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.
