Ophthalmic surgery; a handbook of the surgical operations on the eyeball and its appendages as practiced at the clinic of Prof. Hofrat Fuchs

Front matter

MICHEI LOUTFALLAH

THE LIBRARY

OF

Preface

THE forelying volume is based on the lectures which for years I have given during the courses in Ophthalmic Surgery at the Clinic of Professor Fuchs, in Vienna. Among the numerous visiting physicians who have attended these lectures, many have come from English-speaking countries, and it is in pursuance of their oftexpressed wish that this publication has been made.

In consecutive chapters there are described in detail and pictured the most important ophthalmic operations, as they are performed at the Clinic of my Chief, Hofrat Fuchs. Under his valuable guidance, my clinical education and cultivation have been acquired, and a large part of the operative procedures herein set forth I have learned from him personally. Although presented under the names of their originators, many of the operations are described with the modifications and improvements which the very extensive experience in our Clinic has gradually led us to adopt as the best routine practice. Some of the methods, however, are essentially my own: for example, the extirpation of the tear-sac. Had I not been much pressed for time, these would have been published years ago. As it is, I now for the first time publicly present them in this book.

I take this opportunity of acknowledging my indebtedness to Dr. M. Sachs, the former first assistant of the Clinic, to whose staff I was attached as a beginner in ophthalmology. To him I offer assurance of warmest thanks and sincere devotion. The drawings for the illustrations are from the skillful hand of Wenzel, who gave himself to his difficult labor with great earnestness and artistic care. To Dr. William M. Sweet my thanks are due for his friendly counsel and aid in effecting the publication of my work. I also desire to record my appreciation of the faithful and scholarly assistance of Dr. Walter L. Pyle, in reviewing the English translation of my manuscript.

JOSEF MELLER.

Vienna, June, 1908.

v

CHAPTER I. EXTIRPATION OF THE LACHRYMAL SAC i

Topographical anatomy of the lachrymal-sac region; the anterior lachrymal crest and the internal canthal ligament; the most important landmarks for the finding of the sac; incision through skin and superficial fascia; insertion of Mueller's speculum; division of the muscle; clearing of the deep fascia; incision of the deep fascia along side of the crest; peeling of the sac from its capsule: first along the lateral wall with division of the lachrymal canaliculi, then along the median wall, and finally dissection of the apex and resection of the sac from the duct ; curettement of the duct, suture and pressure -dressing; healing by first intention; retention of secretion.

Chapter II. Extirpation Of The Lachrymal Sac. (continued.) 15

Anesthesia and anemia of the field of operation; importance of deep injections; the operation is bloodless and painless; difficulty of operation; direction of the dissection toward the bone; injury of the fascia; fultility of curettement for removal of retained particles of the sac; formation of fistula; necessity of a second dissection of the remnants of the sac; dilatation of the sac; tuberculosis of the sac; treatment of acute dacryocystitis; indications for extirpation of the lachrymal sac.

Chapter III. Excision Of The Palpebral Lachrymal Gland 22

Indications; section of the excretory ducts of the orbital gland; preservation of the tarso-orbital fascia; no danger of a drying of the conjunctiva; probing; course of the lachrymal canaliculi; dilatation with the conical probe; production of a false passage; slitting the canaliculus for the purpose of passing probes is not to be recommended; indications for slitting; treatment of beginning ectropion; slitting with the aid of Weber's knife; introduction of Bowman's probe; lavage of the sac with fluids inducing anesthesia and anemia; Ariel's syringe; probing through the upper lachrymal duct; probing in newborn children; indications for probing; causes of epiphora; hollow probes.

Chapter IV. Trichiasis-operations 32

Typical methods; method of Anagnostakis (Hotz); modifications of this method; shaving of the tarsus; rolling forward of the thinned tarsus by the sutures; fixation of the suture at the upper edge of the tar-

vii viii CONTENTS.

sus; advantages and disadvantages of the operation; importance of the incision in the intermarginal border; method of Panas; division of tarsus and conjunctiva near the margin of the lid; fixation of the suture in the tarsus near the margin of the wound; advantage of the operation: radical cure of the trichiasis; disadvantages: shortening of the upper lid; danger of necrosis; operation of Spencer Watson for partial trichiasis; atypical operations; transplantation of the mucous membrane of the lip; the outer skin must not be employed for this, electrolytic epilation.

