, 234 
in secondary cataract, 232, 233 
precorneal, 286 
Iris, atrophic, in glaucoma, 250 
cyst of, 278 
forceps, 185 
Hess, 198 
operations for prolapse of, 287 
prolapse of, after simple extraction, 
199 
conjunctivoplasty in, 290 
in anterior sclerotomy, 255 
in extraction without iridectomy, 
199 
operations for, 287 
scissors, 185 
time for excision after prolapse, 296 
transfixion of, in iridectomy, 278 
Iritis, acute, corneal puncture in, 276 
Iron splinters in eye, 318 
Irrigation of anterior chamber, 190 
Jaesche-Arlt operation for trichiasis, 96 
Jod method in retinal detachment, 310 
Kalt suture, 217 
Keratectomy, 160, 302 
Keratitis profunda, corneal puncture in, 
299 
Keratoconus, 301 
Keratome, incision in glaucoma, 243 
Keratoplasty, 303 
partial, 305 
total, 303 
Knapp, ear-flap method in ectropion, 67 
operation for trachoma, 338 
roller-forceps, 338 
skin-flap method in ectropion, 60 
Knife, Graefe, incision for cataract, 182 INDEX 
359 
Knife, in anterior sclerotomy, 253 
incision for glaucoma, 246 
operations for anterior synechia, 
296 
posterior sclerotomy, 267 
Saemisch section, 299 
sclerectomy, 259 
transfixion for seclusion of pupil, 
279 
Sachs’ sickle, 312 
Weber’s, 30 
Kollner’s method of restoration of lids, 
74 
Kronlein, resection of outer orbital wall, 
166 
Kuhnt’s automargino-plastic operation, 
73 
conjunctival flap, 217 
conjunctivoplasty, 290 
excision of upper transitional fold, 
339 
expressor, 338 
method in old coloboma, 71 
operation for canthoplasty, 102 
for senile ectropion, 40 
restoration of lower lid, 62, 67 
tarsal enucleation, 95 
for trachoma, 340 
Kuhnt-Muller operation, 40 
Kuhnt-Szymanowski operation, 40 
Lachrymal abscess, 2, 20 
rupture of, 20 
apparatus, 1 
bone, necrosis of, 22 
canaliculus, 27 
dilatation of, 28 
slitting of, 29 
superior, probing through, 33 
crest, anterior, 1, 21, 35 
posterior, 2, 8, 12 
fistula, 21, 22 
fossa, 1, 8 
gland, excision of palpebral, 23 
Axenfeld method, 25 
de Wecker’s method, 23 
fistula of, 33 
Fricker’s method, 26 
hemorrhage during excision, 25 
indications for, 23 
results of operation, 26 
Lachrymal abscess, passages, test for 
permeability of, 27 
probe, Bowman, 31 
conical, 28 
hollow, 33 
probing, 26 
anesthesia, 27 
contraindications, 33 
diagnosis of stenosis, 27 
indications for, 26 
slitting the canaliculus, 29 
through superior canaliculus, 33 
Weber’s knife, 30 
sac, anatomy of, 1 
acute inflammation of, 21 
disease, varieties of, 21 
excision of, 1 
accidents and complications, 18 
after-treatment, 17 
anesthesia, 3 
cure ting naso-lachrymal duct, 16 
exposing the sac, 8 
fistula following, 19 
hemorrhage during, 14, 20 
indications for, 2 
infiltration solution, 3 
injury to sac during, 19 
locating the sac, 18 
opening into the orbit, 19 
removing the sac, 11 
retained portions of sac, 19 
results of, 20 
suppuration after, 20 
Toti’s dacryocysto-rhinostomia, 34 
tuberculous disease, 22 
Lachrymal sac, 2 
West’s operation, 37 
syringe, introduction of, 27 
Lachrymo-nasal duct, cureting, 16 
occlusion of, in new-born, 33 
probing of, 31 
Lagophthalmos, after Motais operation, 
128 
Lagrange operation for glaucoma, 258 
Lamp, Sachs’, 329 
Landolt, method of bridge flap, 62 
method in coloboma of lid, 71 
restoration of upper lid, 68 
Latent outward deviation, 147 
Lattice bandage, Fuchs’, 84, 196 
Lens, backward luxation of, 216 360 
INDEX 
Lens, discission for cataractous, 226 
transparent, 229 
dislocation of, 216, 252, 277 
extraction of cataractous, 175 
injury to, during iridectomy, 251 
in trephining cornea, 295 
linear extraction, 237 
removal of, in high myopia, 229 
subluxation of, 252 
Lens capsule, anterior, incision of, 226 
spontaneous rupture of, 251 
wound of, in excision of iris, 251 
Lexer, method of restoration of orbital 
margin, 76 
method of replacement of cilia, 68 
Lid-elevator, 215, 331 
Lid, Kuhnt automargino-plastic opera- 
tion, 73 
ectropion, 38 
entropion and trichiasis, 83 
old coloboma of, 71 
recent coloboma of, 69 
Lids, granular. See Conjunctivitis, 
Granular. 
