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DZOGCHEN TEACHINGS
DZOGCHEN TEACHINGS
Chögyal Namkhai Norbu

Edited by
Jim Valby and Adriano Clemente

Snow Lion Publications

Ithaca, New York • Boulder Colorado
Snow Lion Publications
P. O. Box 6483
Ithaca, NY 485 USA
(607) 273-859
www.snowlionpub.com

Copyright © 2006 Associazione Culturale Communità Dzogchen

IPC – 434EN06 – Approved by the International Publications Committee

of the Dzogchen Community founded by Chögyal Namkhai Norbu.

All rights reserved. No part of this book may be reproduced

without prior written permission from the publisher.

Printed in Canada on acid-free recycled paper.

ISBN-0 -55939-243-6
ISBN-3 978--55939-243-3

Library of Congress Cataloging-in-Publication Data

Namkhai Norbu, 938-

Dzogchen teachings / Chogyal Namkhai Norbu ; edited by Jim Valby
and Adriano Clemente.
p. cm.
ISBN-3: 978--55939-243-3 (alk. paper)
ISBN-0: -55939-243-6 (alk. paper)
. Rdzogs-chen. I. Valby, Jim, 946- . II. Clemente, Adriano. III. Title.
BQ7662.4.N3356 2006
294.3’420423—dc22
2006007689
Contents

Preface 7

Chapter : Discovering Our Real Nature 9

Chapter 2: The Real Condition of All Phenomena 3

Chapter 3: The Difference between Sutra and Tantra 23

Chapter 4: The Meaning of Vajra 33

Chapter 5: Dzogchen—The Path of Self-Liberation 43

Chapter 6: The Base in Dzogchen 53

Chapter 7: Invocation of Samantabhadra 7

Chapter 8: Contemplation in Dzogchen 8

Chapter 9: Introduction and Knowledge in Tregchöd 93

Chapter 0: Dzogchen Longde 0

Chapter : Terma Teachings—Refreshing the Transmission 23

Chapter 2: Yantra Yoga 29

Chapter 3: The Three Sacred Principles 39

Spelling of Tibetan Names and Words 55

Notes 6
Preface

Chögyal Namkhai Norbu’s Dzogchen Teachings is a collection of newly

edited oral teachings originally published in the Mirror, the newspaper
of the international Dzogchen Community established in Italy in 99
by Chögyal Namkhai Norbu Rinpoche. Dzogchen Master Chögyal
Namkhai Norbu was born in 938 in east Tibet, and began teaching in
the West in 976. After having been invited to Rome, Italy in 959 by
the Tibetologist Professor Giuseppe Tucci, Chögyal Namkhai Norbu
became Professor of Oriental Studies at the University of Naples. He
continued in that position from 964 to 993.
For the last twenty-five years, Rinpoche has worked to establish
communities of practitioners throughout the world, and has given nu-
merous public talks as well as over three hundred retreats. This book is a
rich collection of precious teachings given by Rinpoche to his students
in order to benefit their understanding of the Dzogchen tradition and
its value in the modern world.
Dzogchen is the essence of Tibetan Buddhism. Although Dzogchen,
or the path of Total Perfection, is not a religion, tradition, or philoso-
phy, it is, as Chögyal Namkhai Norbu says, “the path of self-liberation

7
 Dzogchen Teachings

that enables one to discover one’s true nature. It is not only the name
of a teaching, but the reality of our true condition, our own totally self-
perfected state. Through the transmission, the teacher gives you meth-
ods for discovering that true condition.”
Through his clear, direct, and precise explanations and instructions,
Master Chögyal Namkhai Norbu makes these profound teachings in
the lineage of Garab Dorje accessible to everyone. Dzogchen Teach-
ings offers an extensive and broad compilation of teachings by a great
Dzogchen master and Tibetan scholar. All the chapters contain benefi-
cial instruction for both beginning and advanced students regardless of
which tradition they may follow, and insights into the genuine meaning
of important subjects related to Sutra, Tantra, and Dzogchen.
This book has been organized according to various topics related to all
aspects of Buddhism and Dzogchen, and although there may be redundan-
cies, the editors felt it was important not to remove anything, as the context
in which they occur is always different. Some statements suitable for a live
teaching situation were removed to maintain literary cohesiveness.
We are pleased to present the vast wisdom and breadth of knowl-
edge found within these pages, and it is the intention of the editors
that the publishing of these teachings to the worldwide community
will benefit those interested in the study and practice of Dzogchen. We
would also like to extend our gratitude to Jim Valby for the final edit-
ing of the original versions, and to Adriano Clemente for ordering the
chapters and writing the footnotes. We also wish to thank Igor Legati
for coordinating the project, and Steven Landsberg for revising the final
draft.

Naomi Zeitz
Managing Editor, The Mirror
www.melong.com

8
 Discovering Our Real Nature 

When we follow a teaching, the main point is that we understand what

the teaching really is, and its purpose. There is something concrete in
the teaching for daily life. What is the use of receiving these teachings
if they are not understood, and we only seek techniques of practice?
Techniques are useful for understanding and as methods for realiza-
tion, but if we go too much after titles, then we have lost the main
point. There are hundreds and thousands of titles and techniques, but
they are all used for the purpose of discovering our real condition. This
is the essential teaching of Buddha, Garab Dorje,2 and all the important
masters.
For example, there are collections of the teachings of Buddha called
the Kangyur and the Tengyur.3 There are hundreds of volumes. We know
that if we are going to study only one sutra or tantra, we need our whole
life to really understand its contents and different teachings. In order
to learn all these books, we would need many lives. When would we
get time to realize? This is our concrete condition. It is relative, and not
really the main point. The main point is what Buddha once said: “I dis-
covered something profound and luminous beyond all concepts. I tried

9
 Dzogchen Teachings

to communicate it with words, but nobody understands. So now I will

meditate alone in the forest.” This verse of Buddha is the conclusion of
the teaching.
The teaching is not a title or book. The teaching is not Sutra or
Tantra or Dzogchen. The teaching is knowledge and understanding for
discovering our real nature. That is all it is; however, it is not easy. That
is why the Buddha explained many kinds of teachings according to dif-
ferent circumstances and the various capacities of beings. Some people
understand and discover what is communicated and how it should
work. However, many people don’t understand, do not have that capac-
ity, and must work in a different way. We must explain in various ways.
That is why there are many kinds of teachings and techniques.
Some people consider that the teaching means not doing anything,
just relaxing, and doing what one feels. That is not the teaching. That
is the continuation of samsara. We are always doing that, but no one
has realized in this way. Some people think that the teaching is judging,
analyzing, thinking, and then establishing a point of view; but this is
not the sense of the teaching, because everything is relative.

DIRECT INTRODUCTION

As there are three ways of communicating related to our three aspects of

existence—the physical body, energy, and mind—similarly, the teaching
is communicated by working on these three levels, which are charac-
teristic of the teaching. For introducing knowledge in Dzogchen we
use direct introduction. This doesn’t mean we are going to a teacher
or a powerful realized being, and we stand in front of that teacher
and get awakened or realized after spending a little time with him
or her.

