CHAPTER VIII

OPERATIONS UPON THE EYELIDS

SURGICAL ANATOMY

The eyelids consist of well-marked planes of tissue, which are, from without inwards--

1. Skin with very little subcutaneous fat.

2. Orbicularis muscle.

3. Tarsal plates, which are attached to the orbital margins by the palpebral ligaments and which thereby form a barrier to the passage of infection backwards into the orbit.

4. Subconjunctival tissue and conjunctiva.

It is most important for successful results that flaps and incisions should be made accurately down to and in the correct layer of the lid.

Along the lid margin, between the eyelashes and the posterior border of the eyelid, is a white line (intermarginal line) formed by the edge of the tarsal plate. In the many operations in which the lid is split the incision is carried along this line.

The blood-supply to the eyelids is derived from arterial arches--two in the top lid, and one in the lower--which run parallel to the margins. As far as possible, therefore, flaps should be planned with their bases at right angles to the course of the vessels. The extreme vascularity of the lid, together with the small amount of subcutaneous fat, allows of almost complete detachment of flaps of skin without fear of necrosis, but at the same time every care should be taken to avoid injuring these flaps when manipulating them. Hæmorrhage is controlled during the operation by means of clamps or by direct pressure of the lid between the finger and thumb. As a rule a general anæsthetic is required for most of the operations.

SUTURE OF WOUNDS OF THE EYELIDS

_Wounds which involve the skin only_ are brought together in the ordinary way with a few fine sutures. In wounds of the upper lid care should be taken to suture the levator palpebræ, if divided, as otherwise traumatic ptosis may result.

_Suture of wounds involving the lid margin._

(_a_) In _simple division_ the margins of the lids are brought together by means of a fine suture; the conjunctival surface is first approximated, and then the skin by a deep suture which includes the tarsal cartilage. Accurate apposition of the lid border is very essential. Unfortunately a certain amount of ectropion frequently follows, which may require for its relief one of the operations given below (see p. 284).

(_b_) _Occasionally the lid margin carrying the lashes may be torn off._ As a rule, the strip remains attached to the lid. It should then be accurately sutured in position, taking care that the lashes take their correct turn outwards. In cases where the strip is torn off entirely, the skin and conjunctiva should be sutured together. When large portions of the lid are lost, some form of plastic operation, such as is performed for making a new lid, is required (see p. 287).

(_c_) _When the canaliculus has been divided_ the end attached to the lachrymal sac should be sought for and divided for a short distance inwards from the wound (see p. 291), the entrance being kept open daily by a probe to prevent traumatic stricture.

OPERATIONS FOR ANKYLOBLEPHARON

Fusion of the eyelids together is either a congenital condition or the result of injury, and may take the form of bands or firm fibrous union. It is rarely complete and is often associated with symblepharon. The union should be divided on a director, or by careful dissection, taking care not to wound the underlying globe. The raw surfaces are kept apart by daily dressing until they are covered by epithelium. No externa[l] dressing should be applied.

OPERATIONS FOR SYMBLEPHARON

_Partial adhesion of the lid to the globe_ in which a few bands pass from the lid to the globe are best treated by division followed by union of the ocular conjunctiva over the raw surface; no external dressing should be applied. Any tendency to fresh adhesion may be prevented by daily inspection.

_In extensive adhesion of the lid to the globe_, where the lids are entirely adherent to the globe and the cornea is destroyed, interference is inadvisable. In less extensive adhesion, the lid is first separated from the globe, reunion being prevented by covering the denuded area on the globe with a flap of bulbar conjunctiva transplanted from an area that does not come in contact with the raw surface on the eyelid (Teale’s operation), or by Thiersch’s grafts from a situation where there are no hairs; or by grafting mucous membrane from the mouth of the patient or a frog. Teale’s operation, or some modification, is by far the most satisfactory, but unfortunately it cannot always be carried out when the loss of conjunctiva is large.

OPERATIONS UPON THE PALPEBRAL APERTURE

CANTHOPLASTY

=Indications.= In contraction of the palpebral aperture, either due to a congenital condition, or the result of a wound, trachoma, or other cicatricial contraction.