Chapter V. Ectropion -operations 42

Spastic ectropion: Snellen's suture; senile ectropion: combination of the methods of Kuhnt and Szymanowski; shortening of the tarsus and skin of the lid; the intermarginal incision; measurement of the piece of tarsus to be excised; shape of the piece of skin to be excised; three sutures through the tarsus; displacement of the skin outward with simultaneous slight elevation; necessity of a dressing over both eyes; advantages of the operation; paralytic ectropion: tarsorrhaphy; cicatricial ectropion; plastic operations; use of sutures; employment of flaps with pedicles; advantage of flaps without pedicles; technic of transplantation of flaps without pedicles; production of a wound-surface of as great a size as possible; manner of preparation from the skin of the arm; the most perfect adaptation possible; after-treatment.

Chapter VI. Operations For Spastic Entropion 58

Gaillard's suture; excision of an obliquely oval piece of skin; shortening of the skin in a perpendicular direction; Graefe's entropion -operation; shortening of the skin in an oblique direction; canthoplasty; Ammon's operation; provisional canthoplasty; indications; Kuhnt's canthoplasty: formation of a skin -flap; tarsorrhaphy; indications; method of Fuchs; advantage of the growing together of planes; tarsorrhaphy as a cosmetic operation; total closure of the palpebral fissure; median tarsorrhaphy; preservation of the lachrymal canaliculi and the internal canthus; method of Arlt.

CHAPTER VII. PlOSIS-OPERATIONS 71

Method of Hess; undermining of the skin of the lid; production of a union with the tfrontalis muscle; moist chamber for two to three weeks; good result; indications; Pagenstecher's suture; operation of Everbusch; advancement of the levator palpebrae; topographical anatomy of the field of operation; preparation of the muscle; shortening of the muscle ; indications ; advantages and disadvantages of the method ; Panas's operation for ptosis is not to be recommended for cosmetic reasons; Motais' method.

Chapter VIII. Strabismus-operations 84

The technic of tenotomy; grasping of the tendon-insertion with forceps; the technic of advancement; application of loop-sutures; shortening of the muscle; suturing of the muscle to the sclera near the limbus; technic of the suture through the sclera; fixation

CONTENTS. IX

of the muscle to the conjunctiva alone is insufficient; application of the strabismus-operations; how much correction does tenotomy produce; the assisting suture; its indications; the counteracting suture; its application; how much does advancement correct?; importance of suturing forward to the limbus; allowance of the immediate result of advancement; incalculable action of tenotomy and advancement, when performed at the same time; the advancement is the physiologically more valuable operation; under-correction in convergent strabismus; over-correction in divergent strabismus; operation of cases of convergent strabismus of slight degree (to 15 degrees); medium degree (to 30 degrees); high degree (over 30 degrees); difference in the value of tenotomy and advancement of the internal rectus in proportion to the same operation on the external rectus; simultaneous performance of advancement of the internal rectus and tenotomy of the external rectus in divergent strabismus; assisting suture for the operation of divergent strabismus; advancement of the internal rectus after tenotomy; unpleasant results of tenotomy; operation in exophoria; operation for paralytic strabismus; value of strabismus-operations almost only cosmetic; time to perform the operation.

Chapter IX. Kmvi.eatiox Of The Eyeball And Allied Operations 103

Technic of enucleation; performance of the operation under cocain-anesthesia; necessity of preserving the conjunctiva; resection of the optic nerve; hemorrhage; indications for enucleation; procedure in panophthalmitis; evisceration of the bulb; optico-ciliary neurotomy; compensatory operation for enucleation; indications; immediate compression after resection of the optic nerve; exenteratio orbits; indications and technic of the operation; subperiosteal preparation.

Chapter X. Plastic Operations 115

Plastic lid -operations having a pedicle; method of Fricke; to prevent recurrence of epitheliomas the operation must be performed at leas! '. cm. beyond the visible margin of the tumor; disadvantage of Dieffenbach's method; Buedinger's ear-cartilage method; shaving down and thinning of the ear-cartilage; attachment of the skin-ear-cartilage flap to the lid-flaps; protection of cornea through the drawn-down upper lid; difficulties in replacing an entire upper lid; operations for symblepharon; sutures; pediculated flaps from the surrounding conjunctiva; non-pediculated flaps from the conjunctival fornix; futility of grafting of rabbit conjunctiva; both wound -surfaces should be covered; employment of skin-flaps from the surrounding tissue with pedicles; method of Rogman; combination of it with a plastic operation of the conjunctiva; employment of cutaneous flaps without pedicles; formation of conjunctival sacs to enable the wearing of protheses.