0
 Discovering Our Real Nature

Many people have this idea, but this is not direct introduction.
Nobody can do that—not even Buddha Shakyamuni. If Buddha
Shakyamuni could do that, why didn’t he do that for all sentient beings
instantly? Why isn’t everybody realized? Buddha has infinite compas-
sion. He is not missing any amount of compassion for doing actions for
others. Buddha is omniscient; he knows the condition of samsara and
suffering, so there would be no reason for him not to do that. But that
is not the way it happens.
Even if there is a fantastic teacher, a realized being, and we receive a
little vibration from that master, we still can’t realize our nature in this
way. If we go to a teacher, the teacher teaches; that is why he or she is
called a teacher. The teacher teaches and does not only sit or meditate.
The teacher teaches us how to get in our real nature—explaining with
words and ordinary language. That is called oral transmission. That’s the
reason why a teacher gives retreats and teachings and explains different
methods and ways of discovering our real nature for hours and hours.
It’s not because the teacher likes to talk. If the teacher did not talk, how
could people understand what the direct transmission means?
The teacher gives examples, and explains using symbols like the
mirror, the crystal, and a peacock’s feather. Using these symbols, we can
understand our real condition and potentiality. With these symbols and
explanations we can have an idea. Once this has been explained, you are
more or less ready to receive direct transmission. In this case, the teacher
gives you instructions of what you must do in order to have direct ex-
perience. It could be that you are doing it together with the teacher,
or that you receive the instructions, apply them, and discover. That is
called direct introduction. It’s important that you understand this.
Sometimes people read Dzogchen books and teachings in which
direct transmission is explained—what Garab Dorje said about it, and


 Dzogchen Teachings

the method of entering our real nature. Some people have the idea that
the teacher can give direct introduction like a gift or an object. They
go to the teacher and ask, “Please give me direct introduction.” And
they think, “Oh, maybe the teacher is not giving direct introduction to
everyone, so if I ask the teacher alone, then he or she will give it only
to me.” This is not true. If teachers could give realization to all sentient
beings, then they always would. The teacher likes it if all sentient beings
are realizing and getting in their real nature, but this is not always easy.
For that reason we need to work and explain one by one, orally and
with symbols, constructing very precise ideas. Then we can go into the
instruction of direct transmission. In this way we can have knowledge
and understanding, and can really have a sense of the teaching. We must
remember that this is the principle. At a retreat lasting many days we
learn various techniques; however, we must remember that the purpose
of all of them is that principle, to discover our real nature, particularly
if we are following the Dzogchen teaching.

2
2 The Real Condition of All Phenomena4

When we speak of Dharma teachings, there are many different forms

and traditions, but the principle is neither the form nor the tradition.
Dharma means “knowledge, understanding.” The term dharma comes
from Sanskrit, and the real meaning is “all phenomena.” That means we
need to have knowledge and understanding of all phenomena.
In general, people say, “We are following Dharma,” and speak of it
as a kind of religion created by Buddha Shakyamuni. That is not a cor-
rect point of view. Buddha never created any kind of school or religion.
Buddha was a totally enlightened being, someone beyond our limited
point of view. The teaching of the Buddha is to have presence in that
knowledge.
If we are interested in Dharma, we are interested in knowledge
and in understanding the real condition of all phenomena. How can we
gain such knowledge? It does not mean we learn in an intellectual way,
merely in the condition of subject and object, judging and considering
things outside us.

3
 Dzogchen Teachings

Generally we have the idea, “I am here. I see these objects in front of

me and I consider that this is good, that is bad.” In this way we perform
many types of analysis through which we develop infinite limitations.
For that reason the Buddha taught from the beginning that we should
not only look outwards, but should observe ourselves a little. Working
in that way, we can discover what the real situation is.
When we speak of the Buddha’s teaching, we speak of three differ-
ent yanas, or vehicles,5 the roots of which are all in the teachings he gave
in his lifetime in India. We can also study how Buddha transmitted this
teaching.

SUFFERING

There is a teaching that is universal to all Buddhists called the Four

Noble Truths.6 This was the first teaching transmitted by Buddha.
Even if we have different methods in the teaching, such as Tantra and
Dzogchen, they are always based on the Four Noble Truths. Why are
they called the Noble Truths? They are noble because they are impor-
tant for knowledge and understanding.
For example, in the Four Noble Truths, we start with the under-
standing of suffering. In general, suffering is not so difficult to under-
stand. Even if we know what it is, we are distracted and not present,
and, in particular, we are not aware that suffering has a cause. Suffer-
ing is the fruit, or the effect of a cause. If there is an effect or a fruit,
there is a cause. Why did Buddha explain suffering in the first of all his
teachings? It is not because it was particularly interesting, or that people
wanted to know about it, but because suffering is universal, and every-
one has had that experience. Suffering is not a subject about which we
can agree or disagree.

4
 The Real Condition of All Phenomena

If Buddha had explained the nature of mind, for example, there

would have been many who agreed or disagreed with him. We human
beings are in general very limited. We have very strong egos, and, gener-
ally, people are convinced they have knowledge and understanding with
their points of view.
First of all, there are many arguments regarding the nature of mind.
The main point of Buddha’s teaching was not to convince or to argue,
but to make clear our real condition. Ordinary people can understand
something of which they have concrete experience. If we have no expe-
rience, it is difficult to understand or accept anything.
A baby or small child, for example, has no experience of life. They
do not know their condition or their limitations. When we tell children
not to touch the fire, we say, “You’ll hurt yourself.” If the child has no
experience of fire, it is very difficult for the child to accept; but if the
child touches the fire, then the child will have direct experience. When
they see the fire burning, they will not touch it again. Of course this is
an experience of suffering—a concrete problem that everyone has—but
we do not think much about the cause.

KARMA

When we have problems, we start to struggle with these problems

directly. We say, “Where there is a problem, there is also a solution
through struggling.” Buddha first explained that the condition of suf-
fering is something unpleasant, and nobody likes it. If you do not want
suffering, you must research into the cause of suffering. To overcome
the problem, the solution is not to struggle or fight.
In order to discover the cause, there are explanations of causes and
effects and the relationship between them. All Buddhists and Hindus

5
 Dzogchen Teachings

speak of karma. For most people in Asia, karma is familiar; however, it

is not so familiar in the Western world. Although some people find the
concept hard to accept and they do not use the word, they accept karma
because there is always a cause, an effect, and a relationship with time.
Everyone accepts this. That is the main point.
Buddha explained in the Sutra teaching, using hundreds and hun-
dreds of different examples, what cause and effect are, and how they
manifest. This teaching is for deepening this knowledge; it is not for just
developing the habit to say, “We are Buddhists; we believe that.”
I think that karma is very real to everybody, and that it is very
important to understand it in the correct way. Some people think of
karma as something preprogrammed that we are destined to follow. If
problems arise they say, “This is my karma. What can I do?” They are
resigned and complacent. This is not a correct understanding of karma.
Karma is relative to time and to actual situations in which karma is
manifesting.
There is a very famous saying of Buddha Shakyamuni: “To know
what we did in our past lives we must examine our present situation.”
That means we are now human beings; we have a human body, speech,
and mind. Our present existence is produced by past karma. Buddha
then said, “To know how our next life will be, we must examine our
present actions.” This means that our present actions can produce the
fruit of our next life, and that we can also modify and purify them. We
can do anything.
All Buddhist traditions have many different practices for purifying
negative karma. This means that when we have the problem of some
negative karma, there is also a chance to purify it. We cannot simply
say, “This is my karma; there is nothing to do.” The potentiality of kar-
ma manifests in the way seeds planted in a field grow. They have the

6
 Another Random Document on
Scribd Without Any Related Topics
between the layers of the cornea; this is recognized in the resistance
offered to the side-to-side movement of the spatula, which should be
withdrawn slightly and the point depressed so as to engage the
ligamentum pectinatum. (3) Subchoroidal hæmorrhage has been
known to occur after the operation.

SCLERECTOMY
The object of the operation is the production of a filtration cicatrix
free from iris tissue for the relief of intra-ocular tension in chronic
glaucoma.
Instruments. As for glaucoma iridectomy, with the addition of a
small curved pair of scissors.

Operation. Under cocaine.

First step. The incision is performed as for glaucoma iridectomy (see
p. 221), except that the incision should be rather smaller and should
be carried more obliquely through the sclerotic, so that a long scleral
flap is obtained. A large conjunctival flap is very essential to cover
the wound.
Second step. An iridectomy is usually performed as for glaucoma;
this may be omitted.
Third step. After all the bleeding has ceased, the conjunctival flap is
turned forwards on to the cornea so as to expose the scleral flap;
with small curved scissors made for the purpose, an elliptical portion
is removed from the sclerotic by a single snip (Figs. 121 and 122),
and the conjunctival flap is replaced in position. As a result, a hole is
made into the anterior chamber, which thus communicates with the
subconjunctival tissue, which is bulged forwards in the form of a
clear vesicle by the escaping aqueous when the wound has healed.
 Fig. 121. Lagrange Fig. 122. Lagrange
Operation For the Operation For Chronic
Production of a Cystoid Glaucoma. Showing the
Scar in Chronic Glaucoma. piece of sclerotic removed
Showing the method of by the scissors (black
removing a piece of the lines).
sclerotic.

