276
JOURNAL OF NATIONAL MEDICAL ASSOCIATION
JULY, 1976
Ectropion in an Adolescent Female A Case Report AXEL C. HANSEN, M.D., F.A.C.S., George W. Hubbard Hospital, Meharry Medical College, Nashville, Tennessee
ECTROPION or eversion of the eyelid is not an uncommon occurrence in the practice of ophthalmology. It is usually seen in elderly patients and most often involves the lower eyelid. When it occurs in young people, it is almost always a transient finding or a complication of a facial injury or burn. This case is reported because of the patient's youth, the debatable etiology, the degree of ectropion, the conjunctival prolapse and the lack of response to conventional management. It is also interesting that an old surgical procedure which was eventually resorted to seems to have corrected the disfiguring abnormality.
solution and gentamycin ointment were prescribed to be used topically and tetracycline by mouth. On subsequent visits the conjunctivitis cleared but severe ectropion with conjunctival prolapse persisted. Accordingly, the patient was hospitalized and on August 9, 1973, an attempt was made to reduce the prolapse under general anesthesia using a modified Snellen mattress suture technic. Three double-armed 4-0 black silk sutures threaded on small rubber pegs were passed through the inferior fornix conjunctivae and tied over rubber boots on the skin surface after emerging below the inferior orbital margin. A modified Frost suture was used to
CASE REPORT
L.R., a 13 year old black female, was first seen in the Eye Clinic of the George W. Hubbard Hospital on July 16, 1973 with marked ectropion of the left lower eyelid and prolapse of the inferior fornix conjunctivae. The history indicated that this condition had been present for about five months, prior to which there was no deformity. The involved conjunctiva was beefy red, edematous and greatly thickened and there was a moderate amount of mucopurulent discharge, but the cornea was not involved (Fig. la). The eyes were otherwise normal and the general health of the patient was excellent. Four months before, the patient had been treated for the same condition at another institution, first as an outpatient and later as an inpatient. On those occasions, she was treated with ampicillin by mouth, neosporin solution and polysporin ointment topically, warm compresses and Saran-wrap moist-chamber shielding of the involved eye. Cultures at that time grew Staphylococcus aureus and diphtheroids and it was thought that the infection may have been factitious. The patient was last seen in the outpatient department of that hospital on April 30, 1973, on which date there was no conjunctival discharge but the ectropion was unchanged. On the initial visit to our eye clinic, material from the involved eyelid was obtained for bacteriological study and the following organisms were grown: Klebsiella, Herellea and Staphylococcus aureus. Based on sensitivity studies of these organisms, neosporin
Fig 1 See text for description raise the lower eyelid and maintain it in a near normal position in relation to the globe and the patient was discharged a few days later. On August 27, 1973 when the sutures were removed, there was no evidence of infection, the prolapse and ectropion appeared much improved and the patient was advised to use neosporin ointment to the eye Q. D On subsequent visits, recurrence of the ectropion and prolapse of the conjunctiva were noted and the patient was rehospitalized on September 10 1973 The following day, under general anesthesia a Terson procedure was done excising a spindle-shaped segment of the inferior palpebral con-
Vol. 68, No. 4
Ectropion in an Adolescent Female
junctiva measuring 2.5 x 0.5 cm., and using a modified Frost suture to position and fix the lower eyelid. The pathological diagnosis of the resected conjunctiva was "chronic inflammation" and the patient was followed in the clinic. Once more, there was a recurrence of the ectropion and the patient was hospitalized for a third time. On October 11, 1973, a Ziegler procedure was performed under general anesthesia. Seven cautery punctures were made through the palpebral conjunctiva at the lower border of the inferior tarsal plate, extending the entire length of the eyelid. Almost immediately, improvement was noted and before the patient left the operating suite, the lower eyelid was in good position and no palpebral conjunctiva was visible. In addition, the prolapse of the fornix conjunctivae was completely reduced and it was unnecessary to place a Frost suture. Post-operative visits were made to the outpatient clinic and on March 6, 1974, the final result was cosmetically and functionally satisfactory (Fig. lb) and vision was corrected to 20/20 in each eye. On March 1, 1976, more than two years after the last surgery, there was no evidence of recurrence and the patient's appearance remains good (Fig. lc). DISCUSSION