=Instruments.= Speculum, forceps, scissors, and three sutures.

=Operation.= The speculum is inserted and opened as widely as possible. One blade of the scissors is passed into the cul-de-sac at the outer angle of the lid and the palpebral aperture enlarged by dividing the outer canthus horizontally. The external tarsal ligament which is split longitudinally is then cut across with scissors passed into the upper and lower wound. The conjunctiva is drawn up into the wound and stitched to the skin at the margin to prevent reunion. The stitches should be removed about the sixth day.

CANTHOTOMY

Canthotomy is simple division of the outer canthus without stitching the conjunctiva into the wound. It is useful in some cases of blepharospasm associated with fissure at the outer canthus.

CANTHORRHAPHY

Union of the eyelids, usually at the outer canthus.

=Indications.= (i) When the eyelids do not cover the globe as the result of--

(_a_) Cicatricial contraction of wounds, burns, &c., about the lid.

(_b_) Long-standing facial paralysis.

(_c_) Exophthalmic goître.

(ii) To help maintain the lid in position after ectropion operations.

=Instruments.= Beer’s knife, fixation forceps, spatula, and sutures.

=Operation.= _First step._ The position for the new external canthus is determined by holding the lids together at the outer canthus, and is marked on the upper and lower lids. From these points incisions are carried outwards to the external canthus along the intermarginal line in the top and bottom lids. These incisions are deepened to about 5 millimetres.

_Second step._ From the inner end of the incision in the lower lid a vertical one is made downwards for about 5 millimetres, and is then carried out to the external canthus. The tissue thus marked out, bearing the lashes, is then removed.

_Third step._ A corresponding, slightly larger, area is similarly removed from the under or conjunctival surface of the upper lid (Fig. 139).

_Fourth step._ These two areas are brought into apposition by means of a strong suture passed through their centre. The suture should have a needle at either end, and these should be passed from the conjunctival surface and brought out through the middle of the raw area in the lower lid, about 2 millimetres apart, and then through the middle of the raw area in the upper lid and out through the skin. The suture is tied so that the two raw areas are brought into accurate apposition. The margins of the wound may then be brought together by sutures if necessary. The main suture should be left in for at least ten days.

TARSORRHAPHY

=Indications.= (i) Complete union of the eyelids may be required when an eye has been removed and for some reason an artificial one cannot be worn.

(ii) Partial union is effected in cases of paralysis of the first division of the fifth nerve when corneal ulceration threatens. A similar union is also useful in keeping the lower lid in position during the process of cicatrization in many of the operations for ectropion described below. The adhesions produced can be subsequently divided when contraction has ceased.

=Instruments.= Knife, forceps, scissors, spatula.

=Operation.= _Complete._ As narrow a strip of tissue as possible is removed from the lid borders behind the eyelashes. This is best performed by everting the upper lid and shaving off the posterior margin with a sharp knife; the lower lid is then treated similarly. The raw areas are brought into apposition with fine sutures.

_Partial._ When only a temporary adhesion is required, as after ectropion operations, it is sufficient to make raw corresponding areas of about 2 millimetres on the posterior margins of the top and bottom lids on either side of the central position of the cornea and unite them with sutures, which may be removed about the end of the first week.

PTOSIS OPERATIONS

The following operations are usually only undertaken for congenital ptosis, but they are occasionally required for the paralytic and traumatic varieties. All the operations are far from satisfactory, and should only be undertaken when the lid covers the pupil completely or so nearly that the head has to be thrown back to see objects directly in a line with the eyes. The relative value of the various operations apart from their indications is a matter of opinion amongst ophthalmic surgeons; therefore the various types of operations which are performed are given below.

There are four types of operation, which respectively aim at--

1. Shortening the eyelid by excision of a portion of the tarsal plate.

2. Attachment of the lid to the occipito-frontalis muscle.

3. Advancement of the levator palpebræ muscle.

4. Grafting of part of the superior rectus muscle into the lid to take the place of the levator palpebræ superioris.

SHORTENING THE EYELID BY EXCISION OF A PORTION OF THE TARSAL PLATE

=Fergus’s operation (modified).= The object of this operation is to shorten the eyelid by removing the upper portion of the tarsal plate, the cut margin of which is subsequently sutured to the tendon of the levator palpebræ and the palpebral ligament.

