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.
On the other hand, if there are no unhealthy secretions, I see no necessity of using a germicide, which is irritating to some eyes, but trust entirely to thorough irrigation with a 2 per cent. sterile boracic acid solution, before, during, and after the operation. I employ the boracic acid, not because I believe it possesses any special germicidal properties, but (as i have stated before) to increase the specific gravity of the liquid. I hold this to be an important point, if solutions are to be injected into the anterior chamber. The above plan of antiseptic surgery has given me highly satisfactory results. Suppuration has been a thing almost unknown, and has never been of a serious character.
Passing now in brief review some of the more recent operations which indicate progress in ophthalmic surgery, I note, first, as one of the most important, the mangle or crushing operation for trachoma. Dr. David Webster says it is one of the greatest discoveries of modern ophthalmology. It is certain, however, that by the judicious employment of this procedure, the poor victims of trachoma are saved months and even years of suffering and annoyance. Dr. Holtz was the first, I believe, to attract the attention of the profession to this plan of treatment; but as he advised the use of the thumb-nails to express the granules, it was not generally employed until others devised instruments which rendered it possible to do more thorough and skilled work.
The various instruments which are being used accomplish the same result by slightly different methods. Dr. Noyes’s angular forceps are simply a squeezing instrument, so constructed as to facilitate the operation well up in the retro-tarsal folds. Dr. Knapp’s roller forceps express the trachomatous substance by a sort of mangle process. Sometimes, in chronic inflammatory cases, before using his forceps, he scarifies the infiltrated parts with the sillonneur of Johnson. Dr. George Lindsay Johnson, the originator of the sillonneur just referred to, scarifies the everted lids, and then destroys the granules with an electrolyzer.
This plan is superior to the old cautery treatment. Other instruments have been made, but they do not differ essentially from those mentioned. In all of the above methods, general anaesthesia is usually necessary in order to thoroughly do the operation. The variety or stage of the disease modifies the character of the operation, and affects, to a considerable extent, the ultimate result. The most highly satisfactory cures are obtained in follicular trachoma. There is one point still unsettled: that is, whether or no better results are secured, when these operations are finished, by rubbing the lids with a corrosive sublimate solution.
I have employed both methods, and think I have gained quicker results by cleansing (but not rubbing) the lids with bichloride. In this connection let me state that I have had very favorable results with “grattage” alone, using a small, stiff brush and the bichloride, 1 to 1000, as advised by Darier, Von Hippel, and others.
One of the unpleasant complications of trachoma is blepharospasm. I have relieved two cases of this condition by stretching the orbicularis with lid-retractors. This operation was first brought to my notice through am article by Dr. Allport. The lids are held widely open for five minutes, and the operation repeated on another day if necessary.
If one subject more than mother has occupied the thought of ophthalmologists during the past few years, it has been that regarding the normal and abnormal conditions of the external ocular muscles. Dr. Harold Wilson will bring before you this subject, so that there is only one point which is pertinent to this paper. Is surgical interference necessary in heterophoria? The vast majority of oculists now answer this in the affirmative for some cases; still there are those yet who have not got their eyes or ideas straight regarding it. I care not for your theories; experience has demonstrated beyond the shadow of a doubt that tenotomy, either complete or partial, is the only means which will permanently cure many cases.
Neither do I think it wise to spend much time discussing whether a complete or graduated tenotomy is the better surgery. I start in with a partial tenotomy; I often end the operation by making it complete. The fact is, when I accomplish factly what I want, I do not quarrel with the method. I hardly see how I could get along without both operations. In some cases of esophoria and exophoria, a graduated tenotomy has proven entirely inadequate; while in slight degrees of heterophoria, especially hyperphoria, it has given just the result I desired. In a few cases where, twenty-four, hours after the operation, the eye had returned to the same relative position as before the tenotomy, I have permanently improved their condition from one-half to one degree by carefully passing the Stevens book into the wound and simply re-opening it.
No haemorrhage occurs, and the healing process is only temporarily interfered with. Two years ago, Dr. Winslow stated that tenotomies changed the corneal curvature. Since that time I have tested, with Javal’s ophthalmometer, a great many cornea after the operation, and only in one case have I been able to verify his experience. Dr. Swan M. Burnett has also been searching for this complication, but writes that he has been unable to discover it. In the January number of the Archives of Ophthalmology, Dr. Eugene Smith presents a new method of performing tenotomy.
He raises the muscle well up from the sclerotic with peculiar ring-shaped forceps, and then passes a De Wecker stop keratome through the conjunctiva and centre of tendon, close to its attachment. The only advantage over Dr. Stevens’s operation is that less haemorrhage occurs. I have not performed the operation, but should fear that there would be some danger of passing the lance-shaped keratome into the sclera.
A few rules have saved to guide me in my surgical work for heterophoria:.
First.-Carefully, repeatedly, and by various methods, test the muscles before deciding upon an operation.
Second.-Correct any existing ametropia and try other plans of treatment first.
Third.-Be reasonably sure that the defect is symptoms- producing.
Fourth.-Be over-careful to do too little rather than too much.
My experience has been that tenotomy for heterophoria, if skilfully performed upon carefully selected cases, gives more uniformly definite results than any other operation in ophthalmic surgery.