Several classifications of ectropion have been proposed."12'3 All of these are very similar, but that suggested by Fox1 probably has the widest acceptance. He divides the condition into two broad categories, congenital and acquired, and subdivides the acquired form into five types: acute spastic, mechanical, senile, paralytic and cicatricial. According to him, congenital ectropion is rare and is usually accompanied by other congenital ocular defects, while acute spastic ectropion is a transient phenomenon due to momentary spasm of the marginal orbicularis oculi fibers. He states that the mechanical variety occurs when the eyelid is pulled away from the globe by the weight of edema or tumor, or pushed away by exophthalmos or proptosis. Mechanical ectropion may also be the result of chronic inflammation with marked thickening and hypertrophy of the palpebral conjunctiva.',5 Senile ectropion, according to Fox, occurs more often than all other types combined and is usually atonic, with loss of muscle tone and subsequent relaxation of the eyelid. When there is paralysis of the orbicularis oculi muscle combined with the pull of gravity, paralytic ectropion may develop, while the cicatricial form of ectropion is associated with scarring and loss of tissue.'
277
The evolution of the case herein reported is questionable, however, it appears that the initial pathology was a severe conjunctivitis. Whether or not the infection was factitious is speculative, however, the mechanical nature of the ectropion requires less conjecture. It may be argued that the conjunctival inflammation triggered an acute spastic ectropion which became chronic, but certainly it was the marked thickening and hypertrophy of the palpebral conjunctiva which added the mechanical factor that caused progression and permanence of the ectropion. For this reason, it is suggested that the ectropion presented by this patient be classfied as mechanical. Although this type of eciropion may not require surgical correction if proper control of the conjunctival inflammation is achieved,5 the management of this case was not that simple. First, an attempt was made to eradicate the infection. After this had been accomplished, the next objective was to reduce the exposure and prolapse of the fornix conjunctivae which persisted. To this end, and not to correct the ectropion, a modified Snellen suture procedure was used, placing three mattress sutures in the inferior fornix instead of through the palpebral conjunctiva as is described.1'6'7 Later, a Terson spindle resection"8 was done to reduce the bulk of the eyelid so that inversion of the lid could be accomplished. Although the result of this surgery was only temporary, following it, there was very little residual horizontal lid laxity. A lid shortening operation was, therefore, not indicated and a Ziegler cautery procedure1' 6 produced the contraction necessary to draw the eyelid margin toward the globe. SUMMARY
A 13 year old black female with mechanical ectropion of the left lower eyelid secondary to severe chronic conjunctivitis is presented. After a prolonged course and three surgical procedures, the condition was cured and the patient remains functionally and cosmetically acceptable more than two years after the last surgical procedure. (Concluded on page 284)
284
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
simple and reproducible calibration and the elimination of the need for an arterial catheter. In addition, the introduction of flow directed balloon-tipped catheters, has made pulmonary artery catheterization a simple and safe bedside procedure. Knowledge of the CO together with the measurement of pulmonary arterial and capillary wedge pressure (PCWP) enable the clinician to construct ventricular function curves and choose appropriate therapy logically. Figure 3 shows results from a patient in whom serial measurements were made using thermodilution. SUMMARY
2.
3. 4.
5.
In summary, these data demonstrate a good correlation between the direct Fick and dye dilution methods, and between the dye dilution and the thermodilution techniques. The advantages of the thermodilution technique make it eminently suitable as a bedside procedure in intensive care units. The ability to measure serially both cardiac output and PAWP at the bedside enables the clinician to closely follow the hemodynamic status of acutely ill patients, choose therapy appropriately, and follow the results of therapy with greater accuracy.
