the conjunctiva is closed by a suture.
It is desirable to slightly stretch the muscle that is to be brought
forward in both the above operations while the eye is rolled towards the
opposite side with forceps. Further, as I always operate under
chloroform, I dispense with the usual test of the immediate effect of
the operation; such tests have no value before the effects of the
narcotic have completely disappeared, and one must be sure in the way
above described that no single fibres are left undivided. I lay special
stress on the fact that the operation is so performed, that it is able
to bring about the desired mechanical effect.
The immediate mechanical effects of simple tenotomy may be easily
deduced; the divided muscle retracts as far as its elasticity and its
relations with the surrounding tissues permit. With reference to the
internal and external rectus with which strabotomy specially has to do,
those relations come principally under observation which the front part
of the muscle enters into with the conjunctival tissues; the greater the
extent to which we loosen these relations, the farther the muscle can
retract. If it is a question of obtaining a greater effect, I am
accustomed to loosen the subconjunctival tissue at the front part of the
muscle behind the lachrymal caruncle to a greater extent--this offers
the additional advantage that the distorting sinking in of the caruncle
is avoided.
By dividing one rectus its antagonist gains in proportion and rolls the
eye towards it as far as its own elastic tension and the powers still
present on the other side permit. The improvement in position which we
strive to obtain is brought about by the elastic power of the
antagonist, and not by the tenotomy itself, and it is seen by this then,
that the term strabotomy simply, does not quite express the
circumstances of the case. Tenotomy is nothing more than the means for
procuring a preponderance of the elastic power of the antagonist,
therefore the effect attainable on the position of the eye does not
depend solely on the division of the muscle, but to a great extent on
the elasticity of the antagonist, and may be nullified at once, if the
antagonist does not perform what we expect from it, and that may happen
without our being able to foresee it. For example:
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