The results of the operation are satisfactory, especially in cases in which there is some movement in the eyelid. The author, who has performed most of the ptosis operations on several occasions, has had most uniform results by this method, the modification of which was first suggested to him by Mr. Treacher Collins.

It has the advantage that the amount of retraction required may be more easily estimated, the corneal complications are of much rarer occurrence, and the resulting scar forms a natural fold in the lid. It is obviously not applicable to cases in which the eyelid is already short, as in the cases of ‘Chinese eye’ in which little can be done beyond enlarging the palpebral aperture.

=Instruments.= Spatula, scalpel, artery and dissecting forceps, scissors, and sutures.

=Operation.= _First step._ The spatula is inserted into the superior fornix. A curved incision is made directly below the orbital margin throughout its whole length. The skin and orbicularis muscle are divided and dissected downwards so as to expose the upper surface of the tarsal plate. A suture is then passed through this flap so that it may be drawn down by an assistant.

_Second step._ A narrow strip about 3 millimetres broad is excised from the whole length of the tarsal plate; in doing this care must be taken not to button-hole the conjunctiva or flap of skin.

_Third step._ The cut margin of the tarsal plate is sutured to the levator palpebræ and palpebral ligament by two sutures passed in the following manner: A thick catgut suture armed with a curved needle is passed through the upper cut margin of the orbicularis palpebrarum, palpebral ligament, and levator palpebræ (if the latter be present) at about the junction of the middle and inner thirds of the wound, a firm hold being taken on these structures. The needle is then passed through the tarsal cartilage parallel to the lid border for a distance of about 3 millimetres and out again on to its anterior surface. The needle is then again carried through the levator palpebræ, palpebral ligament, and orbicularis in the upper part of the wound. A similar suture is passed about the junction of the middle and outer thirds of the wound. When both sutures are in position they are tied sufficiently tightly to produce the retraction of the lid desired, slight over-correction being necessary. The skin wound is then closed with sutures.

ATTACHMENT OF THE LID TO THE OCCIPITO-FRONTALIS MUSCLE

There are three chief methods of affecting this attachment:--

(_a_) By cicatricial bands (_e.g._ Hess’s operation).

(_b_) By a suture left permanently in position (_e.g._ Harman’s operation).

(_c_) By the attachment of the skin of the lid to the muscle (_e.g._ Panas’ operation).

=Indications.= In the majority of the cases of congenital ptosis the levator palpebræ is completely absent, as shown by the want of upward movement in the lid, and it is for this condition that one of the operations of this type is performed. In rare cases the occipito-frontalis muscle is also absent or imperfectly developed, and in these cases these operations should not be undertaken.

=Hess’s operation.= The object of this operation is to insert silk stitches between the eyelid and the occipito-frontalis muscle, and to leave them in long enough for a fibrous band of union to form along the stitch tracks.

=Instruments.= Scalpel, dissecting forceps, needle and holder, spatula, artery forceps.

=Operation.= _First step._ The eyebrow having been shaved, an incision 2 inches long is made about in the line of the brow, and the skin is dissected down almost to the lid margin.

_Second step._ Three sutures are passed, one in the middle, and one at each end of the lid; each suture carries two needles. The needles are inserted in the intermarginal line of the lid about 3 millimetres apart and brought out into the wound above, so that the lid margin is held by the loops. These threads are then carried deeply beneath the upper edge of the wound into the substance of the occipito-frontalis muscle, brought out through the skin well above the eyebrow and tied over a piece of drainage tube. The sutures should be drawn tight enough to produce an undue amount of retraction of the lid, as this tends to drop again after removal of the sutures. The skin wound is then closed and a small dressing is applied to cover the drainage tube on the forehead. The eye itself should be covered with a celluloid shield, as it is usually impossible for the patient to close the palpebral aperture, and the cornea is liable to be injured by exposure. The deep sutures should be left in for at least three or four weeks, so that they may bring about a fibrous band between the muscle and the eyelid by their irritation. The immediate result of the operation is usually excellent, but the lid is very apt to drop again in the course of six months or a year after removal of the stitches.

