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.