Lieberman’s ganglion anesthesia, 152 
Ligament, internal canthal, 5, 8 
palpebral, 1, 7 
Light-field in cataract, 175 
Lindner, method in coloboma of lid, 70 
Linear extraction, 237 
for soft cataract, 237 
for total cataract, 241 
Local anesthesia, 149, 347 
Loop, Weber’s, 210 
Lowenstein’s ganglion anesthesia, 150 
Lower lid, bridge flap, 62, 67 
ectropion, 38 
entropion and trichiasis, 82 
Lyritza operation for trachoma, 340 
Magi tot’s cartilage implantation, 161 
Magnet, giant, 321 
Haab, 322 
Hirschberg, 322 
operation, 322 
Magnetic foreign bodies, 322 
Malar bone, caries of, 50 
Malignant growths, operation for, 74 
glaucoma, 270 
May’s method in total symblepharon, 80 
McReynolds operation for pterygium, 336 
Median tarsorrhaphy (Arlt), no 
Mercury, subconjunctival injections of, 
298, 333 
Metallic foreign bodies, removal of, 318 
Method of excision of palpebral lachrymal 
gland, 23 
Middle turbinated bone, resection of, 36 
Morgagnian cataract, 209 
Morton’s method in total symblepharon, 
80 
Motais operation for ptosis, 124 
complications of, 128 
corneal ulceration after, 128 
lagophthalmos after, 128 
staphyloma after, 128 
Movable stenopaic disk, 284 
Mucous membrane flaps, 97 
Mules’ operation, 160 
Muller’s incision for choked disc, 173 
method of sclero-corneal trephining, 
266 
operation for ectropion, 40 
resection of sclera, 311 
tear-sac speculum, 6 
Muscles, operations on, 129 
Myopia, discission for, 229 
indications for discission, 230 
retinal detachment in, 306 
Naso-lachrymal duct, cureting, 16 
occlusion of, in new-born, 33 
probing of, 31 
Needle, curved, for Siegrist anesthesia, 
150 
operation for congenital cataract, 226 
for secondary cataract, 231 
knife, 226 
straight, for ganglion anesthesia, 150 
Zur Nedden, 315 
Needles, Carlsbad, 54 
discission, 226 
for tattooing cornea, 300 
Nerve, optic, resection of, 160, 163 
Neurectomy, optico-ciliary, 163 
Neurotomy, optico-ciliary, 162 
New-born children, probing in, 33 
Non-magnetic foreign bodies, 328 
Non-pedicled skin-flaps, 51 
restoration of eyebrows by, 69 
Novocain, injections of, with adrenalin, 
348 INDEX 
361 
Occlusion of lachrymal duct in new-born 
children, 33 
Ocular muscles, operations upon, 129 
paralysis of, 147 
Opacities, corneal, 284 
Ophthalmic assistant, duties of, 340 
Ophthalmoscope, diagnosis in foreign 
body injuries, 319 
in operation for retinal detachment, 
3x0 
Optic nerve, resection of, 160, 163 
Optic nerve sheath, incision of, 173 
Optical iridectomy, 283 
Optico-ciliary neurectomy, 163 
neurotomy, 162 
Optochin in ulcers, 298 
Orbicularis muscle in excision of lachrymal 
sac, 7 
Orbit, anatomy of, 113 
operations on, 165 
indications for, 165 
removal of contents of, 164 
resection of outer wall, 166 
Orbital cavity, exenteration of, 164 
margin, caries of, 50 
restoration of, 76 
spatula, 169 
Osteoplastic resection of outer orbital 
wall, 171 
Pagenstecher’s sutures for ptosis, 123 
Palpebral fissure, complete closure of, 11 x 
operation for lengthening, 100, 101 
for shortening, 104 
widening of, in tenotomy, 131 
lachrymal gland, excision of, 23 
Panas operation for ptosis, 124 
for entropion and trichiasis, 92 
Panophthalmitis, enucleation in, 149, 223 
evisceration in, 149, 160 
Paquelin cautery in enucleation, 159 
Paracentesis of cornea, 276, 298 
Paralysis of ocular See Ocular 
Muscles. 
