EWING: An Operation for Atrophic Entropion.
I5
AN OPERATION FOR ATROPHIC ENTROPION, ESPECIALLY OF THE LOWER LID. BY ARTHUR E. EWING, M.D.,
ST. Louis, Mo.
When the lower eyelid has been distorted by.disease, as from trachoma or other cause, so that the cilia turn against and rub upon the globe, it has been my experience that operations for the correction of the defect are frequently unsuccessful. With most of the methods in common use, the removal of a strip of skin or of muscle, 'or both, is the rule, although the atrophied lids can ill afford to lose any of their already shrunken tissue. To such lids Dr. Green's operation is the kindest of all, because collodion (contractile) is used as a splint for keeping the lips of the tarsal incision apart until healing can be effected, so that no tissue is sacrificed; in fact, after the healing there is an actual gain in the height of the tarsal surface. The operation has the further valuable feature that it may be repeated upon the same lid as often as may be necessary, without ally evil results. It also truly everts the margin of the lid, and with time the cilia tend more and more to take their proper direction. That this should be so is easily understood when we consider that the incision is made through the tarsus along a line very near the bases of the papillae of the cilia. WVith the consolidation of the cicatrix these bases are drawn to it, and thus the lashes are gradually tilted into a more normal position. One of the subjects of the operation to be described had suffered with trachoma for nine years, and besides this had been from time to time presented by electrolysis. When she presented herself the entropion was complete throughout the full length of both the upper and lower lids, and the conjunctival sacs were greatly shrunken. A canthoplasty upon each eye improved
i6
EWING: An Operation for Atrophic Entropion.
the condition somewhat, and the operation by Dr. Green's method upon the upper lids resulted with them as favorably as could be desired. The same operation was tried twice thoroughly upon the right lower lid, and once upon the left, each time with improvement in the position of the lid margins, but still leaving the cilia along the central portion of each lid turning in,. During the long course of inflammation from which the patient had suffered, the atrophy had become so great that the lids of each eye at best barely came together when normally closed. For this reason it was imperative to obtain a result by the tarsal incision, or by some means that would lengthen the tarsal portion of the lid instead of shortening it. This seems to have been accomplished in the following manner: Beginning on the inner surface of the lid as near the openings of the Meibomian glands as is possible, the conjunctiva, along the full length of the lid, from the outer canthus as far as to the punctum, was dissected back three to four millimeters (Figs. i and 2). Then, about two and a half to three millimeters from .the lid margin, an incision was made entirely through the tarsus (as in Dr. Green's method) also the full length of the lid (Figs. i and 3). The portion of the tarsus containing the cilia was then turned .forward, and into its posterior edge next the orbicularis muscle a suture was introduced about the centre of the lid, and brought out about the centre of the incised surface of the cartilage. The same needle was then again entered upon the skin surface in the line of the cilia, and carried vertically downward and brought out through the skin about six millimeters below the point of entrance (Fig. 4). A similar suture was placed in the inner half of the lid, and another in the outer half. A firm roll of moist aseptic gauze, or absorbent cotton, about three millimeters in diameter, was then placed along the lid just below the cilia, and over this the sutures were tied, making a sort of flexible quill suture (Fig. 5). It is not necessary or advisable to tie these sutures very tightly, for fear of impairing the circulation in the.central portion of the lid. Their purpose is to evert the margin of the divided tarsus and bring the raw surface into the position formerly
FIG. I. '-,
::----
.:.:.!..'
%':'
.. 11."::
i,
FIG. II.
FIG. III.
FIG. IV.
FIG. V.
Fig. L - Conjunctival flap (f ), and the tarsal incision (c). Fig. II.- Cross-sectioh showing the dissected conjunctival flap; Fig. III. the tarsal incisiOn; Fig. I I. the mode of suturing; Fig. V. the application of the gauze or cottont roll.
EWING: An Operation for Atropht
Entro.pion.
