Howard Reed

CARDIAC SLOWING DURING STRABISMUS SURGERY

CARDIAC arrest is a frightening complication which may confront a surgeon at any operation. It is fortunate that it is relatively uncommon, but there is a danger of false security. Eye surgeons face this complication less frequently than general or thoracic surgeons, but few ofthose who have practised for many years have not met cases of actual or threatened cardiac arrest. Kirsch, Samet, Kugel, and Axelrod (1957) have estimated that cardiac arrest occurs in about 1 in 1,500 cases in general surgery and in about one in 3,500 cases in eye operations. Snyder, Snyder, and Chaffin (1953) considered that cardiac arrest occurs in about 1 in 2,500 cases. Milstein (1956) quoted estimates varying from 1 in 858 to 1 in 4,950 operations. Gartner and Billet (1958) estimated that about 45 deaths occurred during eye surgery in the United States of America every year. This problem is, therefore, a very real one.

MÖBIUS'S SYNDROME

Various terms have been applied to this condition: Mobiuss syndrome, congenital facial diplegia, congenital oculo-facial paralysis, nuclear agenesis, and congenital nuclear aplasia. It was originally described by von Graefe (1880), Harlan (1881), and Chisolm (1882). M6bius (1892) collected 43 cases of congenital and acquired cranial nerve palsies and classified them into six groups. One group consisted of six cases of bilateral abducens and facial nerve palsies. Since then Mobiuss name has been associated with this condition. It is relatively uncommon and its bizarre association of lesions may cause affected children to be taken to a paediatrician, an orthopaedic surgeon, an ophthalmologist, or a child psychiatrist. The purposes of the present paper are to record three more cases of this rare condition, to report the absence of any association with Rh incompatibility, and to suggest that the clue to its aetiology may lie in a more detailed investigation of pregnancy histories. A typical case of Mobiuss syndrome shows the following features: (1) Bilateral Facial Palsy.-This is the most obvious feature and it may or may not be complete. If it is not complete the lower part of the face is usually less affected than the upper. This is unlike a supranuclear facial palsy in which the upper part of the face escapes, nor does it resemble a nerve trunk lesion in which the whole side of the face is equally affected. Another feature characteristic of this condition is the absence of the sagging of the facial tissues, which is so disfiguring a feature of acquired seventh-nerve palsies. If the flesh of the cheek is palpated between finger and thumb it feels peculiarly thin. Contraction of the facial muscles, like that which occurs in cases of Bells palsy with recovery, is never seen. Invariably there is a history of sucking and feeding problems in infancy. Dribbling tends to persist into childhood, and when the child is eating, food tends -to lodge in the cheeks and has to be pushed out with the fingers. The orbicularis oculi muscle is defective so that there is incomplete closure of -the lids in sleep, infrequent blinking, tearing, and a tendency to a recurrent lowgrade kerato-conjunctivitis from exposure. (2) Absence of Abduction of either eye beyond the mid-line, and palsy of the horizontal gaze, so that when looking to either side the child must turn the head. (3) Convergence.-This is usually present but defective. The pupils constrict -normally during convergence. (4) Vertical Gaze.-Movements are normal and Bells phenomenon is intact. (5) Convergent Strabismus is occasionally present.

USE OF DIMETHYL SULPHOXIDE FOR PRESERVING CORNEAL TISSUE

SINCE it was discovered by Polge, Smith, and Parkes (1949) that living cells could be protected during freezing and thawing by adding glycerol to the storage medium, various substances and methods have been used in an attempt to achieve better results (Fleming,: 1952; Eastcott, Cross, Leigh, and North, 1954; Lovelock, 1954). We have been concerned with retaining the viability of corneal tissue after freezing and in the past (Reed, Stanfield, and Nagel-Leindl, 1960) have corroborated the findings of Eastcott and others (1954) and of Cockeram, Basu, and Ormsby (1957), who have shown that a 15 per cent./V solution of glycerol is the optimum concentration for the preservation of cornea at dry ice temperatures. The value of this freezing method has been demonstrated clinically (Eastcott and others, 1954) as well as experimentally, using the growth of the corneal tissue in tissue culture as the criterion for viability (Reed and others, 1960; Ormsby and others, 1957). Lovelock (1954) experimented with various neutral solutes and has demonstrated that living cells are afforded protection only when the solute is permeable to the cell. In more recent experiments, Lovelock and Bishop (1959) used dimethyl sulphoxide, a neutral solute with a low molecular weight which is more readily permeable to living cells than glycerol. However, it was found to be less effective than glycerol in the protection of bull spermatozoa during freezing. Our need to maintain a supply of stored corneae for keratoplasty prompted us to set up an experiment to evaluate the usefulness of dimethyl sulphoxide in preserving the viability of cornea during freezing.

Keratome or Knife Incision for Cataract : Assessment of 180 Cases

DAVIEL (1753) described the first satisfactory method of cataract extraction before the Academie Royale de Chirurgie in 1752. He opened the eye with an instrument similar to the modern keratome and enlarged the incision with scissors. This method gradually displaced the ancient practice of couching until von Graefe described his cataract knife for making the incision in 1865. Von Graefes cataract knife then remained in common use until about 10 years ago when the keratome began to regain favour. In America the keratome is now the most popular instrument, but in England the cataract knife is still in most common use. The incision is one of the biggest factors in performing a successful extraction, and it is important to try to determine which is the better method. This series of extractions was planned in an attempt to assess the relative value of using the keratome or the cataract knife for this purpose. A few series have been reported in which the results of each type of operation performed by a number of operators have been compared (Davis, 1950; Randolph and Eareckson, 1953), but this is not satisfactory because it does not eliminate the varying skills of the different operators. The skill of the operator may be a bigger factor than the type of incision used. In this series all the operations were performed by the author and ail cataract extractions performed during the period under review have been included. In an attempt to elinminate all possible variables the two methods were used alternately. This routine was broken only when operating upon the second eye of a patient when the alternative method of incision was used. In this consecutive series of 180 cataract extractions ninety were made with a cataract knife and ninety with the keratome and scissors. I intended at first to use no sutures, because a bad section can be firmly closed by accurate corneoscleral suturing and a good section can be made to gape by faulty sutures. In the first 82 cases in this series, I used conjunctival sutures in four cases only, but in the last 98 cases the conjunctival flap was closed with three or four silk sutures. No corneoscleral sutures were used because I considered they would influence the comparison of the two types of incision.