The immediate results of this operation are satisfactory provided that

enough sclerotic be removed to produce a filtration cicatrix. As yet
sufficient time has not elapsed for any statistical results to be
obtained, but the cases in which the operation has been performed
are reported as satisfactory.

POSTERIOR SCLEROTOMY

Indications. Posterior scleral puncture is performed—

(i) For the relief of tension, the indications for which have already
been described under the indications for iridectomy in glaucoma (see
p. 218).
(ii) For the evacuation of fluid behind a detached retina.
The operation in the latter instance, although not yielding very
satisfactory results with regard to the reattachment of the retina,
may be carried out with some hope of success in certain cases.
Before performing the operation the pathological cause of the
detachment should be carefully investigated, for it is obvious that it
would be useless to perform the operation in a case of detachment
due to a choroidal tumour or if definite bands of fibrous tissue could
be seen in the vitreous pulling off the retina. Undoubtedly it should
be undertaken as soon as possible after the detachment has
occurred and the puncture should enter the space filled with
subretinal fluid. Whether the puncture should penetrate the overlying
retina is still a disputed point.
After the operation a pressure bandage should be applied and the
patient should be kept on his back and not allowed to raise his head
from the pillow for at least three weeks. This latter part of the
treatment is most essential; indeed as good results may be obtained
with complete rest as by performing scleral puncture. Unfortunately,
recurrence is very liable to take place whichever method be used,
even if reattachment of the retina be obtained.
Instruments. Speculum, fixation forceps, Graefe’s knife.

Operation. Under cocaine. If no special position be indicated the

puncture is best made upwards and inwards. The patient is made to
look outwards and downwards. The conjunctiva over the sclerotic,
well behind the ciliary body, is drawn down so that when released it
shall form a valvular opening to the scleral wound. The Graefe’s knife
is driven through the conjunctiva and sclerotic, the incision being
made antero-posteriorly in the direction of the fibres of the sclerotic
to avoid wounding the choroidal vessels. It is probably better to
enlarge the wound when withdrawing the knife than to turn the latter
at right angles before it is withdrawn, as has been recommended by
some surgeons. A bead of vitreous usually escapes under the
conjunctiva. If the tension be not lowered, gentle massage of the
globe through the lid should be employed.

PARACENTESIS OF THE ANTERIOR CHAMBER

Indications. Evacuation of the contents of the anterior chamber

is performed for several conditions:—
(i) To reduce the tension of the eye when due to an altered
consistency of the aqueous, as for instance in cyclitis.
(ii) To evacuate pus from the anterior chamber following metastatic
infection.
(iii) To evacuate the anterior chamber in bad corneal ulceration,
especially when associated with hypopyon and tension.
(iv) To examine the aqueous for organisms in cases of cyclitis
following operation or of metastatic origin.
(v) To evacuate soft lens matter (see p. 194).
The operation is usually performed through an
incision directly behind the limbus. In the case
of corneal ulceration it is sometimes
performed by dividing the base of the ulcer Fig. 123. Hollow Needle
with a Graefe’s knife (Sämisch’s section). Used for Paracentesis Of
the Anterior Chamber.
When collecting the aqueous for This is used when it is
bacteriological examination, a sterile hollow desired to examine the
needle with a point similar to a discission aqueous
needle, attached to a hypodermic syringe, bacteriologically. Care
should be passed into the anterior chamber at should be taken to see
that the cutting blade is
the limbus and the fluid withdrawn into the sufficiently wide to take
syringe by an assistant (Fig. 123). The spot the shaft of the needle.
through which the needle is passed is first
touched with the electro-cautery to ensure asepsis.
Instruments. Speculum, fixation forceps, bent broad needle, iris
spatula.

Operation. Under cocaine. The puncture is usually made

upwards and outwards unless there be some other special indication
for its position, such as a mass of pus in the lower angle of the
anterior chamber. The eye is fixed opposite the spot at which the
puncture is to be made, and the bent broad needle is passed into the
anterior chamber through an incision directly behind the limbus. The
needle is then withdrawn and is usually followed by a rush of
aqueous. The remainder of the aqueous is then evacuated by
pressing the lower margin of the wound with an iris spatula. In some
cases where a very tenacious hypopyon is present it may be
withdrawn with the iris forceps. The only complication liable to occur
is prolapse of the iris into the wound, which should be replaced with
the spatula, or failing that, removed.

OPERATIONS FOR PENETRATING WOUNDS OF THE GLOBE

Indications. Of all the conditions which a surgeon is called upon

to see, penetrating wounds of the globe may present the most
difficult problems as to treatment. The most important factors in their
treatment and prognosis are—
1. The time at which the patient presents himself for treatment and
the condition of the wound are all-important in the prognosis. Thus
in the case of a wound which is obviously septic and going to
terminate in panophthalmitis the eye should be eviscerated.
2. The position and extent of the wound. Formerly it was taught that
if the ciliary body were wounded the eye should be excised. The
reason for this was that these injuries were so frequently followed by
sympathetic ophthalmia owing to prolapse of the iris and ciliary body.
It is now generally recognized that sympathetic ophthalmia only
follows if the wound becomes septic, irido-cyclitis with keratitis
punctata being present, and it is only after the latter symptom
manifests itself that the eye should be excised, provided that the
wound be not so extensive as to preclude all chance of recovery from
the outset.
In wounds of the sclerotic all portions of the uveal tract and vitreous
which prolapse should be removed, and the wound closed with
sutures passed through the superficial episcleral tissue. Unless the
wound be small the prognosis is not good, as it is liable to be
followed by irido-cyclitis, or, if this does not occur, detachment of the
retina may ensue, following on organization of the exudates in the
vitreous.
Wounds of the cornea usually result in prolapse of the iris, which
should be removed in the manner described under iridectomy (see p.
208).
3. If the lens be injured. Unless the wound amounts to little more
than a punctured wound of the globe involving the lens, the
prognosis is bad. The wound in the lens capsule and the breaking up
of the lens mean the presence of soft matter in the anterior chamber
—a condition which favours sepsis and is liable to produce increased
tension from blocking the angle of the chamber. In patients under
thirty the pupil should be dilated with atropine and the lens allowed
to absorb—assisted at a later date by needling, when the eye has
entirely settled down after the original injury. If the patient be over
thirty it is often extremely difficult to decide whether extraction of the
lens should be undertaken at the time of the injury or at a later date.
The results of both procedures are very unsatisfactory, and the
surgeon should be guided partly by the position and extent of the
wound. Given these in a fairly favourable position, it is probable that
immediate extraction will give the best result.
4. If the eye contain a foreign body. Usually these are pieces of metal
or glass. The following points should be investigated to determine
whether the foreign body be in the eye:—
(i) The history of these accidents is usually the same. The patient is
chipping with a hammer and chisel, and a piece flies off and strikes
the globe. In the case of glass it is usually a mineral-water bottle
which bursts.
(ii) The position and nature of the wound in the cornea and sclerotic.
(iii) The condition of the anterior chamber—whether evacuated or
not.
(iv) The tension of the eye, which may be lowered.
(v) The presence of a hole in the iris.
(vi) The presence of traumatic cataract.
(vii) Whether the foreign body is visible with the ophthalmoscope or
by focal illumination.
(viii) The localization of the foreign body by the X-rays. The latter is
the most important factor of all, since the foreign body may pass
right through the
globe and be
embedded in the
orbit.