6.
7.
8.
ACKNOWLEDGEMENTS
We are grateful to Dr. Robert Barndt for assistance with methodology and to Mrs. Arleen Olson and Mr. Gerard Willey for expert technical assistance. LITERATURE CITED
1. COURNAND, A. and H. A. RANGES, and R.
9.
10.
JULY, 1976
L. RILEY. Comparison of Results of Normal Ballisto Cardiogram and Direct Fick Method in Measuring Cardiac Output in Man. J. Clin. Invest., 21:287, 1942. HAMILTON, W. F. and R. L. RILEY, et al. Comparison of the Fick and Dye Injection Methods of Measuring the Cardiac Output in Man. Amer. J. Physiol., 153:309, 1948. FEGLER, G. Measurement of Cardiac Output in Anesthetized Animals by a Thermodilution Method. Quart. J. Exp. Physiol., 39: 153, 1954. MILLER, D. E. and W. L. GLEASON and H. D. MCINTOSH. A Comparison of the Cardiac Output Determination by the Fick Method and Dye Dilution Method Using Indocyanine Green Dye and a Cuvette Densitometer. J. Lab. Clin. Med., 59:345, 1962. WERKO, L. and H. LAGEXLOF, H. BUCHT, B. WEHLE, and A. HOLMGREN. Comparison of Fick and Hamilton Methods for Determination of Cardiac Output in Man. Scand. J. Clin. Lab. Invest., 1:109, 1949. VENKATARAMAN, K. and S. DURAIRAJ, M. DE GUZMAN, and L. J. HAYWOOD. Hemodynamic Effect of Sublingual Isosorbide Dinitrate in Acute Myocardial Infarction. (Abstract) Clinical Res., 24:90A, 1976. GANZ, W. and R. DONOSO, H. S. MARCUS. et al. A New Technique for Measurement of Cardiac Output by Thermodilution in Man. Am. J. Cardiol., 27:392, 1971. FORRESTER, J. S. and W. GANZ, G. DIAMOND et al. Thermodilution Cardiac Output Determination with a Single Flow Directed Catheter. Am. Heart J., 83:306, 1972. WEISEL, R. D. and R. L. BERGER and H. B. HECTMAN. Measurement of Cardiac Output by Thermodilution. N. Engl. J. Med., 292:682, 1975. SMITH, H. J. and A. ORIOL, J. MARCH, and M. MCGREGOR. Hemodynamic Studies in Cardiogenic Shock. Treatment with Isoproterenol and Metaraminol. Circulation, 35:1084, 1967.
(Hansen, from page 277) LITERATURE CITED
1. FOX S. A. Ophthalmic Plastic Surgery, 4th ed. New York, Grune and Stratton, 1970. 2. HILL, J. C. Ectropion. Int. Ophthalmol. Clin., 4:95-112, 1964. 3. BEARD, C. Ectropion. In Hughes, W. L. (ed.): Ophthalmic Plastic Surgery. Rochester, Minn., Am. Acad. Ophthalmol. and Otolaryng., 1961. 4. DUKE-ELDER, W. S. System of Ophthalmology, Vol. XIII, Part 1. St. Louis, C. V. Mosby, 1974.
5. ALLEN, J. H. In Liebman, S. D. and S. S. Gellis, (eds.): The Pediatrician's Ophthalmology. St. Louis, C. V. Mosby, 1966. 6. KING, J. H. and J. A. C. WADSWORTH. An Atlas of Ophthalmic Surgery, 2nd ed. Philadelphia, J. B. Lippincott Co., 1972. 7. CALLAHAN, A. Surgery of the Eye-Injuries. Springfield, Charles C. Thomas Publisher, 1950. 8. FOX, S. A. Lid Surgery-Current Concepts. New York, Grune and Stratton, 1972.