17
occupied by the inverted mouths of the Meibomian glands. It -is also not necessary to enter these sutures at the cilia and carry them through the skin. They may be carried over the roll and tacked into the skin below it. The only reason for entering them at the cilia is that the track through the skin will form a slight scar which may assist in maintaining the eversion. After the eversion was accomplished, the conjunctival flap was brought forward by numerous fine sutures and stitched deeply into the angle made by the turning forward of the everted portion of the tarsus (Fig. 5). This covers, with an epithelial surface, both the raw edge of the divided tarsus and the exposed fibres of the orbicularis. The conjunctival sac was then irrigated with corrosive sublimate, I15000 solution, and the eye bandaged. The following day the eye was again cleansed in the same manner. The third day the roll of gauze was removed and the threads drawn out from their tracks under the skin, but not from their tarsal attachment. They were still utilized to maintain the eversion by pasting them, in company with such cilia as were available for the purpose, to the skin surface with contractile collodion. The conjunctival sutures, being very superficial, generally come away of themselves after five or six days, or they may be removed as may seem best. The greatest difficulty in the operation is to dissect the conjunctival flap evenly and smoothly. For this purpose I use a thin, double-edged, round-ended spatula-shaped knife, the cutting edge extending around the end. The same knife may also be used for the tarsal incision. The bellied half-round knife used bv Dr. Green for the tarsal incision is also excellent for this dissection. In this, as in Dr. Green's operation, it is of the greatest importance that the tarsus be thoroughly divided. When this is accomplished it is known by the dark muscle showing in the incision, by the ecchymosis on the skin surface, and by the ease with which the two parts of the divided tarsus may be raised. up from the muscle tissue. The incision should be kept at least two and a half millimeters from the lid margin, as the papillae of the cilia extend thus far into the tarsus. Should any of these papillx OPH.-2
18
WEEKS: Operative Treatment of Entropion.
be left on the posterior portion, cilia would be very likely to sprout up through the incision. The formation of granulomata is not so common as when the tarsal incision is left uncovered by mucous membrane. When they appear in the line of the divided tarsus, they may be removed by curette, knife, or scissors. Puckering of the lid margin may follow, as in the simple tarsal incision; this may be remedied later by making one or more deep vertical incisions, as practiced by Dr. Green, or it may be left to take care of itself. I have usually found that in time it straightens out of .its own accord with advantage to the desired eversion. The method differs from that of Dr. Green only in the applying of the quill suture, and in covering a portion of the incision with mucous membrane. A combination of a form of quill suture with the tarsal incision has, I am told, been used by Professor Voelckers in the University at Kiel for a number of years.
OPERATIVE TREATMENT OF ENTROPION BY THE TRANSPLANTATION OF A FLAP OF MUCOUS MEMBRANE. BY JOHN E. WEEKS, M.D., NEW YORK CITY.
Shrinkage of the palpebral conjunctiva from whatever cause may produce entropion, but by far the most common cause is trachoma. The long-continued congestion of the tarsus occasions .some hypertrophy of that body. The traction of the shrinking tarsal conjunctiva lessens the vertical dimension of the tarsus, causing it to become more concave on its posterior surface and more convex on its anterior surface. The same condition is found in the lower as in the upper tarsus, but the former is so much narrower and thinner that the deformity is much less.
I5
AN OPERATION FOR ATROPHIC ENTROPION, ESPECIALLY OF THE LOWER LID. BY ARTHUR E. EWING, M.D.,
ST. Louis, Mo.
When the lower eyelid has been distorted by.disease, as from trachoma or other cause, so that the cilia turn against and rub upon the globe, it has been my experience that operations for the correction of the defect are frequently unsuccessful. With most of the methods in common use, the removal of a strip of skin or of muscle, 'or both, is the rule, although the atrophied lids can ill afford to lose any of their already shrunken tissue. To such lids Dr. Green's operation is the kindest of all, because collodion (contractile) is used as a splint for keeping the lips of the tarsal incision apart until healing can be effected, so that no tissue is sacrificed; in fact, after the healing there is an actual gain in the height of the tarsal surface. The operation has the further valuable feature that it may be repeated upon the same lid as often as may be necessary, without ally evil results. It also truly everts the margin of the lid, and with time the cilia tend more and more to take their proper direction. That this should be so is easily understood when we consider that the incision is made through the tarsus along a line very near the bases of the papillae of the cilia. WVith the consolidation of the cicatrix these bases are drawn to it, and thus the lashes are gradually tilted into a more normal position. One of the subjects of the operation to be described had suffered with trachoma for nine years, and besides this had been from time to time presented by electrolysis. When she presented herself the entropion was complete throughout the full length of both the upper and lower lids, and the conjunctival sacs were greatly shrunken. A canthoplasty upon each eye improved
i6
EWING: An Operation for Atrophic Entropion.