Operative
treatment. If
the injury be a recent
one and the foreign
body a metal of
magnetizable
properties, it is best
removed by an
electro-magnet after
localization by the X-
rays (Fig. 124).
Sideroscopes have Fig. 124. Author’s Chair for the Localization of Foreign
been used, but are Bodies in The Eye by the X-rays. a is a rifle sight for
centring the anode, c, on the cross wire, b, behind
not so satisfactory. If which the photographic plate is subsequently placed.
the foreign body be p is the screw clamping the head-piece on to the
non-magnetizable, patient’s head. q is the screw for regulating the height
such as a piece of of the tube and the distance from the patient. r is the
copper cap or screw for regulating the height of the head-piece. The
inset shows the arm carrying the tube more highly
manganese steel, an magnified. e is the sliding arm carrying the tube for
attempt may be lateral displacement marked for stereoscopic
made to remove it photographs. f is the pointer for marking the position
with forceps after of the anode. d is the screw for clamping when in
localization. If the position.
foreign body be
embedded in the lens it is often advisable to extract the lens together
with it. If the foreign body be of glass, and it be only small, it is
usually best left alone, unless capable of easy removal, e.g. if it be
situated in the anterior chamber; the eye will often tolerate the
presence of glass provided it be aseptic.
The eye should be removed—
(i) If the wound be obviously septic.
(ii) If the wound be very large, more especially if the lens be injured.
(iii) If the foreign body be a large piece of metal and cannot be
extracted.
(iv) If the eye does not settle down after one of the operations
described below, especially if irido-cyclitis with keratitis punctata
should have supervened.
If the injury be of long standing. It is of little use as a rule
attempting to extract a foreign body from the eye after three days,
unless it be loose in the vitreous or embedded in the lens, as it
becomes surrounded by lymph. Under these circumstances it is
better to leave it alone, or, if it be causing signs of irritation, to
enucleate the eye.

ELECTRO-MAGNET OPERATIONS
Magnets for the removal of magnetizable foreign bodies from the eye
are of two types—(1) a small magnet, which is inserted into the
globe, (2) a giant magnet, which is used to attract the foreign body
in the eye from the outside.
Surgeons differ as to which is the best
method to employ. The statistical
results of both are about the same.
Many surgeons in this country, and
with them the author, prefer the small
magnet, especially of the recent more
powerful type (Hirschberg), which
runs off the main electric current, for Fig. 125. Small Electro-magnet for
the following reasons: it is more extracting Pieces of Steel from the
Eye. It is made to work direct off
accurate (after localization by the X- the electric main.
rays), there is less trauma to the
globe involved, it is more portable,
and, when the foreign body is in the anterior or the posterior
chamber, it is much easier to extract it with a small magnet than with
a large one.

With the small magnet. Instruments. Beer’s knife,

fixation forceps, magnet (Fig. 125), and suture. The points of the
magnet, which are detachable, are sterilized by boiling.
Operation. The foreign body is first localized accurately by means of
the X-rays. If it lies near the wound of entrance the magnet point is
inserted, the electric circuit completed, and the foreign body
withdrawn, the wound of entrance being enlarged if necessary. If the
foreign body lies at some distance from the wound, as for instance in
the vitreous, an antero-posterior incision is made in the sclerotic, as
near to it as possible, by plunging the knife through the conjunctiva
and the sclerotic, the former having previously been drawn to one
side so as to form a valvular opening. The size of the incision should
be such that it will admit the point of the magnet and allow the
foreign body to come out, the size of the foreign body being judged
by the X-ray photograph. After the knife has been withdrawn, the
point of the electro-magnet is inserted and the circuit closed, the
magnet being withdrawn with the foreign body attached to it. The
conjunctival wound is closed by a suture if necessary. If the foreign
body be situated in the anterior or posterior chamber or the lens, an
incision should be made into the anterior chamber with a keratome,
the point of the magnet inserted, and the foreign body withdrawn. In
cases in which the foreign body is deeply embedded in the lens,
more especially in patients over thirty years of age, extraction of the
lens together with the foreign body should be performed.
Complications. Immediate. Failure to extract the foreign body may
arise from—
1. The foreign body being embedded in lymph. It is therefore of the
utmost importance that the operation should be performed as soon
as possible after the injury.
2. The foreign body being deeply embedded in the sclerotic so that
the magnet will not exert sufficient traction to withdraw it.
3. The foreign body being non-magnetic (all steel is not magnetic).
4. Too small a wound being made for its extraction, the metal being
wiped off on the edges of the wound as the magnet is withdrawn.
5. Insufficient power in the magnet.
Remote. 1. Panophthalmitis, which must be treated by evisceration.
2. Irido-cyclitis; if this be prolonged, and
keratitis punctata appear, enucleation
should be performed.
3. Traumatic cataract; this may
subsequently require needling.
4. Detached retina as the result of
organization in the vitreous; this may occur
months after the original injury.

With the giant magnet. The

foreign body should have been previously
localized by the X-rays, and its position and
size determined, so that it may be removed
by the shortest possible route and with the
least amount of injury to the eye.
Instruments. Giant magnet (Fig. 126), Fig. 126. Large Electro-
steel spatula. (Watches and magnetizable magnet. The current is
metal should be removed from both the turned on by means of the
patient and the surgeon.) foot pedal.

Operation. Under atropine and cocaine. The patient is at first

seated in a chair some three feet in front of the magnet, the eyelids
being held apart by the surgeon; the electric circuit is closed. The
patient’s head is next gradually advanced towards the magnet. If a
foreign body be present in the eye and be magnetizable, the patient
will usually withdraw his head or cry out with pain, and the foreign
body may be seen bulging forward the iris from the posterior
chamber. From this position it may be removed by manipulating the
head and eye in relation to the magnet so as to withdraw it into the
anterior chamber, from whence it is removed through the entrance
wound or an incision at the limbus either by the giant magnet
directly applied to the wound or by magnetizing a steel spatula which
is inserted into the anterior chamber and connected with the magnet
by a flexible steel cable. The small magnet previously described may
be used, or the foreign body removed by means of iris forceps.
A piece of steel in the vitreous always travels round the posterior
surface of the lens and through the suspensory ligament, and does
not injure the lens capsule.
Complications. These are similar to those described under the
small magnet operation.

CHAPTER V

OPERATIONS UPON THE CORNEA AND

CONJUNCTIVA

OPERATIONS UPON THE CORNEA

REMOVAL OF A FOREIGN BODY FROM THE CORNEA

Removal of a foreign body from the cornea requires a good light
(focal illumination). The use of a binocular lens is also of service.
Foreign bodies lodged on the surface of the cornea can be removed
easily under cocaine with a spud. If the foreign body be deeply
embedded in the cornea a fine sterile discission needle should be
used. When a foreign body, such as a chip of iron, is deeply
embedded, the needle should be inserted slightly to one side of the
entrance wound and passed beneath the foreign body so as to lift it
from its bed. When the foreign body has partially penetrated the
anterior chamber but still lies in the cornea, an incision should be
made with a keratome at the limbus and the foreign body pushed
back through the entrance wound with the aid of an iris spatula. If
the foreign body be iron, the electro-magnet may be of use, and in
this case should be tried before resorting to an incision in the
anterior chamber. A stain is left frequently after the removal of
foreign bodies; this should be removed as far as possible.
Subsequently the eye should be bandaged for a few days and bathed
with boric lotion. Atropine should be instilled if there be any signs of
infiltration around the wound.

CAUTERIZATION OF THE CORNEA

Either a chemical or the actual cautery may be used.

Indications. Corneal ulceration. The cornea being extremely

dense, organisms do not penetrate very deeply into its substance, so
that destruction of the bacteria is effected by cauterization of the
spreading portion of an ulcer; the albumin is also coagulated and so
a barrier is presented to their advance.