Paralytic ectropion, 48, 104, in 
squint, 147 
Partial keratoplasty, 305 
symblepharon, 76 
trichiasis, 96 
Passing of probes in new-born children, 
33 
Pedicled flaps in eyelid operations, 56 
Penetrating wounds of eyeball, 318 
Perinuclear cataract, 283 
Peripheral iridectomy, 198 
Pfliiger, cataract extraction, 198 
Pflugk method in old coloboma, 71 
Pince-ciseaux, de Wecker’s, 185 
Plaster strips in entropion, 83 
Plastic operation on eyelids, Biidinger, 65 
Dieffenbach, 64 
for symblepharon, 76 
for trichiasis, 97 
Fricke, 63 
with pedicled flaps, 56 
Posterior lachrymal crest, 2, 8, 12 
sclerotomy, for detachment of retina, 
3°9 
in glaucoma, 267 
Post-operative delirium, 220 
Pravaz’s syringe, 3, 149, 150 
Precorneal iridotomy, 286 
Pre-equatorial sclerectomy, 314 
Preliminary iridectomy, 177 
Primary glaucoma, operation for, 242 
Probes, Bowman’s, 31 
conical, 28, 34 
contraindications to use of, 33 
hollow, 33 
Probing of naso-lachrymal duct, 31 
contraindications, 33 
in new-born, 33 
superior canaliculus, 33 
Prolapse of ciliary body in scleral wounds 
293 
of iris, after simple extraction, 199 
conjunctivoplasty in, 290 
in anterior sclerotomy, 255 
in linear extraction for soft cata- 
ract, 240 
operations for, 287 
time for excision after, 296 
of vitreous, during discission, 231 
in cataract extraction, 210 
in iridectomy for glaucoma, 252 
Protein, intramuscular injections of, 222, 
326 
Prothesis after symblepharon operation, 
79 
glass, 76 
glass shell, 81 
Henning, 165 362 
INDEX 
Pterygium, 334 
Arlt operation, 335 
excision of, 335 
inversion operation, 334 
McReynolds operation for, 336 
transplantation, 336 
Ptosis, after excision of lachrymal gland, 
25 
contraindications for operation, 112 
Eversbusch operation, 113 
Hess operation, 118 
Motais operation, 124 
Pagenstecher’s sutures, 123 
Panas operation, 124 
Puncture of cornea, 276, 298 
of sclera for retinal detachment, 312 
Pupil, connective-tissue membranes in, 
287 
seclusion of, operation for, 278 
tests with dilated, before optical 
iridectomy, 285 
Purtscher’s sclero-corneal trephining, 266 
Rabbit’s conjunctiva, transplantation of, 
77 
Raupp method of suturing canaliculi, 34 
Reclination for cataract, 217 
Rectus externus, advancement and resec- 
tion of, 132 
advancement with tenotomy of 
internus, 143 
tenotomy of, 131 
internus, advancement of, 146 
tenotomy of, 129, 146 
Reisinger’s double tenaculum, 211 
Removing the lachrymal sac, 11 
Resection of lachrymal sac, 1 
of nasal bone, 36 
of optic nerve in enucleation, 163 
of outer orbital wall, 166 
of sclera, 311 
Restoration of eyebrows and lashes, 68 
Hirschberg method, 68 
Lexer method, 68 
of lids, 74 
of orbital margin, 76 
Retina, detachment of, 306 
following prolapse of vitreous, 216 
indications for operation, 307 
in myopia, 306 
neoplasms as cause of, 306 
Retina, detachment of, operations for, 308 
posterior sclerotomy for, 309 
resection of sclera, 311 
Retraction of caruncle following teno- 
