Ophthalmic surgery / by J. F. Streatfield.

  • Streatfied, J. F.
Date:
[1872]
Catalogue details

Licence: Public Domain Mark

Credit: Ophthalmic surgery / by J. F. Streatfield. Source: Wellcome Collection.

Provider: This material has been provided by UCL Library Services. The original may be consulted at UCL (University College London)

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    it may quite safely be done in any case, even if only temporarily, required ; for, if it do no good afterwards, it does no harm, and the imperfection of the punctum seems to be of no more serious importance than is that of the pupil- lary aperture after an iridectomy that was needed and then done. As the lower lid is of the two the most subject to ectropion, so also it seems that the lower punctum is the more frequently everted, obstructed, or obliterated. Gravity is perhaps concerned in both. The Surgeon's attention is seldom called to the upper punctum ; if it be too small, altogether absent, or abnor- mally placed, perhaps he is not called on to discover the fact; but, on exami- nation, the punctum is generally found to be in right position and patent, and yet insufiicient to prevent lacrymation when the lower punctum, to which the tears gravitate, is not fit to receive them, or the canaliculus and nasal duct to convey them away. If the lower punctum be so much everted that for any length of time it is dried, it probably becomes narrowed, and would not carry away the tears, even if the ectropion were remedied and the ptmctum again moistened. Operation.—The patient is seated in a chair, in a good light, with his head thrown back, a towel over it, and resting on the chest of the operator, who is standing behind him. A finger or the thumb of the left hand is placed lightly on the lower and outer part of the skin of the lower lid, which is di-awn forcibly down and outwards, and fixed by pressure on the malar bone sufficient to over- come the force of the orbicularis. If the punctum be not everted, so that it may be fairly seen, it is well exposed to view by slight traction wdtli another finger on the skin of the inner part of the lower lid, drawing it downwards a little and fixing it in that position. If the skin of the lower lid be wet with tears or greasy with ointment, it should be first of all wiped dry ; or a corner of the towel may be required to be applied between the fingers and the eyelid. The knife employed is very narrow, and about an inch in length altogether. It ends in a small probe, of about a line in length, with a slightly bulbous extremity, bent somewhat towards the cutting edge (Fig. 452, h). It is held with the probe-point turned down- wards and directed into the punctum; and, when the Surgeon is sure of its being in the right position, some little force may be employed, if necessary, for its passage through the punctum. If the punctum be quite obstructed or disguised, it is well to be as sure as possible that the knife is rightly directed ; if little pits be made in the soft skin or conjunctiva with the probe-end, it is so much the more difficult afterwards to make sure of the real position of the punctum. A minute depression, made oval by traction on the skin of the lid, will be detected in the right anatomical position of the punctum, even if it be P ' quite impervious to the tears. The right position may be a, b, judged of by relaxing for an instant the dragging force, and, Fig 452 — a bathed in tears, it may be wiped dry, and a very Bowman's Probe little quantity of the tears may be detected lying in the natural Duct'^6*^°Webe?s P^* ^r oozing from it. The probe-point being within the CanaiicSus^^^^^^ piuictum, the knife is turned half-round, so that the cutting edge is directed upwards and towards the nose, and the probe- end, which is not in a line with the rest of the instrument, is directed in that which, anatomically, is known to be the direction of the canaliculus. This is then slit up, as far as the probe end will let the knife go, towards the nose, or, at least, well into that part of the palpebral conjunctiva in which the tears