Operation. The eye is thoroughly cocainized, and the spreading

portion of the ulcer is first defined by staining with fluorescine,
washing away the excess of stain with boric lotion.
By a chemical caustic. Liquefied carbolic (carbolic acid crystals
liquefied in 10 per cent. of water) is applied upon a sharpened
match. Any excess should be removed so as to prevent its running on
to the cornea. A speculum is inserted and the cornea is dried by
blotting with cigarette paper; the stained area is lightly touched with
the point of the stick, particular attention being paid to the spreading
margin. A dense white plaque is the result; this usually clears up in a
few days. Atropine ointment is applied daily to the conjunctival sac.

Fig. 127. Electro-cautery.

By the actual cautery. The electro-cautery (Fig. 127) point should be
extremely fine and only raised to a dull red heat. The stained area
should be touched lightly with the point.
The actual cautery is best for serpiginous corneal ulcers, carbolic acid
being more satisfactory for those of the vesicular type.

OPERATIONS FOR CONICAL CORNEA

Indications. Since the operation for conical cornea is not

without serious risks, it should only be undertaken when the vision
cannot be improved with glasses to 6/18; high + or - cylinders will
often yield satisfactory results. The object of all forms of operation is
the flattening of the cone.

Operation. This may be carried out either by excision of the

apex of the cone or by cauterization.
Excision of the apex of the cone is probably the more satisfactory
method, although it is somewhat more difficult to perform. The
object of the operation is to remove an elliptical portion of the whole
thickness of the cornea from the apex of the cone, the long axis of
the ellipse being placed horizontally. It leaves the eye with only a
minute scar as compared with the nebula produced by the cautery,
which is often so great as to require an optical iridectomy to restore
vision.
Instruments. Speculum, fixation forceps, a narrow Graefe’s knife,
straight iris forceps, and scissors.
The operation is done under cocaine, atropine having been previously
instilled.
First step. The apex of the cone is transfixed by the Graefe’s knife
with the blade directed slightly upwards and forwards, the knife
being made to cut out. The cornea in this situation is extremely thin,
being often not more than 1 mm. in thickness. The length of the
incision should not exceed 2 mm.
Second step. The flap of corneal tissue thus made is seized with the
straight iris forceps and removed with iris scissors, producing a small
elliptical opening. The chief difficulty of the operation is the seizing of
the corneal flap, which is most difficult to hold; care must be taken
not to injure the lens capsule with the iris forceps or scissors when
the cornea has collapsed as the result of the evacuation of the
anterior chamber. The eye should be firmly bandaged subsequently,
and the patient kept in bed until the anterior chamber has re-formed.
Complications. Slow re-formation of the anterior chamber. The
anterior chamber will often take two or three weeks to re-form,
owing to the hole in the cornea not closing. During this time the eye
is open to septic infection and therefore the greatest care should be
taken to keep it aseptic when dressing it. For this reason and also
because the following complications are due to the same cause, it is
desirable to remove as little corneal tissue as possible in performing
the operation. It is probable that conjunctivoplasty (see p. 245)
would considerably facilitate the rapid closure of the wound.
Anterior polar cataract may result from prolonged contact of the lens
with the wound in the cornea. As a rule this seldom interferes much
with vision.
Anterior synechiæ from incarceration of the iris in the wound
occasionally result and may require subsequent division.
Acute glaucoma is by no means an infrequent complication—indeed
the author has seen four successive cases of conical cornea,
operated on both by excision and by the cautery, followed by this
complication. It is probably due to adhesion of the root of the iris to
the back of the cornea during the time the anterior chamber is
empty. It can usually be relieved by an iridectomy.
The electro-cautery operation. The operation generally adopted
is known as the target operation. It consists in surrounding the apex
of the cone with two rings of cautery marks, the outer made at a dull
red heat, the inner with the point slightly brighter, whilst the apex is
cauterized at a red heat, so that rings of different depth are
obtained. Cauterization of the apex should stop just short of
perforation, the inner ring being deeper than the outer. With this
method secondary glaucoma and anterior synechiæ are not so liable
to occur. On the other hand, an optical iridectomy has to be
performed more frequently. A few surgeons still cauterize the apex of
the cone until a perforation is produced. This latter operation seems
to have the disadvantages of both methods and the advantages of
neither.

REMOVAL OF TUMOURS INVOLVING THE CORNEA

Tumours which involve the cornea are usually secondary to tumours
occurring at the limbus. The chief of these are: simple—dermoid
patches, moles of the limbus; malignant—sarcoma, endothelioma,
epithelioma. Dermoid patches should be shaved off as close to the
cornea as possible; the white area left after their removal can be
improved by tattooing.
Malignant tumours in very early stages may be removed locally with
scissors and forceps, the cautery being applied to their base, since
they do not tend to invade the sclerotic deeply.

TATTOOING THE CORNEA

Indications. (i) To do away with the blinding effects of light

through a scar after iridectomy has been performed (see p. 215).
(ii) To simulate a pupil on a white scarred cornea.
The operation is not without risks, as it may light up old inflammation
in a previously quiet eye. Panophthalmitis and sympathetic
ophthalmia have both been known to follow it. The pricking of the
needle may carry in epithelium and implantation dermoids may arise.
Instruments. A fine single needle is generally used, occasionally a
bundle of needles (Fig. 128).

Fig. 128. Tattooing Needles.

Operation. Under cocaine. Chinese ink, sterilized and prepared
by rubbing up with 1–6,000 perchloride of mercury, is smeared over
the area to be tattooed. Multiple punctures in an oblique direction are
then made into the cornea over the area desired. More paste is then
rubbed in over this area. The cornea should be intensely black after
the operation, as a certain amount of the ink is carried away by
phagocytosis and shedding of the epithelium. Subsequent reaction
may be reduced by means of an iced compress. Atropine should be
instilled.

SCRAPING CALCAREOUS FILMS

Calcareous films, when not associated with active irido-cyclitis, may
be removed with advantage to the vision. Care should be taken to
see that no keratitis punctata is present before the operation is
undertaken.
Instruments. Speculum, fixation forceps, a spoon which should
have rather a blunt edge.

Operation. Under cocaine. The area is very lightly scraped with

the spoon. The calcareous changes are in the deeper layers of the
epithelium and Bowman’s membrane and hence are easily removed.
The scraping should be carried well beyond the apparent margin of
the film. The epithelium often takes some time to regenerate. As a
rule the results are satisfactory, although the film is apt to recur in
the course of years, but it may be removed again if necessary.

OPERATIONS UPON THE CONJUNCTIVA

THE REMOVAL OF FOREIGN BODIES

Foreign bodies lodged in the conjunctival sac, unless embedded in
the conjunctiva, are usually found by the surgeon under the upper
lid, the sulcus subtarsalis being a favourite situation. They are easily
removed with a spud or needle, after the instillation of a drop of 4%
cocaine solution. Subsequently the eye should be bandaged for a few
hours until the effect of the cocaine has passed off, as in wiping the
eye the patient may wipe off the epithelium of the cornea whilst it is
insensitive from the cocaine.
In order to evert the upper lid the patient is made to look strongly
down, the eyelashes are seized between the thumb and forefinger of
the left hand, the skin of the upper lid is pushed down above the
tarsal cartilage with the thumb of the right hand, and the lid is
everted by pulling it upwards against the point of the thumb.

OPERATION FOR PTERYGIUM

Indications. Pterygium should be removed when advancing

across the cornea, especially when the pupillary area is becoming
involved. The operation of ablation is the one now generally in use.
Instruments. Speculum, straight iris forceps, small sharp-pointed
scissors.

Operation. Under adrenalin and cocaine the neck of the

pterygium is seized with the forceps and the body and neck are
carefully dissected from the conjunctiva. The body and neck should
be very carefully separated right up to the corneal margin by means
of forceps and scissors. The head is then stripped off the cornea with
a sharp pull. The wound in the conjunctiva should be subsequently
closed with fine sutures, otherwise the disease will certainly recur. In
stripping the head from the cornea some of the epithelium may be
torn off with it. This usually regenerates without impairing the vision.

EXPRESSION

This is an operation for the removal of follicular formations in the

conjunctiva, and is used more especially in trachoma.
Instruments. Graddy’s forceps (Fig. 129), fixation forceps.
 Fig. 129. Graddy’s Forceps.

