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ly toward each border. The small traction hook shown be- low is then introduced beneath the tendon whicli it draws forward. The needle is carried tbrouffh the tendon as far March 30, 1889.) STEVENS: SHORTENINO THE RECTI MUSCLES. 347 back as necessary. If it is carried so far back as to leave in front of it any considerable extent of the tendon, this may be shaved off by the scissors so as to leave a very thin bor- der. The needle is then carried through the anterior lip of the tendon, as has already been directed, and the suture se- cnred as before. Before finally tying in either case the pa- tient should be tested in respect to the result, when, if it is excessive, the suture may be loosened before finally tying, and, if insufficient, the operation can be carried further. No extensive cicatrization occurs after such operations. The tendon is not bound either to the sclera or the conjunc- tiva. Union takes place by first intention, hence there is very slight prospect of losing the result of the operation, al- though, owing to the elasticity of the parts included in the suture, an excess of effect should be temporarily induced. Owing to the extreme fineness of the thread, no inflamma- tion is set up about it. It may be removed after five or six days, or it cuts its way out without assistance. A few weeks after such an operation only minute traces of it can be dis- covered. No unsightly scar and no adhesions are left to remind the patient or the surgeon that an operation has been done. Two great disadvantages following the standard opera- tions for strabismus are the recession of the caruncle and the loss of ability to bring the cornea of the eye operated on sufficiently toward the canthus corresponding to the severed tendon. These defects may be avoided by the adoption of two measures : 1, The tenotomy is to be made by the method which T have described * for heterophoria, except that the division of the tendon is made more com- plete. Little, if any, recession of the caruncle succeeds to such an operation, as the wound of the conjunctiva is re- duced to the smallest extent, and the tissues are not sepa- rated from the sclera as in the ordinary operation. 2. The tenotomy should not be carried to the extent of so complete a setting back of the tendon as to alter the position of the caruncle or to seriously interfere with the rotating action of the muscle. After a moderate relaxation of the shortened tendon by such a guarded tenotomy, tendon resection of the opposing muscle can be made to supplement the effect, thus maintaining a more uniform tension of the two op- posing muscles than could be preserved after a greater set- ting back of the tendon or after an advancement without tenotomy. In most cases of the ordinary converging or diverging strabismus, therefore, tendon resection can be advantage- ously combined with moderate tenotomy on one or both eyes. I have found that, in a certain proportion of cases of heterophoria in which the balance appears to be lost through the feeble action of one set of muscles rather than through the immoderate contraction of their opponents, tendon re- section preserves more perfectly the functions of the recti muscles than does tenotomy. In high grades of esophoria or exophoria, also, tendon resection is advantageously com- bined with tenotomy. In such cases we make a slight short- ening of each of the weaker muscles, followed by tenotomy * "Archives of Ophthalmology," vol. xvi, No. 2, June, 1887, and vol. xvii, No. 2, June, 1888. of each of the opposing tendons. There is less objection to so many operations tlian to a single excessive tenotomy. For the performance of tenotomies Buy Sildalis or of tendon resec- tions in the manner which I have described, certain forms of instruments are necessary and certain others desirable. It will therefore be in place here to refer to the various in- struments which I find useful in these operations. They are such as have resulted from the necessities or conven- iences of the operations during the various stages of their evolution. It is with much satisfaction that I acknowledge the prac- tical assistance which I have received from time to time from Mr. F. A. Stohlmann, of Messrs. Tiemann & Co., who has brought to the work his great experience and a sincere desire to render every aid in perfecting the instruments. Each instrument is so constructed as to admit of perfect cleanliness, those having crossed blades being provided with Charriere's lock ; they can, therefore, all be kept easily and perfectly aseptic. Fig. \.

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