JOURNAL OF NATIONAL MEDICAL ASSOCIATION
JULY, 1976
Ectropion in an Adolescent Female A Case Report AXEL C. HANSEN, M.D., F.A.C.S., George W. Hubbard Hospital, Meharry Medical College, Nashville, Tennessee
ECTROPION or eversion of the eyelid is not an uncommon occurrence in the practice of ophthalmology. It is usually seen in elderly patients and most often involves the lower eyelid. When it occurs in young people, it is almost always a transient finding or a complication of a facial injury or burn. This case is reported because of the patient's youth, the debatable etiology, the degree of ectropion, the conjunctival prolapse and the lack of response to conventional management. It is also interesting that an old surgical procedure which was eventually resorted to seems to have corrected the disfiguring abnormality.
solution and gentamycin ointment were prescribed to be used topically and tetracycline by mouth. On subsequent visits the conjunctivitis cleared but severe ectropion with conjunctival prolapse persisted. Accordingly, the patient was hospitalized and on August 9, 1973, an attempt was made to reduce the prolapse under general anesthesia using a modified Snellen mattress suture technic. Three double-armed 4-0 black silk sutures threaded on small rubber pegs were passed through the inferior fornix conjunctivae and tied over rubber boots on the skin surface after emerging below the inferior orbital margin. A modified Frost suture was used to
CASE REPORT
L.R., a 13 year old black female, was first seen in the Eye Clinic of the George W. Hubbard Hospital on July 16, 1973 with marked ectropion of the left lower eyelid and prolapse of the inferior fornix conjunctivae. The history indicated that this condition had been present for about five months, prior to which there was no deformity. The involved conjunctiva was beefy red, edematous and greatly thickened and there was a moderate amount of mucopurulent discharge, but the cornea was not involved (Fig. la). The eyes were otherwise normal and the general health of the patient was excellent. Four months before, the patient had been treated for the same condition at another institution, first as an outpatient and later as an inpatient. On those occasions, she was treated with ampicillin by mouth, neosporin solution and polysporin ointment topically, warm compresses and Saran-wrap moist-chamber shielding of the involved eye. Cultures at that time grew Staphylococcus aureus and diphtheroids and it was thought that the infection may have been factitious. The patient was last seen in the outpatient department of that hospital on April 30, 1973, on which date there was no conjunctival discharge but the ectropion was unchanged. On the initial visit to our eye clinic, material from the involved eyelid was obtained for bacteriological study and the following organisms were grown: Klebsiella, Herellea and Staphylococcus aureus. Based on sensitivity studies of these organisms, neosporin
Fig 1 See text for description raise the lower eyelid and maintain it in a near normal position in relation to the globe and the patient was discharged a few days later. On August 27, 1973 when the sutures were removed, there was no evidence of infection, the prolapse and ectropion appeared much improved and the patient was advised to use neosporin ointment to the eye Q. D On subsequent visits, recurrence of the ectropion and prolapse of the conjunctiva were noted and the patient was rehospitalized on September 10 1973 The following day, under general anesthesia a Terson procedure was done excising a spindle-shaped segment of the inferior palpebral con-
Vol. 68, No. 4
Ectropion in an Adolescent Female
junctiva measuring 2.5 x 0.5 cm., and using a modified Frost suture to position and fix the lower eyelid. The pathological diagnosis of the resected conjunctiva was "chronic inflammation" and the patient was followed in the clinic. Once more, there was a recurrence of the ectropion and the patient was hospitalized for a third time. On October 11, 1973, a Ziegler procedure was performed under general anesthesia. Seven cautery punctures were made through the palpebral conjunctiva at the lower border of the inferior tarsal plate, extending the entire length of the eyelid. Almost immediately, improvement was noted and before the patient left the operating suite, the lower eyelid was in good position and no palpebral conjunctiva was visible. In addition, the prolapse of the fornix conjunctivae was completely reduced and it was unnecessary to place a Frost suture. Post-operative visits were made to the outpatient clinic and on March 6, 1974, the final result was cosmetically and functionally satisfactory (Fig. lb) and vision was corrected to 20/20 in each eye. On March 1, 1976, more than two years after the last surgery, there was no evidence of recurrence and the patient's appearance remains good (Fig. lc). DISCUSSION