tomy, 131 
Rhinostomia, Toti’s dacryocysto, 34 
Rochat-van Lint method of akineses, 178 
Roentgen rays, 321 
Rogman’s operation for symblepharon, 78 
Roller-forceps, Knapp’s, 338 
Sac, excision of lachrymal, 1 
Sachs’ lamp, in foreign body in vitreous, 
329 
method of puncture of sclera, 312 
operation for anterior synechia, 294 
sickle-knife, 312 
Saemisch section in serpiginous ulcer, 299 
Salt-solution, subconjunctival injections 
of, 333 
Saw, electric, 171 
wire, 170 
Scars, cystic, 303 
Schnabel, theory of entropion, 82 
Schiotz tonometer, 279 
Scissors, enucleation, 156 
iris, 185 
Sclera, discission through, 235 
extraction of foreign bodies through, 
325 
puncture of, in retinal detachment, 
312 
resection of, in retinal detachment, 
3ii 
rupture of, 148 
Scleral puncture in glaucoma, 267 
in retinal detachment, 312 
sutures, 293, 329 
trephining, 262 
wounds, treatment of, 293 
Sclerectomy, 258 
anterior, 253 
posterior, for retinal detachment, 309 
in glaucoma, 267 
pre-equatorial, in retinal detachment, 
3i4 
Scopolamin-morphin anesthesia, 151, 348 
Seclusion of pupil, operation for, 278 
Secondary cataract, 231 
capsulotomy, 232 
discission, 231 INDEX 
363 
Secondary cataract, discission through 
sclera, 235 
with two needles, 232 
iridotomy, 233 
glaucoma, 275 
iridectomy, 277 
paracentesis, 276 
transfixion, 278 
Seidel posterior orbital injection, 152, 167 
Senile cataract, extraction of, 175 
ectropion, 39 
Kuhnt operation, 40 
Kuhnt-Miiller operation, 40 
Kuhnt-Syzmanowski operation, 40 
entropion, 82 
Gaillard’s suture, 85 
Graefe operation, 85 
Serpiginous ulcer, iridectomy after, 300 
optochin (ethylhydrocuprein) in, 298 
Saemisch section in, 299 
subconjunctival injections in, 298 
thermocautery in, 298 
Sickle-knife, Sachs’, 312 
Sideroscope, in foreign bodies in eyeball, 
320 
Simple extraction, 180 
glaucoma, 257 
Skin-covered mold in symblepharon, 81 
Skin grafting, for ectropion, 50 
for symblepharon, 80 
non-pedicled, 51, 69 
adaptation of to wound, 53 
dressings, 54 
preparation of the flaps, 52 
pedicled, 56 
after Celsus, 60 
bridge flaps, 62 
indications for use of, 56 
Knapp’s method, 60 
Muller’s method, 62 
preparation of the flaps, 57 
sliding flaps, 59 
turn flaps, 58 
v. Hacker’s method, 62 
wandering flaps, 62 
Wicherkiewicz’s method, 61 
Thiersch method, 63 
Wolfe graft, 63 
Slitting of lachrymal canaliculus, 29 
Snellen’s cup, 195 
operation for trichiasis, 92 
Snellen's suture for spasmodic ectropion, 
38 
Soft cataract, linear extraction, 237 
Sounds, hollow, in orbital resection, 170 
use of, in lachrymal disease, 26 
Spasmodic ectropion, 38 
Snellen suture, 38 
entropion, 82 
Gaillard suture, 85 
Spastic ectropion, 38 
entropion, 82 
Spatula, in cataract extraction, 180, 193 
orbital, 169 
Zur Nedden, 316 
Speculum, lid, indications for use of, 341 
Muller’s tear-sac, 6 
Spencer Watson operation for trichiasis, 
96 
Splitting of cornea, 299 
Spontaneous rupture of lens capsule, 251 
Spoon, Daviel’s, 180, 192, 342 