Operation. The operation may be performed under cocaine and

adrenalin, a little solid cocaine being rubbed into the area to be
expressed. In severe cases in which both eyes are affected, and in
small children, a general anæsthetic may be necessary.
Although a number of instruments are in use, perhaps the best, and
certainly the least painful, is Graddy’s forceps. In the case of the
upper lid it is everted, one blade of the forceps being passed into the
fornix, the other being placed over the upper surface of the everted
lid. A gentle steady pressure is applied, and the lid is drawn out
between the blades. In this way as much of the conjunctiva is gone
over as is necessary. The lower fornix is best expressed by picking up
the loose fold of the fornix with ordinary forceps and then expressing
with Graddy’s.
If only one or two follicles be present they can be picked up with the
ordinary fine dissecting forceps and expressed, but when situated on
the tarsus the follicles are best enucleated with a spud; a solution of
1 in 50 perchloride of mercury in glycerine is then rubbed into the
conjunctiva. The operation may have to be repeated several times as
new follicles form.

CONJUNCTIVOPLASTY

Conjunctivoplasty is an operation for the transplantation of a flap of

conjunctiva to cover some loss of substance or defect in the
continuity of the globe.

Indications. The operation may be necessary—

(i) To close large recent wounds of the cornea.
(ii) To close the wound made by the excision of a cystoid scar.
(iii) To facilitate the healing of a clean ulcer such as Mooren’s ulcer, or
to cover the aperture made by an ulcer that has perforated.
(iv) In the treatment of conical cornea by excision of the apex of the
cone, it might facilitate the rapid closure of the wound and assist in
flattening of the cornea.

Operation. First method. Under cocaine. A flap of conjunctiva is

raised from around the limbus, having its base as near the area to be
covered as possible; its breadth should be one and a half times the
width of the area to be covered. This flap is drawn across the defect
in the cornea and stitched to the conjunctiva on the other side; the
wound made in raising the flap should be allowed to heal by
granulation.
The stitches holding the flap in position cut through in two or three
days, but by that time their purpose will have been served. If the flap
be still adherent to the wound its base may be divided and any
superfluous tissue removed; the remainder will disappear rapidly.
Second method. The conjunctiva is dissected up all round the cornea
as close to the limbus as possible, and backwards as far as the
insertion of the recti. A purse-string suture is then inserted around its
margins and drawn tight so that the whole cornea is covered by
conjunctiva. The operation is suitable for cases in which large areas
have to be covered.

REMOVAL OF TARSAL CYSTS

The Meibomian glands being embedded in the tarsal plate, cysts in
them present both on the conjunctival surface and towards the skin,
but the contents are always evacuated from the former.
Instruments. Walton’s iris knife, sharp spoon.

Operation. Under adrenalin and cocaine. The eyelid is everted

and a drop of the solution is injected into the cyst with a hypodermic
syringe. A vertical stab is made into the cyst with the knife and the
contents are then evacuated with a sharp spoon.
Difficulty may arise in fixing the cyst whilst making the incision; this
is best obviated by holding the everted lid between the finger and
thumb.
In some cases, when the cyst has persisted for a considerable time,
the sac-wall becomes so thickened that it has to be dissected out
before the mass in the lid will disappear.

CHAPTER VI

OPERATIONS UPON THE EXTRA-OCULAR

MUSCLES

SQUINT OPERATIONS

Indications. Operations upon eyes with concomitant squint are

undertaken for two purposes:—
(i) For cosmetic reasons, to remedy a deformity due to a squinting
eye which is amblyopic.
(ii) To rectify the muscular equilibrium in alternating or latent squints,
so that binocular vision may be regained.
When the operation is performed for the latter reason the adjustment
will naturally have to be much more accurate than for the former, so
as to bring about the superimposition of the images falling on each
macula. The muscular balance is interfered with by the
administration of a general anæsthetic, and therefore the results
cannot be gauged accurately. Thus it is desirable that operations
upon the ocular muscles should be performed under local
anæsthesia. This is usually possible, except in the case of very small
children.
During and after the operation muscular equilibrium is tested by
means of an electric light fixed to the ceiling immediately over the
head of the patient (see Fig. 74). The room is darkened and the
patient is made to look at the light. In a case with an amblyopic eye
the reflection of the light should appear in the middle of each cornea
if the eye be properly adjusted. In cases where good vision is present
in both eyes the Maddox rod test should be used, the rod being
placed before the eye not being operated on; the bar of light
produced by the rod should pass through or within a few inches of
the light if the adjustment has been performed accurately.
The tendons of the recti muscles are inserted into the globe at the
following distances from the corneo-sclerotic junction: internal, 5
mm.; inferior, 6 mm.; external, 7 mm.; superior, 8 mm. Each muscle
is held in place by expansions on either side of the tendon as well as
by the tendinous insertions. Division of these expansions allows a
greater retraction of the muscle and is, therefore, to be undertaken
when a considerable degree of squint has to be overcome. On the
other hand, there will be a danger that the muscle may not regain a
proper attachment to the globe if division be too freely performed,
and a squint in the opposite direction may result; proptosis also may
be caused thereby. It is, therefore, better to combine tenotomy with
advancement in high degrees of squint over twenty degrees
convergent and in all cases of constant divergence. This is usually
better than performing a tenotomy in the other eye, as there still
remains the muscle of the other eye in reserve to tenotomize if
necessary, if the advancement be insufficient to correct the squint.
Further, it is much easier to rectify a muscular error by accurate
tenotomy than by advancement. Division of the tendon of the
internal rectus only, without its expansion, will usually rectify cases of
latent convergent strabismus with a deviation of about 12° prism
(Maddox test). Cases of latent divergent strabismus of about 8°
prism (Maddox test) require complete division of the tendon of the
external rectus, and, in some cases, of the expansion as well.
Tenotomy of the superior rectus for hyperphoria should only be
undertaken in bad cases; that is to say, of over 12° prism, any lateral
deviation being first corrected, as occasionally the correction of the
lateral deviation, especially when this is due to the faulty insertion of
a muscle, will sometimes correct the hyperphoria present.
Partial tenotomies are performed by some surgeons for the
correction of latent muscular errors, but the experience of most in
this country is that little benefit is gained unless the tendon be
completely divided. Tendon-lengthening by various methods has
been performed, but has not come into general use.
After all operations upon the ocular muscles both eyes should be
occluded to keep the eyes at rest whilst the muscle is gaining its
fresh attachment to the globe; this usually takes about seven days,
after which time both eyes should be uncovered, and if there is a
tendency to convergence atropine should be used. Glasses correcting
any error of refraction should be worn.

TENOTOMY
Tenotomy may be performed by (1) the open, or (2) the
subconjunctival method.
Instruments. Speculum, straight blunt-pointed scissors, strabismus
hook, needle and silk, needle-holder.