Several classifications of ectropion have been proposed."12'3 All of these are very similar, but that suggested by Fox1 probably has the widest acceptance. He divides the condition into two broad categories, congenital and acquired, and subdivides the acquired form into five types: acute spastic, mechanical, senile, paralytic and cicatricial. According to him, congenital ectropion is rare and is usually accompanied by other congenital ocular defects, while acute spastic ectropion is a transient phenomenon due to momentary spasm of the marginal orbicularis oculi fibers. He states that the mechanical variety occurs when the eyelid is pulled away from the globe by the weight of edema or tumor, or pushed away by exophthalmos or proptosis. Mechanical ectropion may also be the result of chronic inflammation with marked thickening and hypertrophy of the palpebral conjunctiva.',5 Senile ectropion, according to Fox, occurs more often than all other types combined and is usually atonic, with loss of muscle tone and subsequent relaxation of the eyelid. When there is paralysis of the orbicularis oculi muscle combined with the pull of gravity, paralytic ectropion may develop, while the cicatricial form of ectropion is associated with scarring and loss of tissue.'
277
The evolution of the case herein reported is questionable, however, it appears that the initial pathology was a severe conjunctivitis. Whether or not the infection was factitious is speculative, however, the mechanical nature of the ectropion requires less conjecture. It may be argued that the conjunctival inflammation triggered an acute spastic ectropion which became chronic, but certainly it was the marked thickening and hypertrophy of the palpebral conjunctiva which added the mechanical factor that caused progression and permanence of the ectropion. For this reason, it is suggested that the ectropion presented by this patient be classfied as mechanical. Although this type of eciropion may not require surgical correction if proper control of the conjunctival inflammation is achieved,5 the management of this case was not that simple. First, an attempt was made to eradicate the infection. After this had been accomplished, the next objective was to reduce the exposure and prolapse of the fornix conjunctivae which persisted. To this end, and not to correct the ectropion, a modified Snellen suture procedure was used, placing three mattress sutures in the inferior fornix instead of through the palpebral conjunctiva as is described.1'6'7 Later, a Terson spindle resection"8 was done to reduce the bulk of the eyelid so that inversion of the lid could be accomplished. Although the result of this surgery was only temporary, following it, there was very little residual horizontal lid laxity. A lid shortening operation was, therefore, not indicated and a Ziegler cautery procedure1' 6 produced the contraction necessary to draw the eyelid margin toward the globe. SUMMARY
A 13 year old black female with mechanical ectropion of the left lower eyelid secondary to severe chronic conjunctivitis is presented. After a prolonged course and three surgical procedures, the condition was cured and the patient remains functionally and cosmetically acceptable more than two years after the last surgical procedure. (Concluded on page 284)
284
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
simple and reproducible calibration and the elimination of the need for an arterial catheter. In addition, the introduction of flow directed balloon-tipped catheters, has made pulmonary artery catheterization a simple and safe bedside procedure. Knowledge of the CO together with the measurement of pulmonary arterial and capillary wedge pressure (PCWP) enable the clinician to construct ventricular function curves and choose appropriate therapy logically. Figure 3 shows results from a patient in whom serial measurements were made using thermodilution. SUMMARY
2.
3. 4.
5.
In summary, these data demonstrate a good correlation between the direct Fick and dye dilution methods, and between the dye dilution and the thermodilution techniques. The advantages of the thermodilution technique make it eminently suitable as a bedside procedure in intensive care units. The ability to measure serially both cardiac output and PAWP at the bedside enables the clinician to closely follow the hemodynamic status of acutely ill patients, choose therapy appropriately, and follow the results of therapy with greater accuracy.