the condition somewhat, and the operation by Dr. Green's method upon the upper lids resulted with them as favorably as could be desired. The same operation was tried twice thoroughly upon the right lower lid, and once upon the left, each time with improvement in the position of the lid margins, but still leaving the cilia along the central portion of each lid turning in,. During the long course of inflammation from which the patient had suffered, the atrophy had become so great that the lids of each eye at best barely came together when normally closed. For this reason it was imperative to obtain a result by the tarsal incision, or by some means that would lengthen the tarsal portion of the lid instead of shortening it. This seems to have been accomplished in the following manner: Beginning on the inner surface of the lid as near the openings of the Meibomian glands as is possible, the conjunctiva, along the full length of the lid, from the outer canthus as far as to the punctum, was dissected back three to four millimeters (Figs. i and 2). Then, about two and a half to three millimeters from .the lid margin, an incision was made entirely through the tarsus (as in Dr. Green's method) also the full length of the lid (Figs. i and 3). The portion of the tarsus containing the cilia was then turned .forward, and into its posterior edge next the orbicularis muscle a suture was introduced about the centre of the lid, and brought out about the centre of the incised surface of the cartilage. The same needle was then again entered upon the skin surface in the line of the cilia, and carried vertically downward and brought out through the skin about six millimeters below the point of entrance (Fig. 4). A similar suture was placed in the inner half of the lid, and another in the outer half. A firm roll of moist aseptic gauze, or absorbent cotton, about three millimeters in diameter, was then placed along the lid just below the cilia, and over this the sutures were tied, making a sort of flexible quill suture (Fig. 5). It is not necessary or advisable to tie these sutures very tightly, for fear of impairing the circulation in the.central portion of the lid. Their purpose is to evert the margin of the divided tarsus and bring the raw surface into the position formerly
FIG. I. '-,
::----
.:.:.!..'
%':'
.. 11."::
i,
FIG. II.
FIG. III.
FIG. IV.
FIG. V.
Fig. L - Conjunctival flap (f ), and the tarsal incision (c). Fig. II.- Cross-sectioh showing the dissected conjunctival flap; Fig. III. the tarsal incisiOn; Fig. I I. the mode of suturing; Fig. V. the application of the gauze or cottont roll.
EWING: An Operation for Atropht
Entro.pion.
17
occupied by the inverted mouths of the Meibomian glands. It -is also not necessary to enter these sutures at the cilia and carry them through the skin. They may be carried over the roll and tacked into the skin below it. The only reason for entering them at the cilia is that the track through the skin will form a slight scar which may assist in maintaining the eversion. After the eversion was accomplished, the conjunctival flap was brought forward by numerous fine sutures and stitched deeply into the angle made by the turning forward of the everted portion of the tarsus (Fig. 5). This covers, with an epithelial surface, both the raw edge of the divided tarsus and the exposed fibres of the orbicularis. The conjunctival sac was then irrigated with corrosive sublimate, I15000 solution, and the eye bandaged. The following day the eye was again cleansed in the same manner. The third day the roll of gauze was removed and the threads drawn out from their tracks under the skin, but not from their tarsal attachment. They were still utilized to maintain the eversion by pasting them, in company with such cilia as were available for the purpose, to the skin surface with contractile collodion. The conjunctival sutures, being very superficial, generally come away of themselves after five or six days, or they may be removed as may seem best. The greatest difficulty in the operation is to dissect the conjunctival flap evenly and smoothly. For this purpose I use a thin, double-edged, round-ended spatula-shaped knife, the cutting edge extending around the end. The same knife may also be used for the tarsal incision. The bellied half-round knife used bv Dr. Green for the tarsal incision is also excellent for this dissection. In this, as in Dr. Green's operation, it is of the greatest importance that the tarsus be thoroughly divided. When this is accomplished it is known by the dark muscle showing in the incision, by the ecchymosis on the skin surface, and by the ease with which the two parts of the divided tarsus may be raised. up from the muscle tissue. The incision should be kept at least two and a half millimeters from the lid margin, as the papillae of the cilia extend thus far into the tarsus. Should any of these papillx OPH.-2
18
WEEKS: Operative Treatment of Entropion.
be left on the posterior portion, cilia would be very likely to sprout up through the incision. The formation of granulomata is not so common as when the tarsal incision is left uncovered by mucous membrane. When they appear in the line of the divided tarsus, they may be removed by curette, knife, or scissors. Puckering of the lid margin may follow, as in the simple tarsal incision; this may be remedied later by making one or more deep vertical incisions, as practiced by Dr. Green, or it may be left to take care of itself. I have usually found that in time it straightens out of .its own accord with advantage to the desired eversion. The method differs from that of Dr. Green only in the applying of the quill suture, and in covering a portion of the incision with mucous membrane. A combination of a form of quill suture with the tarsal incision has, I am told, been used by Professor Voelckers in the University at Kiel for a number of years.
OPERATIVE TREATMENT OF ENTROPION BY THE TRANSPLANTATION OF A FLAP OF MUCOUS MEMBRANE. BY JOHN E. WEEKS, M.D., NEW YORK CITY.
Shrinkage of the palpebral conjunctiva from whatever cause may produce entropion, but by far the most common cause is trachoma. The long-continued congestion of the tarsus occasions .some hypertrophy of that body. The traction of the shrinking tarsal conjunctiva lessens the vertical dimension of the tarsus, causing it to become more concave on its posterior surface and more convex on its anterior surface. The same condition is found in the lower as in the upper tarsus, but the former is so much narrower and thinner that the deformity is much less.