Chapter XI. Operation For Senile Cataract 124

Technic of the individual steps; fixation of the eye; use of the right and left hand; avoidance of the slightest pressure on the eyeball "with the forceps; grasping of the conjunctival fold in the vertical meridian; technique of position; position of the incision; discussion

X CONTENTS.

of the relative position of the limbus and the angle of the chamber; after perforation of the anterior chamber the knife must neither be pulled back nor checked in its advance; turning of the knife beneath the conjunctiva; iridectomy; use of Wecker's scissors; opening of the anterior lens-capsule; the capsule-forceps and its use; a large piece of the anterior capsule must be pulled out; use of the cystotome; advantage of the capsule-forceps; expression of the cataract; delivery of the cortical substance; toilet of the eye; reposition of the iris; management of the spatula; proper position of the conjunctival flap.

Chapter XII. Operation For Senile Cataract. (continued.) 140

Discussion of complications and mistakes; other remarks; tearing out of conjunctiva; fixation of the eye to a muscle -attachment; corneal incision; scleral incision; disadvantage of both; length of the incision; too short an incision; direction of the incision; intralamellar incision; method of holding the knife; use of the right and left hand; hemorrhage in iridectomy; the eye should be fixed only during the incision; production of iridodyalisis; the iris falls against the knife; bridge-coloboma; indication for the use of the cystotome; procedure when the anterior lens-capsule is markedly tense or is thickened; extraction of the lens in the capsule; causes which prevent the delivery of the lens: too short an incision; resistance of the sphincter; the anterior capsule is not opened; dislocation of the lens; diminution in size of the lens-nucleus; prolapse of vitreous; Weber's loop; Reisiger's hook; symptoms of the approaching or beginning vitreous prolapse; pouring out of fluid vitreous; luxation of the lens into the vitreous; corneal collapse; expulsive hemorrhage; extraction without iridectomy; advantages and disadvantages; indications; excision of the prolapse.

Chapter XIII. Operations On The Soft, Transparent Or Cataractous Lens 159

Discission per corneam; crucial incision into the anterior lens-capsule; attention to prevent injuring the posterior capsule; discission of the transparent lens in myopia operations; production of traumatic cataract; puncture to remove the swollen lens-masses; procedure to prevent increase in tension; indications for myopia -ope rations; their value; discission of partial cataracts; procedure in perinuclear cataract; viscual acuity by narrow and wide pupil; discission or optical iridectomy; technique of the latter; pre-corneal iridotomy; other indications for optical iridectomy; estimation of the probable value of an optical iridectomy in corneal opacities; movable stenopaeic slit or fissure; dilatation of the pupil for purposes of examination; provisional tattooing of the cornea; successes of optical iridectomy; discission of completely dimmed lenses; operation for complete congenital cataract; advantage of discission as compared with linear extraction in small children.

Chapter XIV. Operations For Soft Cataract And Secondary Cataracts 169

Discission per corneam in operation for secondary cataract; injury of the vitreous; necessity of dilatation of the pupil by atropin; laceration in the iris-attachment; transient depression of the membrane into the vitreous; Bowman's discission; capsulotomy and iridotomy in com-

CONTENTS. XI

plicated secondary cataract; scar-formation after extraction during iridocylitis; use of Graefe's knife for the incision; importance of an immediate pressure -dressing to prevent hemorrhage; direction of the incision; advantages of this method of operation; discission per scleram; technique of the operation; advantage as compared with discission per corneam; unpleasant complications: glaucoma; cyclitis; linear extraction; upper limit of age thirty-five years; technic of the operation; extraction of the soft lens-masses by massage; enlargement of the incision laterally in the presence of a large nucleus; careful treatment of the iris; extraction of the lens with the capsule; prolapse of vitreous; suture.