6.
7.
8.
ACKNOWLEDGEMENTS
We are grateful to Dr. Robert Barndt for assistance with methodology and to Mrs. Arleen Olson and Mr. Gerard Willey for expert technical assistance. LITERATURE CITED
1. COURNAND, A. and H. A. RANGES, and R.
9.
10.
JULY, 1976
L. RILEY. Comparison of Results of Normal Ballisto Cardiogram and Direct Fick Method in Measuring Cardiac Output in Man. J. Clin. Invest., 21:287, 1942. HAMILTON, W. F. and R. L. RILEY, et al. Comparison of the Fick and Dye Injection Methods of Measuring the Cardiac Output in Man. Amer. J. Physiol., 153:309, 1948. FEGLER, G. Measurement of Cardiac Output in Anesthetized Animals by a Thermodilution Method. Quart. J. Exp. Physiol., 39: 153, 1954. MILLER, D. E. and W. L. GLEASON and H. D. MCINTOSH. A Comparison of the Cardiac Output Determination by the Fick Method and Dye Dilution Method Using Indocyanine Green Dye and a Cuvette Densitometer. J. Lab. Clin. Med., 59:345, 1962. WERKO, L. and H. LAGEXLOF, H. BUCHT, B. WEHLE, and A. HOLMGREN. Comparison of Fick and Hamilton Methods for Determination of Cardiac Output in Man. Scand. J. Clin. Lab. Invest., 1:109, 1949. VENKATARAMAN, K. and S. DURAIRAJ, M. DE GUZMAN, and L. J. HAYWOOD. Hemodynamic Effect of Sublingual Isosorbide Dinitrate in Acute Myocardial Infarction. (Abstract) Clinical Res., 24:90A, 1976. GANZ, W. and R. DONOSO, H. S. MARCUS. et al. A New Technique for Measurement of Cardiac Output by Thermodilution in Man. Am. J. Cardiol., 27:392, 1971. FORRESTER, J. S. and W. GANZ, G. DIAMOND et al. Thermodilution Cardiac Output Determination with a Single Flow Directed Catheter. Am. Heart J., 83:306, 1972. WEISEL, R. D. and R. L. BERGER and H. B. HECTMAN. Measurement of Cardiac Output by Thermodilution. N. Engl. J. Med., 292:682, 1975. SMITH, H. J. and A. ORIOL, J. MARCH, and M. MCGREGOR. Hemodynamic Studies in Cardiogenic Shock. Treatment with Isoproterenol and Metaraminol. Circulation, 35:1084, 1967.
(Hansen, from page 277) LITERATURE CITED
1. FOX S. A. Ophthalmic Plastic Surgery, 4th ed. New York, Grune and Stratton, 1970. 2. HILL, J. C. Ectropion. Int. Ophthalmol. Clin., 4:95-112, 1964. 3. BEARD, C. Ectropion. In Hughes, W. L. (ed.): Ophthalmic Plastic Surgery. Rochester, Minn., Am. Acad. Ophthalmol. and Otolaryng., 1961. 4. DUKE-ELDER, W. S. System of Ophthalmology, Vol. XIII, Part 1. St. Louis, C. V. Mosby, 1974.
5. ALLEN, J. H. In Liebman, S. D. and S. S. Gellis, (eds.): The Pediatrician's Ophthalmology. St. Louis, C. V. Mosby, 1966. 6. KING, J. H. and J. A. C. WADSWORTH. An Atlas of Ophthalmic Surgery, 2nd ed. Philadelphia, J. B. Lippincott Co., 1972. 7. CALLAHAN, A. Surgery of the Eye-Injuries. Springfield, Charles C. Thomas Publisher, 1950. 8. FOX, S. A. Lid Surgery-Current Concepts. New York, Grune and Stratton, 1972.