Groenholm, 331 
Squint, paralytic, 147 
Staphyloma, after Motais operation, 128 
Beer-de Wecker operation, 302 
operations for, 160, 302 
Steel in eyeball, 318 
Stenopaic disk, movable, 284 
Stenosis of lachrymal duct, 27 
Stent’s composition for prothesis, 79 
Strabismus, 129 
abduction in, 144 
adduction in, 144 
advancement of rectus externus, 132 
of rectus internus, 146 
anesthesia, 138 
bandaging of fixing eye, 138 
convergent, 138 
advancement of rectus externus, 
132 
indications for operation, 138 
spectacle treatment, 137 
stereoscope in, 138 
tenotomy of rectus internus, 129 
counteracting suture after tenotomy, 
142 
divergent, 145 
advancement of rectus internus, 
146 
after tenotomy of rectus internus, 
146 364 
INDEX 
Strabismus, exophoria, 147 
glasses in, 137 
hook, 13, 132 
paralytic, 147 
supporting suture after tenotomy, 
140 
tenotomy of rectus externus, 131, 146 
of rectus internus, 129, 143 
Subconjunctival injections, 298, 333 
for serpiginous ulcer, 298 
Subcutaneous injection of cocain, 4, 27, 
101, 114, 348 
of scopolamin-morphin, 151, 348 
Subluxation of lens in iridectomy, 252 
Superior maxillary process, resection of, 35 
rectus muscle in ptosis operation, 124 
Subretinal fluid, drainage of, 309 
Supporting sutures, in tenotomy, 140 
Suppuration, after excision of sac, 20 
Sutures, counteracting, in tenotomy, 142 
in cicatricial ectropion, 51 
Pagenstecher’s for ptosis, 123 
scleral, 293, 329 
Snellen, for spasmodic ectropion, 38 
supporting, in tenotomy, 140 
Suturing the canaliculi, 34 
Elschnig method, 34 
in old injuries, 34 
Raupp method, 34 
Symblepharon, 76 
complete, of lower lid, 77 
partial, 76 
prothesis of glass in, 76 
Rogman’s operation, 78 
total, 78 
Haitz method in, 80 
Morton and May method in, 80 
skin-covered molds in, 81 
Sympathetic inflammation after cataract 
extraction, 223 
after injuries, 148 
Synechia, annular, operation for, 278 
anterior, extensive iridectomy in, 
290 
glaucoma following, 252, 270, 294 
operations for, 252, 294 
Sachs’ operation, 294 
Syringe, Anel’s, 27 
Pravaz’s, 3, 149 
Szymanowski operation for senile ectro- 
pion, 40 
Tarsal enucleation for trichiasis, 95 
Tarso-orbicular fascia, 69 
Tarso-orbital fascia, 25, 67 
Tarsoplasty, 92 
Tarsorrhaphy, 104 
Arlt operation, no 
Elschnig operation, 107 
for Basedow’s disease, 104 
Fuchs’ operation, 105 
in cicatricial ectropion, 50 
Tarsus, excision of, for ectropion, 43 
extirpation of, for trachoma, 340 
Tattooing needles, 300 
of cornea, 285, 300 
Froelich’s method, 301 
Tear-duct, blennorrhea of, 2 
Tear-sac speculum (Muller’s), 6 
Tenaculum, blunt, in operation for 
synechia, 289, 304 
pointed, to open lens capsule, 189 
Reisinger’s double, 211 
Tenon’s capsule, artificial globe in, 161 
implantation of cartilage in, 161 
of fat in, 161 
Tenotomy, 129, 131, 143, 146 
and advancement performed simul- 
taneously, 143, 146 
counteracting sutures in, 142 
rectus, externus, 131 
internus, 129 
accidents and complications, 131 