Chapter XV. Operations For Glaucoma 180

Iridectomy in glaucoma; technic of the individual steps; incision; relative position of angle of chamber and limbus; the incision with the lancet; beginning of incision i£ mm. behind the limbus; fixation of the eye in the vertical meridian; change of position of the lancet into the plane of the iris; direction and length of incision; difficulty of the lancet-incision; the lancet must be pulled out slowly; the incision with Graefe's knife; indications; advantages of the incision with the lancet; the incision with the knife is less dangerous; difference between this iris-operation and the iridectomy in cataract-operations; difficulty of reposition; indications for iridectomy; complications during the operation; tearing out of the conjunctiva; intralamellar incision; impaling of the iris; production of iridodyalisis during the incision with the lancet; injury of the lens; incorrect position of the incision; anesthesia of the iris before operation; caution during the use of the iris-forceps because of possible injury of the lens-capsule; iridectomy at the lower part of the iris; hemorrhage during the operation; importance of reposition ; liberation of a part of the iris held into the wound ; prolapse of the vitreous; expulsive hemorrhage.

Chapter XVI. Operations For Glaucoma. (continued.) 193

Complications of iridectomy for glaucoma; subluxation of the lens;. formation of a cataract; injury of the lens-capsule produced by the operator; spontaneous rupture of the lens-capsule; rupture of the capsule at the lens-equator; spontaneous emersion of the lens from the eye; technic of cyclodyalisis after Heine; liberation of the ciliary body from the sclera; avoiding injury of the anterior ciliary veins and the ciliary body; no danger of iridodyalisis after an injury to the canal of Schlemm; pressure-dressing if hemorrhage is started; the operation certainly does not act only because of the puncture; diminution of tension within a few days; value of cyclodyalisis; operations for secondary glaucoma; puncture of the cornea; technique of the operation; prevention of the loss of aqueous humor during the incision; repetition of the puncture; prolongation of the incision to remove masses of lens-matter; difficulty of performing iridectomy in secondary glaucoma; procedure in subluxation and luxation of the lens; transfixion; anterior sclerotomy; incision of the angle of the chamber; iridodyalisis; results of the operation; indications; posterior sclerotomy; incision at the meridian; no filtration -scar; results and indications.

\ii CONTENTS.

Chapter XVII

OPERATIONS FOR PROLAPSE OF THE IRIS AND ITS SEQUELA: ANTERIOR SYNECHIA; ECTASIA OF THE SCAR, ETC., CORNEAL AND CONJUNCTIVAL

PLASTIC OPERATIONS 209

Every prolapse must be excised; technic of excision; removal of the fibrous layer; liberation of the prolapse with the conical probe; drawing the iris forward; amputation at the edge of wound; reposition of the portion of the iris; resection in perforation of ulcers; difficulties of the operation; healing of the perforation opening; if prolapse is too large, it must not be excised; iridectomy when considerable of the iris is healed in the wound; serpigineous ulcer in the stage of scarification and in glaucoma; plastic operations on conjunctiva; development of the operation through Kuhnt; flaps with a pedicle cover the defect; de Wecker's procedure to cover corneal defects; prolapse of the ciliary body or chorioid; application of the scleral suture; procedure by prolapse existing for some time; iridectomy and pressure dressing to flatten the recent scar; cutting off of the scar and excision of the iris.

Chapter XVIII. Corneal Operations 216

Fuchs' corneal transplantation to replace ectatic and fistulous scar-tissue in the cornea; technic of the operation; keratoplasty; v. Hippel's partial keratoplasty; total keratoplasty; worthlessness of the operation from the optic standpoint; Hippel's trephine; indications for the keratoplastic restoration of corneal scars; general indications for operative procedures, particularly in anterior synechia; Sach's temporary scarresection; technique of the operation; injury of the lens-capsule when it heals in the corneal scar; liberation of a portion of the iris healed in the scar; procedure for cystic scars after iridectomy for glaucoma.,

Chapter XIX

EXTRACTION OF FOREIGN BODIES FROM THE INTERIOR OF THE EYEBALL. 222 Difficulty of the operation; diagnosis of intra -ocular foreign bodies; importance of examination of the posterior portion of the eyeball with the ophthalmoscope; sideroscopic examination; Roentgen examination; deference to small wounds or scars; technic of extraction with the giant magnet; advancement of the foreign body from the vitreous to the anterior chamber; extraction of a foreign body from the anterior chamber; use of Hirschberg's magnet; extraction of an iron splinter through the sclera; indications; prognosis of injuries from iron-splinters; extraction of particles other than those of iron; opening of the eyeball through a long scleral incision; marked facilitation of the operation through the lamp of Sachs; procedure in old injuries.

