A System of Operative Surgery, Volume 4 (of 4)

by Unknown

Fig. 130. Tenotomy. Showing the method of holding the scissors and the position of the hands.

First step. The speculum is inserted and the patient is made to look away from the muscle to be divided. The conjunctiva is freely divided vertically with scissors directly over the insertion of the tendon into the globe (see Fig. 130) and dissected backwards.

Fig. 131. Tenotomy by the Open Method. The tendon is first button-holed about its centre and the expansions are then divided upwards and downwards to the required extent.

Second step. The tendon of the muscle is then seized with fixation forceps and button-holed about its centre as close to the globe as possible (Fig. 131). The lower blade of the scissors is then passed through the hole in the tendon, and the rest of the tendon and its expansions are divided upwards and downwards to the extent required to bring the eye straight as tested by its appearance or by the Maddox rod test. The strabismus hook may be inserted, both upwards and downwards, to see that the tendon is properly divided, but all pulling on the muscle with a hook should be avoided, as it is painful and disturbs the muscular equilibrium. The conjunctiva is then brought together with a fine silk suture. If the squint be over-corrected by the tenotomy, a deep hold should be taken with the stitch so as to draw the eye back into position.

2. By the subconjunctival method. This is unsatisfactory in that accurate adjustment by division of the expansion of Tenon’s capsule is not possible. It is painful, and is sometimes followed by a troublesome hæmorrhage into the capsule of Tenon. Occasionally it may be of use in some cases of amblyopic eyes where a small wound is desirable. The conjunctiva is button-holed below the tendon, and separated from the surface of the muscle. The capsule of Tenon is then opened below the tendon, a strabismus hook is passed through the opening with its concavity against the globe, and is then rotated upwards beneath the tendon, which is subsequently divided between the hook and the globe.

Complications. These may be immediate or remote.

Immediate. 1. Hæmorrhage into the capsule of Tenon, leading to intense proptosis, only occurs when the subconjunctival method is adopted. As a rule the hæmorrhage ceases on the application of pressure, but occasionally it may be necessary to open up the wound and turn out the blood-clot.

2. Perforation of the globe has been known to occur during the division of a tendon in an obstreperous patient. It should be treated as a wound of the sclerotic (see [p. 235]).