Operation. The operation is performed under adrenalin and

cocaine.
1. By the open method. The surgeon stands on the right side facing
the patient when dividing the right external or the left internal rectus,
but at the head of the table when dividing the right internal or the
left external rectus.
 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.
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 Fig. 131. Tenotomy by the Open
by the Maddox rod test. The Method. The tendon is first
strabismus hook may be inserted, button-holed about its centre and
both upwards and downwards, to see the expansions are then divided
that the tendon is properly divided, upwards and downwards to the
but all pulling on the muscle with a required extent.
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).
3. Tenonitis very rarely occurs, but may lead to matting down of all
the extra-ocular muscles and defective movements of the globe.
Panophthalmitis has been known to follow this condition.
Remote. 1. Failure to correct the muscular error. If the error be
large it must be rectified by tenotomy of the corresponding muscle of
the other eye or by the advancement of the opposing muscle of the
same eye. This should not be undertaken until five or six weeks have
elapsed since the previous operation.
2. Over-correction of the muscular error at the time of the operation
may be remedied by stitching the tenotomized muscle forward to the
extent required to bring the eye straight. Advancement of the
tenotomized muscle should be performed if the over-correction be
only discovered after the operation. In cases with binocular vision
lesser degrees of deviation may be corrected with prisms if they are
causing symptoms, while small errors of over-correction, of about 3°
prism, often disappear after the first few weeks.
3. Defective movement in the tenotomized muscle is usually present
for the first week or two after the operation, but recovery usually
takes place after the muscle has regained its attachment to the
globe; it may persist, however, to a slight extent; this is most liable
to occur after free division of the tendon and its expansion (more
especially in the case of the external rectus), or because the tendon
has not been divided close enough to the globe. In patients with
previous binocular vision diplopia is present after the operation on
turning the eyes towards the same side as the tenotomized muscle,
but this usually disappears.
4. A granulation may form at the site of the tenotomy wound. It may
be due to a tag hanging from the wound or to a portion of a stitch
that has been imperfectly removed. It should be snipped off with
scissors and the conjunctiva drawn together over its base.
5. Proptosis may result from too free a division of a tendon.
6. Retraction of the caruncle is best avoided by closing the
conjunctival wound with a stitch, and thus pulling the caruncle
forward.

ADVANCEMENT
Advancement is an operation undertaken to rectify a squint by
forming a fresh attachment for one of the ocular muscles nearer the
cornea, and at the same time shortening it. There are three main
types of operation performed:—
1. The capsulo-muscular, in which the tendon, together with the
attachment of the capsule of Tenon to it, is advanced.
2. The tendon only is isolated, shortened, and advanced.
3. The tendon is shortened by folding it upon itself.
The first operation is by far the most satisfactory of these, owing to
the fact that a broader new insertion of the muscle is obtained, which
is less likely to yield subsequently; it is the operation usually
performed in this country.
The chief cause of unsatisfactory results after advancement
operations is the cutting through of the sutures holding the tendon in
position. The various operations, which are some fourteen in number
and have mostly their respective surgeon’s name attached, differ
principally in the method of insertion of these sutures. Whichever
method of inserting sutures be used, the main factors which aim at
preventing the stitches from cutting out are (1) that the stitches
should take a good hold in the scleral and episcleral tissues on the
corneal side of the wound, for the passing of which it is most
essential that the needles should be sharp; (2) that complete rest of
the muscles should be ensured by bandaging both eyes for the first
seven days after the operation; (3) that the opposing muscle should
be tenotomized so as to prevent traction on the sutures.
Of the many operations that have been devised the capsulo-muscular
advancement or some modification of it is most frequently used.
Instruments. Speculum, straight scissors, fixation forceps, Prince’s
advancement forceps (Fig. 132), four sharp needles and strong silk,
needle-holder.

Fig. 132. Prince’s Forceps for Advancement. Care

 should be taken to see that the spring catch
holds satisfactorily.

Operation. Under adrenalin and cocaine. First step. The patient

is made to look away from the side on which is the muscle to be
advanced, and the conjunctiva over the muscle is freely divided with
scissors, by a curved incision with the convexity towards the cornea,
and dissected back.
Second step. The capsule of Tenon is button-holed by a small incision
well above or below the tendon. A tenotomy hook is passed beneath
the tendon and its expansion and brought out through a small hole in
Tenon’s capsule on the opposite side of the tendon. The smooth
blade of Prince’s forceps is then inserted in place of the hook, and
the tendon with its expansion is grasped between the blades. The
forceps are given to an assistant, who should avoid all traction on the
muscle. The eye is then rotated in the direction of the muscle to be
advanced, and tenotomy of the opposing muscle is performed by the
open method.
Third step. The muscle to be
advanced and its expansion,
which are clamped between the
blades of Prince’s forceps, are
separated from the globe with
the scissors and given again to
the assistant to hold. Three
strong silk sutures are passed in
the following order, middle, Fig. 133. Advancement by the Three-stitch
Method. Showing the sutures in position.
upper, and lower, first through A firm hold on the sclerotic to the
the conjunctival and episcleral corneal side of the wound is essential to
tissue on the corneal side of the the success of the operation.
wound and then as far back as
possible through the muscle and out through the conjunctiva near
the cut margin on the other side of the wound (Fig. 133). Care
should be taken that the middle stitch is passed through the
episcleral tissue exactly opposite the horizontal plane of the cornea
and the central portion of the tendon. The portion of the tendon and
capsule within the grasp of the forceps is then removed with scissors
by cutting close to the blades of the Prince’s forceps, taking care not
to cut the sutures.
Fourth step. The middle suture should be first tightened to the extent
required to bring the eye straight. The upper and lower sutures are
then tied.
If, on testing with the Maddox rod, the error be found to be slightly
over-corrected by the advancement, the eye can be drawn back by
taking a firm hold with the conjunctival stitch over the tenotomy
wound. The conjunctival stitch may be removed on the fourth day,
but the stitches holding the advanced muscle in position should not
be removed till after the tenth day. Atropine in both eyes is desirable,
especially when there is any tendency to convergence. Glasses
should be worn on uncovering the eyes.

Complications. 1. The eyes may not be straight after the

operation. No further operation for rectification should be undertaken
for at least two or three months. If there be a tendency to
convergence, glasses should be worn and atropine used. Small latent
errors may be corrected by prisms. If the muscular error be
insufficiently corrected tenotomy may be performed on the other eye.
If the muscular error be over-corrected it may also require tenotomy
on the other eye, the adjustment by tenotomy being more accurate
than that by advancement.
2. Thickening over the site of the advanced muscle usually
disappears in a few months.
Other complications as described under tenotomy may occur (see p.
250).

CHAPTER VII
 ENUCLEATION OF THE GLOBE AND ALLIED
OPERATIONS
The principal substitutes for simple enucleation are evisceration,
Mules’s and Frost’s operations.

ENUCLEATION
Enucleation is the removal of the globe from Tenon’s capsule.
Indications. Enucleation should be performed in preference to
Mules’s operation in—
(i) Malignant tumours.
(ii) Injuries followed by cyclitis.
(iii) Painful blind eyes.
In malignant tumours enucleation should only be performed when
there are no signs of extra-ocular extension. If extra-ocular extension
be present, evisceration of the orbit should be performed, provided
there be no evidence of general metastasis. In cases of glioma of the
retina it is especially desirable that the optic nerve should be cut as
far back as possible and the cross-section carefully examined for
gliomatous tissue, since the disease spreads to the brain along this
structure.
In injuries followed by non-suppurative cyclitis enucleation or Frost’s
operation is preferable to Mules’s operation, since cases have been
recorded of sympathetic ophthalmia following the latter operation,
and it is these cases of non-suppurative cyclitis which are especially
prone to give rise to that disease.
Blind painful eyes, especially when affected with glaucoma, are best
removed, as occasionally the underlying cause, when not known,
may prove to be an intra-ocular growth.
Instruments. Speculum, fixation forceps (two pairs), straight
scissors, strabismus hook, strong curved scissors.
Operation. Before the anæsthetic is administered the forehead
should be marked over the eye to be enucleated, so as to guard
against the accident of removing the wrong eye. It is usual, at any
rate in the case of hospital patients, to get their written consent for
the operation.
First step. The speculum is inserted. In the case of the right eye the
conjunctiva is seized with the fixation forceps downwards and
outwards, or in the case of the left eye, downwards and inwards. The
straight scissors being held with the right thumb and ring finger, the
conjunctiva is divided freely all the way round, as close as possible to
the cornea, and dissected back.
Second step. The capsule of Tenon is opened below the external
rectus by grasping it with forceps and buttonholing it with the
scissors. The strabismus hook is passed through the opening made in
Tenon’s capsule with its concavity against the globe, turned upwards
beneath the tendon, and the latter is pulled well forward and freely
divided from above downwards between the hook and the globe. The
superior and inferior recti are treated in a similar manner. In dividing
the internal rectus a small portion should be left attached to the
globe, so that subsequently it can be grasped with forceps to rotate
the globe outwards when dividing the optic nerve.
Third step. The globe is dislocated between the lids by opening the
speculum widely and pressing it backwards. If the globe will not
dislocate, it is either because the tendons are imperfectly divided, or
the palpebral aperture is too small to allow of its delivery; the latter
is liable to be the case in small children or in those with a
staphylomatous globe. In such cases the palpebral fissure should be
enlarged by dividing the outer canthus.
The fourth step is the division of the optic nerve. The globe is rotated
strongly outwards, either by pulling on the tendon of the internal
rectus or by pulling the globe outwards with the finger; the optic
nerve is felt for by passing the strong curved scissors behind the
globe. When the nerve is defined the blades are opened widely,
pressed backwards, and the nerve divided. The globe is then pulled
forward with the finger, and the oblique muscles and remaining
attachments divided. Hæmorrhage is easily controlled by pressure
and the use of adrenalin.
Fifth step. When the bleeding has
ceased, the conjunctival wound is
united in a horizontal direction by
means of a thick silk suture running
over and over; no knot is required
and the ends are left long, so that it
may subsequently be removed
easily (Fig. 134). The usual Fig. 134. Enucleation. Method of
dressings are applied with a firm suturing the conjunctiva; the suture
pressure bandage for the first six requires no knot.
hours. The suture should be
removed at the end of the seventh day. No artificial eye should be
worn for at least six weeks after the operation, and then only for a
few hours at a time until the conjunctiva becomes accustomed to it.
It should always be taken out at night.