hemorrhage, 131 
regulating the effect of, 140 
results of, 139 
retraction of caruncle, 131 
supporting suture in, 140 
Tension, intraocular, determination of, 
279 
Thermocautery in serpiginous ulcers, 298 
Thiersch skin grafting method, 63 
Third nerve, paralysis of, 1x2 
Thread operation for ptosis, subcuta- 
neous, 118, 123 
Tonometer, Schiotz, 279 
Tonometry, 279 
Total cataract of young adults, 241 
keratoplasty, 303 
staphyloma, operation for, 160, 302 
symblepharon, operations for, 78 
Toti, dacryocysto-rhinostomia, 34 
results of operation, 36 INDEX 
365 
Trachoma, 337 
canthotomy for, 100 
excision of upper transitional fold, 
339 
expression for, 338 
extirpation of tarsus for, 340 
forceps, Knapp’s, 338 
grattage in, 339 
Lyritza method, 340 
Transfixion of iris in iridectomy, 278 
for seclusion of pupil, 278 
Transparent lens, discission of, 229 
Transplantation of conjuvnctia, 293 
cornea, 303 
partial, 305 
total, 303 
von Hippel’s, 305 
for pterygium, 336 
Trephine, corneal, von Hippel’s, 306 
Trephining of cornea, 294, 301 
for anterior synechia, 294 
of sclera for glaucoma, 262 
Trichiasis, 83 
electrolytic epilation, 98 
Flarer operation, 95 
Hotz-Anagnostakis operation, 86 
Jaesche-Arlt operation, 96 
Kuhnt tarsal enucleation, 95 
mucous membrane flaps, 97 
Panas operation, 92 
Snellen operation, 92 
Spencer Watson operation, 96 
Van Millingen plastic operation, 83 
Trichiasis and entropion, 82 
Tuberculous lachrymal sac, 22 
Ulcer, serpiginous, operations for, 298 
Upper lid, bridge flap for, 68 
everting with Groenholm spoon, 331 
restoration of, 67 
Kuhnt method, 68 
Landolt method, 68 
spasmodic ectropion of, 38 
Urotropin, in infection, 222 
Van Lint-Rochat method of akineses, 
I78 
Van Millingen plastic operation for tri- 
chiasis, 83 
Vapor cautery in corneal ulcers, 298 
Vision, after injuries by foreign bodies, 
318 
Vitreous, aspiration of (Zur Nedden), 315 
extraction of foreign bodies from, 323 
fluid, in myopia, 231 
prolapse of, after cataract extraction, 
210 
during discission, 231 
in iridectomy for glaucoma, 252 
in linear extraction for soft cata- 
ract, 241 
in sclerectomy, 261 
transplantation of, in retinal de- 
tachment, 308 
Von Graefe operation for senile entropion, 
85 
cataract knife, 182 
knife for incision in glaucoma, 246 
for transfixion operation, 279 
Von Hippel’s corneal transplantation, 305 
trephine, 306 
V-Y operation in cicatricial ectropion, 51 
Waldhauer, modified Jaesche-Arlt opera- 
tion, 83 
Watson operation for partial trichiasis, 96 
Weber’s knife, 30 
loop, 210 
Wenzel method of cataract extraction, 207 
Wessely, vapor cautery of, 298 
West’s operation for lachrymal sac dis- 
ease, 37 
Wicherkiewicz, skin-flap method in ectro- 
pion, 61 
Wire saw, 170 
Wolfe graft, 63 
Wounds of cornea, with iris prolapse, 289 
of lens capsule in iridectomy, 251, 289 
in trephining cornea, 295 
of sclera, 293 
war injuries, 49 
Zur Nedden, aspiration of vitreous, 315 
needle, 315 
spatula, 316