Chapter XX

VARIOUS MINOR OPERATIONS. REMARKS CONCERNING ANESTHESIA AND

ASSISTANCE 230

Operative treatment of serpigineous ulcer; subconjunctival injections; cauterization of an ulcer; puncture of the anterior chamber; Saemisch's operation; frequent repetition of the incision; iridectomy to prevent glaucoma; operations for pterygium; transplantation; Arlt's method; tattooing of the cornea; indications; prickling with a multiple needle;

CONTENTS. Xlll

use of the hollow needle; Froehlich's method of tattooing; operations for corneal staphyloma; method of Beer; method of de Wecker; possibility of sympathetic ophthalmia; squeezing trachoma-granules from the conjunctiva; roller-forceps of Knapp; expression by Kuhnt's method; concerning assistance; the lid-speculum is an instrument which endangers the eyes; Mueller's lid-speculum; help rendered by the assistant during the cataract -operation; Desmarres' spoon; downward guiding of the upper lid with the assistance of inserted instruments; operation without fixation-forceps; sponging; other aid which the assistant may render; anesthesia; advantage of local anesthesia; disadvantage of general anesthesia; use of adrenalin; preference given cocain over its various substitutes; dropping cocain on the bared iris; scopolamin-morphin-narcosis; its advantages; Fuchs' wire-shield; Snellen's cup-shield.

IXDEX 245

OPHTHALMIC SURGERY.

Chapter I. The Lachrymal Apparatus

EXCISION OF THE LACHRYMAL SAC.

Anatomy. — Before beginning the operation it is necessary to understand the relative position of the internal palpebral ligament and the anterior lachrymal crest. By placing the finger against the outer canthus and stretching both lids slightly outward in a horizontal direction, the ligament is seen at the inner part of the eye as a slightly circumscribed prominent cord immediately beneath the skin. This ligament is Y-shaped, has a horizontal part, which takes its origin from the bone, whereas the two branches of the Y are continuous with the tarsal parts of the eyelids, in this way fastening them to the bone. The lachrymal sac lies behind this so-called tendo oculi in such a manner that the top of the sac is on the level of the horizontal portion of the tendon, the sac itself extending downward from it for its entire length.

The anterior lachrymal crest is the most important landmark throughout the operation. In thin individuals it may at times be seen through the skin; in all other cases it may be found easily by permitting the finger to glide along the lower orbital edge in a direction upward and inward. In some instances it is prominent, forming a sharp border; in others, it is flat and may then be felt much better by sliding the closed forceps from the side of the nose to the inner wall of the orbit. At times it is relatively superficial; at others, much deeper. At a point where the crest forms a part of the lower bony orbital margin, it is always very prominent; its upper half, however, is usually quite flat. All these circumstances are of considerable importance in the performance of the operation. The more superficial the crest, the more readily it is reached, and the easier is the extirpation of the sac; the deeper the crest, the more difficult the operation.

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, and this will be discussed as the various stages of the operation are described.

In the dissection of the structures we commence the incision through the skin, beginning at a point 2 mm. above the ligament of the internal canthus and 3 mm. to the inner side of the canthus. The direction of this incision is downward and in its lower half curved slightly outward, whereas the upper half has to be perpendicular (Fig. i). If, for instance, the upper half of the cut is not straight, but

FIG. i. — 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.

curved towards 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 position of the crest, we must not pull the lids outward with the idea of making the skin tense. This would prevent the incision from being made at the desired point. 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 against the skin will indicate the direction of the incision, and then to deepen it more readily, the skin may still be stretched.

The length of the incision is not of much importance. The beginner should make a long incision (about if cm.), as this facilitates the dissection of the sac. The expert operator usually prefers a short incision. The length of the cut varies, therefore, from i cm. to if cm. The further from the external canthus the incision is made, the more difficult becomes the dissection of the sac on account of the increasing distance from it.