=Harman’s operation.= The aim of this operation is to insert a fine metal chain between the occipito-frontalis and the lid, the chain being left permanently in position. The operation has not yet been performed sufficiently often to allow any definite statement about the final results to be made.

The results have not been very satisfactory in three cases in which the author has performed this operation.

=Instruments.= A 4-inch straight surgical needle, to which is attached the fine wire chain such as is used by spectacle makers to attach glasses to the dress. It measures about O.75 millimetre in diameter. It is attached to the needle by a soldered ring or by means of a piece of silk doubly looped through the needle without a knot.

=Operation.= Under a general anæsthetic. ‘The method of implanting the chain will be followed readily by reference to Fig. 140. The chain-needle is inserted above the external angular process at A, is passed inwards, and with a slightly upward inclination deeply beneath the tissues of the forehead, to be withdrawn at B; as much of the chain is drawn through as desired. The needle is reinserted at B, passed beneath the brow close to the orbital margin and through the tissues of the lid to C, where it is withdrawn and the chain after it. In like manner it is passed from C to D through the substance of the tarsus and withdrawn. It is now returned from D to E above the brow and withdrawn, and a final length embedded above the brow from E to F, which is just above the internal angular process. The chain should be buried completely and stretched evenly between the points A, B, C, D, E and F; and by traction the loop BCDE should be adjusted at B and E; when the lid is at the desired height the slack at B and E is taken up by traction on A and F.

‘The position of the points E and B is of importance; they must be situated in the region of the most effective elevation of the brow by contraction of the frontalis muscle, as determined by experiment before the commencement of the operation (and they should be placed well above the eyebrow).

‘The lengths of chain lying buried above the brows from A to B and E to F, and the angles A B C and D E F, are arranged so that there is sufficient holding power to prevent the subsequent drop of the lid, but will not prevent adjustment to forcible traction on the lid until the links of the chain have become interwoven and surrounded by the growth of connective tissue. This growth should be sufficiently vigorous by the end of a week to securely fix the chain against all the force of traction of the orbicularis muscle. (In one case in which the author removed the chain after two weeks there was no connective tissue in the links and it was easily withdrawn.) Until this time the free ends of the chain should be turned towards each other over the skin of the brow and cemented in position by a cotton-wool and collodion dressing, after which time the free ends, A and F, are cut off and the free extremities pushed beneath the skin.’

=Panas’ operation.= In this operation a direct adhesion of the skin of the lid to the occipito-frontalis muscle is aimed at.

=Instruments.= Lid spatula, scalpel, dissecting forceps, scissors, sutures.

=Operation.= Under a general anæsthetic.

_First step._ An incision, 2 inches long, is made in the line of the brow, and an incision of a similar length is made into the skin of the lid about half an inch below it. The tissue between these two incisions is undermined so as to produce a band of skin and subcutaneous tissue. From the ends of the lower wound vertical incisions are made into the lid, running slightly outwards and inwards respectively towards the outer and inner canthus (Fig. 141).

_Second step._ The flap, C (Fig. 141), thus produced is raised, and doubly armed sutures, D D, are passed through its upper margin and are carried beneath the band of skin and subcutaneous tissue. The needles are then carried deeply beneath the upper margin of the wound A into the substance of the occipito-frontalis muscle and brought out on to the forehead. Outer and inner sutures, E E, are passed deeply into the substance of the tarsus both ends are then passed beneath the band and brought through into the upper wound, whence they are passed beneath the upper margin of the wound into the occipito-frontalis muscle and are tied over a piece of drainage tube. They hold the lid in position during the process of cicatrization. Considerable over-correction should be employed as the lid tends to drop subsequently. No dressings should be applied over the open palpebral aperture. The stitches are removed on the tenth day. A small depression is usually seen where the skin of the lid passes beneath the band.

ADVANCEMENT OF THE LEVATOR PALPEBRÆ MUSCLE

This is especially suitable for cases in which the levator palpebræ has some power, that is to say, when there is some movement of the lid present. It is also suitable for cases of traumatic and paralytic origin. The movement of the lid by the levator palpebræ is best estimated by eliminating the action of the occipito-frontalis by holding down the brow and asking the patient to raise the lid.