Closely allied to the surgical work for heterophoria are the operations for strabismus. Nothing markedly new has been presented in this field. Dr. Wray has suggested the introduction of a central suture in advancement operations to take the strain off of the supra and infra-corneal sutures. Briefly, his method is as follows: One end of the suture is secured to the stump of the tendon near the cornea; the other is passed well back so as to transfix from within out of the muscle and conjunctiva.
Over this end of the suture is passed a perforated shot, and the amount of traction regulated by means of it. It seems as though this would unnecessarily complicate the operation and annoy the patient. I am securing uniformly good results in advancement by using Dr. C. H. Beard’s single pulley suture. More perfectly than by any other operation which I have employed has this method advanced the muscle in the direct line of its axis.
It has been a reproach upon opthalmology that so little has been accomplished in removing defects, in the shape or transparency of the cornea. Transplantation of the cornea has almost inevitably proven a failure. Galvanism for slight leucoma is far from satisfactory. Dr. Knapp has lately introduced a new operation for kerato-conus, which I think is destined to be quite generally employed in treating this deformity. By means of an oval-tipped electrode he cauterizes the apex of the kerato-conus.
Considerable reaction follows, but all of his six cases reported were ultimately somewhat improved. The advantage of a cautery in ulcerations is being more and more appreciated. I use in my office the Edison current for this purpose, and find that some of the worst corneal ulcers heal as by magic after through cauterization. In fact, it is largely displacing Saemisch’s incision. I have several times perforated the cornea, but no bad results have followed.
There are a number of operations which are in an experimental stage yet and of doubtful expediency. Chief among them are optico-ciliary neurotomy, resection of the optic nerve and injection of the bichloride for deep structural changes, such as in choroiditis.
The last, and still the most important, operation in ophthalmology which I shall consider, is senile cataract extraction. This I cannot hope to present in full, but only touch on certain points, which I trust will elicit discussion.
At the present time no question bearing upon this subject is of greater importance than how to deal with immature cataracts. Statistics, such as presented by Dr. W.A. Brailey, show what a small per cent. of cataracts lenses are mature when first examined. In his practice he found only one in seven, excluding congenital, zonular and secondary. Of the immature cataracts, 45 per cent. remained unchanged; 13 per cent. were slightly better; 19 per cent. slightly worse; and 23 per cent. decidedly worse, the interval of re-examination varying from three months to eight years. Dr. A.B. Norton has given us the results of one hundred cases of incipient cataract treated at this office with Homoeopathic remedies.
Forty-two per cent. remained unchanged; 13 per cent. were improved; 26 per cent. were slightly worse; and 19 per cent. were decidedly worse. There is a striking similarity between the results presented by the two surgeons. This goes to show how hard it is to determine just what is nature and what is drug effect. Dr. Risley believes that vision can be improved or maintained in many cases by correcting errors in the refraction and giving attention to the general health. He emphatically states that increased visual power is not due to “the absorption of any opacities already formed in the lens, but to improved conditions of the vitreous, choroid or retina.”.
Admitting that there are cases helped by the Homoeopathic remedy and correcting of the refraction, still there is large class of immature cataracts in which both of these means are out of the question. Sufficient vision remains to go about, but not to engage in the ordinary avocations of life. These are the patients which enlist our sympathy and tax our skill. Waiting for maturation of the cataract may mean broken-down health, or poverty, or both. What can be done? Two active courses can be pursued:.
First.-Remove the immature lens as it is.
Second.-Artificially mature it and then remove it.
For myself, I prefer the first plan as involving less risk. This can be accomplished by two methods, each with a variety of modification. The one feature which distinctly distinguishes one from the other is whether or not injections are made into the anterior chamber. Dr. Tweedy dose not use injections, but performs an iridectomy and makes a peripheral opening in the capsule with the Grafe knife. He claims that such a capsulotomy keeps the particles of lens substance, which cannot be removed, from coming in contact with the iris. Some surgeons, however, remove a piece of the anterior capsule, and others make a point of doing a preliminary iridectomy.
The method of making intra- ocular injections is rapidly gaining ground. McKeown, De Wecker, Panus, Knapp, Lippincott, and many others, are employing it to a considerable extent. A variety of instruments has been devised for this purpose and a number of different solutions tried. McKeown has used simply distilled water in 70 per cent. and Panus’s solution in 30 per cent. of his cases. De Wecker injects a weak solution, and Knapp a one-half per cent. boracic acid solution, and Knapp a one-half per cent. of sodium chloride.
The bichloride of mercury is not now used because of the discovered danger to the cornea. I have employed injections ten times. If the lens is very immature, as it was n six cases, I do an iridectomy; otherwise not. I make a free laceration of the anterior capsule and inject a warm I per cent. sterile boracic acid solution. I have not had a single had result.
In two cases V = 20/20. A sharp attack of iritis followed in one case, but was controlled, and useful vision resulted. I employ a one-half ounce hypodermic syringe with a sterling silver tip, and never use the same tip on more than one case. A point made by Knapp is not to be overlooked; that is, to introduce the nozzle within the corneal section, so that the liquid will run from within out. This is disregarded by some, but it seems to me that there is an element of danger in washing septic matter into the wound.