The method of tenotomy as I carry it out is as follows: The conjunctiva
is seized with fine forceps exactly over the insertion of the muscle to
be divided, and the fold thus raised cut into with the smallest possible
wound. Provided we operate on the right spot we enter this opening with
the forceps and immediately seize the tendon close to its insertion on
the sclerotic, which is drawn forwards, as was the conjunctiva, and
loosened with flat, curved scissors, the points of which must be rounded
off. The incision must only be large enough to allow a small hook with a
knob to be inserted through it and behind the insertion of the tendon,
which is now lifted up and divided with fine pointed scissors close to
its insertion into the sclerotic. It is important to make sure that a
few threads coming off from the tendon at the ends of the insertion do
not remain uncut; we can only consider the operation to be complete when
the hook, carried behind the edge of the insertion made clearly visible
by the foregoing proceeding, slides up to the margin of the cornea
without any interruption.
The method of performing advancement is as follows: An incision is made
in the conjunctiva over the tendon of the muscle to be brought forward
and just at the outer bend of the latter, then loosened together with
the subconjunctival tissue to the corneal margin; it is desirable to
carry out this loosening close to the sclerotic, as the flap of the
conjunctiva thus formed must afford sufficient support to the muscle to
be brought forward. Then the capsule of Tenon is cut into at one edge of
the insertion, a flat, curved, blunt hook without a knob is carried
between muscle and sclerotic, and out again at the other edge of the
insertion. We must be careful to get the muscle as clean as possible on
the hook in the whole width of its insertion, that is without the
capsule of Tenon, for the suture put in ought only to enclose the
muscle, without at the same time dragging the capsule of Tenon. For the
suture I always use fine catgut which is provided at both ends with
curved needles; needles of slightly different form may be chosen in
order that the threads may be easily distinguished from one another. A
needle is carried behind the hook from each thread, one through the
upper, the other through the lower edge of the muscle, between it and
the sclerotic, then the thread is tied in a knot on the muscle to make
sure that it does not slip back through the loop of the thread after
its separation from the sclerotic. Then the threads are knotted on the
muscle, and the insertion is separated from the sclerotic. As the edge
of the insertion is now exposed we can see how the land lies, and can
carry the threads exactly in the direction of the muscle under the
conjunctiva to the corneal margin, where they are passed through, and
ends tied in a knot. By this means the muscle is drawn forwards
precisely in its normal direction and stretched tighter. The wound in
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