=Instruments.= Lid spatula, knife, forceps, scissors, sutures.

=Operation.= Under a general anæsthetic.

_First step._ A spatula is inserted into the upper conjunctival fornix. An incision is made just below the eyebrow over the upper margin of the tarsal plate throughout its length. The skin, especially of the lower margin of the wound, is dissected up and the orbicularis muscle divided, the tarsal plate, with the superior palpebral ligament attached to it, and the orbital margin being exposed. The superior palpebral ligament is then divided carefully high up near the orbital margin and directly below, in a small quantity of fat, will be found the tendon of the levator palpebræ superioris. The tendon can usually be distinguished from the palpebral ligament by the fact that it is elastic when pulled on.

_Second step._ The advancement of the muscle is then performed in one of the three following ways: (_a_) by excising a portion of the tendon and suturing the divided ends together; (_b_) detaching the tendon from the tarsal plate and bringing it from behind forward through a hole made in the upper margin of that structure and suturing it on its anterior surface towards the lower margin; (_c_) by folding the tendon on itself. The last method is the one most usually performed. Two sutures with a needle at each end are passed through the substance of the muscle and tied (Fig. 142). The ends of these sutures are then carried downwards between the tarsal cartilage and the orbicularis palpebrarum and out in the intermarginal line of the eyelid. The sutures are then tied tightly so as to secure rather more than the amount of retraction required (Fig. 143). The palpebral ligament and orbicularis palpebrarum are then united and the wound in the skin is closed.

GRAFTING A PORTION OF THE SUPERIOR RECTUS INTO THE LID

=Motais’ operation.= =Indications.= This operation is performed for cases of ptosis in which there is partial or complete loss of upward movement of the lid. In cases of congenital ptosis the superior rectus is not infrequently absent or imperfectly developed, as is shown by the defective upward movement of the eye. It need hardly be said that it is most important to see that the superior rectus is well developed before undertaking the operation. Vertical diplopia always follows the operation, and therefore it is advisable only to undertake it when the ptosis is bilateral, a similar operation being performed on both sides. Another somewhat hypothetical objection is that during sleep the eyelids are rolled upwards by the superior recti so that the lids are slightly open, but this occurs in almost all successful ptosis operations. Occasionally there is some defective upward movement of the eye after the operation.

=Instruments.= Speculum, straight strabismus scissors, lid retractor, needle holders and stitches.

=Operation.= A general anæsthetic is desirable in all cases.

_First step._ The superior rectus is exposed through a horizontal incision in the conjunctiva, as in the first stage for advancement. The tendon is defined in the wound and a strabismus hook passed beneath it; its middle portion is isolated and two silk sutures, with a needle at each end, are passed through it and tied.

_Second step._ The speculum is removed and the eyelid everted and pulled upward by means of a retractor or two silk stitches passed through the substance of the lid. Starting from the middle of the wound the conjunctiva of the fornix is divided backwards and the under surface of the tarsal plate is exposed.

_Third step._ An incision is carried through the tarsal plate parallel to and near its upper border well into the substance of the orbicularis muscle on the other side. The needles on each end of the doubly armed sutures holding the isolated portion of the superior rectus muscle are passed through the hole in the tarsal plate and are carried downwards between the orbicularis muscle and the tarsal plate to near the lid margin, where they are brought out through the skin and tied over a piece of drainage tube. The conjunctival wound is closed by sutures.

=Complications.= _Ulceration of the cornea_ is more likely to occur after those operations in which the lid is much over-retracted, such as Hess’s, Panas’ operation, and the advancement of the levator palpebræ. It usually affects the lower corneal margin and may be merely roughening and opacity of the epithelium or deep septic ulceration. If the ulceration be severe, the sutures holding the lid in position should be taken out and the eye treated as for corneal ulceration; on the other hand, slight abrasion of the epithelium will often heal without taking out the sutures.

_Sepsis._ The difficulty of keeping the wound aseptic after these operations is considerable, and not infrequently inflammation may take place; provided it does not go on to suppuration, the final result is improved thereby; should suppuration take place the sutures must be removed.