MEDICAL history records no more rapid and marvelous advancement than has characterized ophthalmology in the past quarter of a century. During this brief period, spanned even by the professional career of some who listen to me to-day, there has gradually developed a science which excels in its perfection and exactness that of my other department of medicine. From a dark and unexplored chamber the eye has been transformed into a ball of light, revealing not only what is within its narrow bounds, but, like a mirror, much that lies outside it.
So vast and important has become the consideration of abnormalities affecting the visual apparatus, and so wonderful, yet still imperfect, our facilities for detecting and overcoming these, that when I was asked to present to this Congress a paper upon ophthalmic surgery and to cover as much of the field as possible, although less than one-tenth of the oculist’s work is strictly surgical, I thought that volumes could not do it justice. I shall therefore endeavor to bring before you not only that which is newest, but that which is most practical.
There are endless unique operations for rare and complicated cases, but they must of necessity be passed by, and only those surgical procedures be presented which will most frequently tax our thought and skill. By Thus limiting the scope of this paper, I hope to elicit a more general and definite discussion.
Aside from a better understanding of the anatomy and physiology of the eye and an improved technique in may operations, three elements-perfected instruments, local anaesthesia by cocaine, and absolute cleanliness secured either by simple irrigation or antiseptic agents-contribute largely toward accomplishing better surgical results than formerly.
Aside from a better understanding of the anatomy and physiology of the eye and an improved technique in many operations, three elements-perfected instruments, local anaesthesia by cocaine, and absolute cleanliness secured either by simple irrigation or antiseptic agents-contribute largely toward accomplishing better surgical results than formerly.
Great improvement has been made in the character and quality of our instruments. I think we are under obligation to the manufacturers for furnishing us such delicate instruments, perfect in adjustment and yet easily rendered aseptic.
A wonderful boon came to ophthalmic surgery in the introduction of cocaine. By it we not only are enabled to secure anaesthesia limited to the parts to be operated upon, but other quite as desirable and important effects. I refer particularly to its power to contract the blood vessels, so that less haemorrhage obscures our work during such operations as tenotomy or advancement for strabismus; and to its action in producing hypotony, a certain degree of which is a great factor in the extraction of cataract. I think more attention should be given to this latter point, because by a careless and unscientific use of cocaine an unnecessary element of danger is artificially induced in operations involving the opening of the eyeball.
My rule has been to apply a 2 per cent. solution three or four times during eight minutes in cases where there was a strong probability that an iridectomy would be unnecessary, care being taken that the lids are kept closed during cocainization so as to prevent dryness of the cornea. This strength I have found to produce sufficient anaesthesia and a degree of hypotony which favors the delivery of the lens in cataract extraction, and at the same time aids in preventing prolapse of the iris.
In fact, it is this action on the part of cocaine which has done much to make simple extraction possible in so many cases. With a 2 per cent, solution I also believe that a smoother incision can be made, and the healing process goes on more rapidly and perfectly because the epithelium of the cornea is less affected than when stronger solution are applied. On the other hand, if there are indications that in iridectomy will be necessary, or if there is a slightly increased tension, I employ a 4 per cent. solution and prolong its action to ten minutes. In operation open the lids or external ocular muscles I use this same strength. By thus individualizing, we can make cocaine serve a double purpose.
The third factor in the general consideration of ophthalmic surgery is antisepsis. The great fact to keep before us is, that the end to be attained is absolute cleanliness, and I have no hesitation in saying that if this can be secured and maintained without the use of chemical germicidal agents, it is much the superior method, but I do not believe this possible under all circumstances. If the truth could be known I doubt not that many major operations are successfully performed when only ordinary, I may say partial cleanliness has been accomplished and not the theoretical, scientific, absolute cleanliness which we talk so much about.
Possibly there is a practical surgical cleanliness which is not synonymous with absolute surgical cleanliness. However, as long as we cannot tell what point less than perfect cleanliness is safe and practical, we must diligently strive after the ideal. The fact to be emphasized is that in our enthusiasm to secure a state of perfect antisepsis, we avoid employing methods or agents irritating to the eye, which indirectly may do more harm than good. Very careful discrimination is necessary. The efficiency of an antiseptic agent is not simply its power to destroy micro-organisms, but to accomplish it quickly.
Many of the drugs which possess truly antiseptic properties are irritating to the eye when used n sufficient quantity to be effective, and the question resolves itself into this, whether the dangers are greater in trying to secure cleanliness by simple irrigation and possibly failure to accomplish the high ideal, or by using active germicidal agents which probably prove thoroughly effective, but in many cases cause some irritation which may mar the result of the operation. This cannot be satisfactorily answered without going somewhat into detail and bringing before us a few recent experiments.
The list of antiseptic drugs which are being used in eye surgery is quite long-Carbolic acid, Peroxide of hydrogen, Pyoktannin, Chlorine water, Boroglyceride, Boracic acid, the Biniodide and Bichloride of mercury. Some of these are too irritating, others act too slowly, and Boracic acid has been shown to possess to germicidal properties, although it is employed as much as any one drug named. I use it very frequently myself as a means to increase the specific gravity of liquids used about the eye.
If it serves no other purpose than raising the specific gravity and thus preventing osmosis, it accomplishes great good. The most effective and at the same time the safest germicide is the Bichloride of mercury. In strengths varying from one to five thousand to one to fifteen thousand, it quickly destroys microorganisms, but when the anterior chamber is opened, there is a possibility of its inducing striped keratitis, resulting impermanent opacity of the cornea. The experiments of Carl Mellinger go to prove the following facts;.
First.-That a solution of corrosive sublimate, 1 to 5000, and even 1 to 15,000, if present in the anterior chamber for any considerable length of time, will cause permanent opacity of the cornea.
Second-That cocaine alone produces no corneal opacity, but that its presence within the anterior chamber increases the effect of the sublimate solution by making the endothelium more permeable. Its use, also, by lowering the tension, favors the retaining of these solutions within the eyeball.
Third.-That a 3 per cent. solution of boracic acid or a one- half per cent. solution chloride can be injected into the anterior chamber without any unpleasant results.
My pain of preparing my instruments and patients for all major operations is as follows: All instruments are placed in boiling water, to which one-third alcohol is added. They are allowed to remain a few minute, then dried and transferred to an Arnold’s sterilizer, in which also I place all solutions of cocaine, atropine, eserine, boracic acid, etc., are in bottles corked with absorbent cotton, and these, with the instruments, are subjected to sterilization for one hour. The instruments are then placed in antiseptic absorbent cotton, and the bottles containing the liquids are not uncorked until necessity requires it.
I could never understand the reasonableness of a surgeon being so very particular about his instruments, and at the same time (as I have seen done) employ solutions of cocaine or atropine made up simply with distilled water, and placed in bottles probably not chemically clean. Such solutions I do not believe are sterile, and therefore safe to use.
In the preparation of my patient, I have the parts about the eye washed with soap and water, and in the cleansing of the lid-margins and conjunctival folds I make the following discrimination: if there are any unhealthy secretions, such as occur in blepharitis, conjunctivitis, or dacrocystitis, I employ the bichloride of mercury, 1 to 5000. Special attention should be given to the cleansing of the cilia and lachrymal sac. I have never found it necessary to adopt the plan of closing the punata by the cautery, or to employ Pagenstecher’s method of sitting the canaliculus, and packing with iodoform cotton.