After completing the cut, the edges of the incision are lifted up and dissected from the underlying tissue with the scalpel turned toward the canthus, so the wound may be readily opened and the tearsac speculum (Miiller's) introduced without difficulty. This instrument is of great advantage, as it takes the place of an assistant and, by compressing the surrounding tissues, aids materially in hemostasis. The speculum is introduced closed, and to insert the hooks properly, the wound edges must first be lifted gently with forceps. Its handle is turned downward and slightly outward. The patient must keep his eyelids closed throughout the entire operation. It is, of course, necessary during the introduction of the instrument to fasten the hooks securely into the wound edges, so that no injury of the cornea be produced by any sudden jerking loose; since even an erosion might become dangerous because of the great liability of infection.

In the wound, pulled open with the aid of the speculum, is laid bare a delicate, thin, white membrane, the superficial fascia. Frequently this is considerably thickened in the direction of the palpebral fissure throwgh layers of connective-tissue fibers, some of which are connected 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.

In place of the scalpel, with which the main incision was made, we now employ a small, slightly curved pair of scissors, both blades of which are pointed and with these the operation is completed. With tooth forceps we pick up a fold of the superficial fascia, transfix it with one blade of the scissors and slit it throughout the entire length of the wound, pushing it back toward both margins of the same. We thus expose a layer of red fibers, the orbicularis muscle (palpebral portion), the fibers of which, as is known, arise from the internal palpebral ligament.

The muscle is slit up in the same manner as the superficial fascia and the fibres pushed back toward both sides with the closed scissors. We now expose to view in the floor of the operative wound a dense white membrane, the deep fascia, which covers the lachrymal sac (Fig. 2). This extends from the anterior to the posterior lachrymal crest and bridges over the fossa containing the lachrymal sac. 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

FIG. 2. — 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 them the anterior lachrymal crest (cr. a.) can always be felt and can usually be seen.

which separates the lachrymal fossa from the orbit. The specially thickened median portions of this fascia form a prominent dense cord which

has already been referred to as internal canthal ligament.

i

The fibers visible at this point may also 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 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 ligaments. 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 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; on the other hand keep from going in the wrong direction from the sac toward the orbit.

The deep jascia has to be split now with the scissors, inserting (he scissors to the outer side of the anterior lachrymal crest, 1-2 mm. behind it. This is not easy, particularly on the cadaver, if we wish to escape injuring the sac. One difficulty is that no fold of tissue can be picked up for transfixion by the scissors, as the fascia is very tense. We are, therefore, forced to perforate the layer with one of the points of the scissors, holding the instrument almost parallel to the plane of the fascia. It is our custom to make the cut through the fascia 1-2 mm. behind the crest, and not, as done by others, right on the crest, so as to make the following dissection of the lateral wall easier.

As the sac lies near the fascia, its anterior wall may be injured by cutting too brusquely. This is particularly true on the cadaver, when the sac is not diseased and the walls are therefore thin and made friable through beginning decomposition. For purposes of demonstration (it may also be done with the best of success at operations), it is as well to slit the fascia along its entire length with a narrow, pointed knife (Graefe's linear knife), holding it obliquely with the cutting surface forward. I myself prefer to use the scissors for this cut. The danger of injuring the tearsac can be diminished by drawing away the fascia from it, by taking the ligament with the forceps and pulling it outward and forward. Moreover, the sac being thickened in the patient, the danger of injuring it is reduced to a minimum. However, the operator should begin with a very short cut through the fascia so that even in case the sac is injured, its perforation need not be extensive.

This cut must be completed through the whole length of the membrane, and severs the ligament of the canthus at the same time. In the slitlike opening thus produced may be seen the lachrymal sac, readily distinguished because of its bluish color (Fig. 3). 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.

The remainder of the operation consists in peeling the sac out of

FIG. 3. — The deep fascia is incised throughout the entire length of the wound i 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 preserved, is cut through at the same time.

its coverings. From now on, the operator must constantly keep close to the wall of the sac, but must not injure the fascia or cut it away at the same time. There are no blood vessels of note in the loose tissue connecting the sac with its fascial capsule, and, therefore, during the dissecting there will be no annoying hemorrhage.

It is my usual 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 the delicate connective-tissue

THE LACHRYMAL APPARATUS.

fibers which connect the sac with the lateral wall of the fascia, beginning in the lower half of the wound and using for the purpose the edge of the closed scissors (Fig. 4). With a few strokes the lateral wall is separated back to the bone.

It is only when reaching the upper part that a disturbing factor is met. There is seen a bluish cord going to the lid, the lachrymal ducts.

FK;. 4. — 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.