Complications. These may be immediate or remote.

Immediate. Cutting into the globe. This may occur during the
division of the optic nerve, and is usually due to imperfect dislocation
of the globe. Although of little consequence as a rule, it may be
extremely serious, as for instance in the case of an intra-ocular
growth, when it is conceivable that a portion of it might be left
behind. If this accident should happen, the portion of the sclerotic
and choroid left behind should be carefully sought for and removed.
Adhesion of Tenon’s capsule. Eyes that have been the subject of
acute inflammation are much more difficult to enucleate, owing to
adhesion of the surfaces of Tenon’s capsule. In these cases the globe
has practically to be dissected out of that structure.
Remote. Hæmorrhage into the stump may occur, leading to
proptosis of the conjunctiva and extravasation into the eyelids and
beneath the skin of the face. The use of a firm pressure bandage and
the omission of the suture is usually sufficient to prevent this
occurring, but the blood-clot may have to be turned out and the
bleeding point sought for and ligatured.
Granulations and polypi in the socket are usually the result of leaving
some tag of tissue between the margins of the wound, and are
therefore more likely to occur when no suture is used to close the
wound. They should be removed with forceps and scissors.
Polypoid masses sometimes form in a socket as the result of an
imperfect artificial eye causing an œdematous condition of the
conjunctiva. They should not be removed, owing to the contraction
caused thereby, but the artificial eye should be left out, when they
will often disappear.
Contracted socket is usually the result of an imperfectly performed
enucleation or loss of large portions of the conjunctiva; for the
operations for its relief, see p. 261.

EVISCERATION
Evisceration is the removal of the intra-ocular contents.

Indications. It is the ideal operation for a suppurating globe; in

these cases enucleation is contra-indicated because the lymph-space
round the optic nerve is opened up by the division of the latter and
the inflammation may spread directly to the meninges.
Instruments. Speculum, fixation forceps, Beer’s knife, scissors,
scoop and stitches.

Operation. A general anæsthetic is necessary.

First step. The eye is transfixed about 4 mm. behind the corneo-
sclerotic junction with a Beer’s knife, which is made to cut out
upwards (Fig. 135). The flap of corneal and scleral tissue is then
seized with forceps and the cornea removed entirely by completing
the incision in the sclerotic round it with scissors (Fig. 136).
 Fig. 135. Mules’s Operation. Fig. 136. Mules’s Operation.
First step. Excision of the The completion of the
cornea. excision of the cornea with
scissors.

Second step. The contents of the globe are then eviscerated by

means of a spoon, and the cavity flushed out with 1 in 4,000
perchloride of mercury lotion. Great care should be taken to remove
all portions of the uveal tract; this is best ensured by visual
inspection after the hæmorrhage has ceased. The interior of the
sclerotic should appear perfectly white.
Third step. Although not absolutely necessary, and inadvisable in the
case of a septic globe, a single suture may be passed through the
centre of the wound in the conjunctiva and sclerotic.
Complications. As the operation is not infrequently performed
for panophthalmitis, much swelling of the lids and discharge from the
socket may take place after the operation; these symptoms usually
subside in the course of a few weeks without further trouble. The
interval which must elapse before an artificial eye can be worn is
considerably longer than after enucleation.

MULES’S OPERATION
Mules’s operation is the insertion of a celluloid globe into the sclerotic
after evisceration, followed by closure of the scleral wound over it. In
both this and Frost’s operation a better stump is formed, so that
more movement may be obtained in the artificial eye which is
subsequently worn over the inserted globe.
Indications. (i) The operation is especially suitable for anterior
staphyloma following ophthalmia neonatorum. In young children the
presence of the ball in the orbit assists the development of that
structure.
(ii) It is also suitable for large, recently made, fairly aseptic wounds
in the globe.
Operation. The first two steps are the same as for evisceration.
Third step. A glass or, better, a celluloid or gold-plated ball is inserted
into the sclerotic, which is closed over it by two rows of interrupted
sutures, one of catgut passing through the sclerotic, the other of silk
closing over the conjunctival wound. To facilitate the closure of the
conjunctival wound it is advisable to dissect the conjunctiva back
from the limbus before excising the cornea. The ball inserted in the
sclerotic should fit the cavity loosely.
Complications. In about 17% of the cases the ball is not retained;
this is not infrequently due to too large a size being used, or to the
wound being imperfectly closed by the sutures. If two rows be used,
as described above, extrusion of the ball is far less frequent than if
one only be inserted. If the globe be extruded the patient is in the
same position as if he had had evisceration performed.

FROST’S OPERATION
In this operation the eye is enucleated, a celluloid globe is inserted
into Tenon’s capsule, and the conjunctiva is closed over it by means
of sutures passing through Tenon’s capsule and the conjunctiva.
Operation. The first four steps in the operation are similar to those
described under enucleation.
Fifth step. A small, loosely-fitting glass globe is inserted into Tenon’s
capsule. A purse-string suture of strong catgut is then inserted into
the cut margin of Tenon’s capsule, taking care to include in the
sutures the cut ends of the tendons of the recti muscles. The suture
is drawn tight and tied so that Tenon’s capsule and the muscles are
thereby drawn over the globe. The conjunctival wound is closed over
this by a separate suture of silk.
The advantage of this operation over the other substitutes for simple
enucleation is that it can be used after any enucleation. The chief
disadvantages are that the globe is sometimes extruded unless the
wound be carefully closed by sutures, and occasionally it may
become dislocated from Tenon’s capsule beneath the conjunctiva,
thus preventing an artificial eye from being worn, and requiring
removal. These disadvantages are largely done away with if the
method of suture described above be used.

OPERATIONS UPON THE SOCKET AFTER THE REMOVAL OF

THE EYE

PARAFFIN INJECTION

Indications. Occasionally after an eye has been removed the

movements in the socket are not communicated sufficiently to the
artificial eye which is placed over it, so that the glass eye has a fixed,
staring appearance. As a rule, this can be remedied by the use of a
Snellen’s improved eye, which has a rounded posterior surface and
fits well on to the stump. If this be not satisfactory, the injection of
paraffin into the stump will often improve the movements
considerably. The injection should be made by what is known as the
‘cold method’.
The ‘cold method’ of paraffin injection is by far the most
satisfactory, for the following reasons:—
(a) The temperature need not be so high, and no damage is
therefore done to the tissues.
(b) It is more easily regulated (see Vol. I, p. 682).
(c) Embolism is less likely to occur.
Instruments. Fixation forceps, tenotomy knife, speculum, a large
paraffin syringe, and a short needle having a big bore.
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