CHAPTER IX

OPERATIONS FOR ENTROPION, REPAIR OF THE EYELIDS TRICHIASIS, AND ECTROPION

The operations commonly performed for entropion and trichiasis are of three types:--

1. Operations for the destruction of the individual hair follicles.

2. Rectification of a faulty curvature of the tarsus.

3. Transplantation of the lash-bearing area.

ELECTROLYSIS

=Indications.= In cases of trichiasis where a few eyelashes turn in on the conjunctiva or cornea they may be removed by this method.

=Operation.= A platinum electrolysis needle (negative pole) is passed alongside each lash into the follicle, and a constant current of about 5 milliampères allowed to pass for a half to one minute. There is usually some bubbling seen around the hair, which will fall out when touched if the operation has been properly performed. It is a comparatively painless operation and free from scarring if the hair follicle be not penetrated by the needle. This is best ensured by using a rather blunt point and not turning on the current until the needle is in position.

SKIN AND MUSCLE OPERATION

=Indications.= This operation is especially suitable for the senile or spastic forms of entropion of the lower lid, not infrequently seen after much bandaging in old people, which has failed to yield to treatment by pulling the lid outwards with strapping.

=Instruments.= Straight scissors, fixation and entropion forceps.

=Operation.= Adrenalin and cocaine solution is injected beneath the skin of the lower lid. A horizontal strip of skin as near the lid margin as possible is seized with the entropion forceps (Fig. 144) and removed by one snip of the scissors. The underlying orbicularis muscle is then removed over the same area and the wound closed with sutures. If a more pronounced result is required, a vertical piece of skin is removed at the outer end of the previous wound and allowed to granulate.

RECTIFICATION OF A FAULTY CURVATURE OF THE TARSUS

DIVISION OF THE TARSAL CARTILAGE FROM THE CONJUNCTIVAL SURFACE OF THE LID

=Burow’s operation.= The object of this operation is to restore the inverted tarsal edge of the lid by dividing the cartilage from the conjunctival surface, and it is especially suitable for those cases in which the whole of the upper lid border is buckled inwards to a slight extent owing to cicatricial contraction such as is often seen in the late stage of trachoma and occasionally as a congenital deformity in the lower lid.

=Instruments.= Lid spatula and Beer’s knife.

=Operation.= The operation is performed under a general anæsthetic.

_First step._ The lid is everted over the lid spatula. An incision is then made along the white line, the result of cicatricial contraction, seen in the sulcus subtarsalis about 3 millimetres behind the upper lid margin; the incision should extend throughout the whole length of the lid and completely divide the tarsal plate. Care should be taken that the cut is made at right angles to, and not obliquely through the tarsal cartilage. When the eyelid is replaced the lid margin will be found to lie in its proper position.

_Second step._ If the skin of the upper lid be very lax or a more marked result be desired an elliptical piece of skin may be removed from the upper lid above the site of the underlying incision and the wound stitched together so as to exaggerate the outward curve of the lashes; this is usually desirable in most cases, since there is a strong tendency for the lid to become inverted again owing to the contraction of the wound, which is allowed to heal by granulation.

DIVISION OF THE TARSAL CARTILAGE FROM THE ANTERIOR SURFACE OF THE LID

=Streatfield’s operation.= The object of this operation is the removal of a wedge-shaped piece of the tarsal cartilage directly behind the lashes throughout the length of the upper lid. The division is made from the outside, and the wound is subsequently sutured so that the margin of the lid is everted. It has the advantage over the previous operation that no granulating area is left to cicatrize; it is especially suitable for cases in which there is much buckling inwards of the upper tarsal plate, and yields most satisfactory results even when the deformity is great.

=Instruments.= Beer’s knife, fixation forceps, lid clamp (Fig. 145), spatula, and sutures with a glass bead threaded on each.

=Operation.= The operation is performed under a general anæsthetic.

_First step._ The lid is fixed in a clamp. The surgeon makes an incision in the skin directly above the lash-bearing area throughout the whole length of the lid and parallel to its margin. A second incision is made about 3 millimetres above this, and its extremities are curved downwards to join the first. The piece of skin and orbicularis muscle between them is removed and the tarsal cartilage is exposed.

_Second step._ A wedge-shaped strip is removed from the tarsal cartilage throughout the whole length of the lid, the apex of the wedge reaching just through the cartilage, but not the conjunctiva on its under surface.

_Third step._ Mattress sutures are then inserted. Each suture should have a needle at either end. A bead may be threaded on the stitch to prevent it cutting into the lid margin. The needles are passed from the margin of the lid directly above the eyelashes, about 3 millimetres apart, and brought out through the lower margin of the wound. They are then passed from within outwards through the tarsal plate and the upper margin of the wound, being brought out through the skin about half an inch above it and tied (Fig. 146). A few points of suture in the skin may be added if necessary.

THE TRANSPLANTATION OF THE LASH-BEARING AREA

=Arlt’s operation.= =Indications.= The operation is suitable for cases of trichiasis in which part or the whole of the lashes of the upper lid turn inwards and rub on the surface of the cornea.

=Instruments.= Beer’s knife, forceps, scissors, sutures, lid clamp.

=Operation.= _First step._ A lid clamp is applied to the upper lid. An incision is made in the intermarginal line and the tarsal cartilage is split behind the lash-bearing area for a depth of about 5 millimetres throughout the whole extent of the lid (Fig. 147).

_Second step._ An incision through the outer surface of the lid above the lashes is made to meet the other at right angles, so that the lashes are carried on a band of tissue attached at each end.

_Third step._ A semilunar piece of skin is then removed by a curved incision above the last, joining it at the outer and inner ends, and the band carrying the lashes is stitched to the upper margin of this incision; the line of the incision along the intermarginal zone behind the lashes is allowed to heal by granulation. The subsequent contraction caused thereby pulls down the band carrying the lashes to a certain extent. It is, therefore, desirable to pull the band of lashes upwards at the time of operation to a greater extent than is required for the final result in order to overcome this tendency for the condition to re-form as a result of cicatricial contraction of the granulating area. In order to obviate the cicatricial contraction some surgeons cover the area with a graft of mucous membrane.

ECTROPION OPERATIONS

Ectropion may affect the upper lid, but it occurs far more frequently in the lower. Operations undertaken for its relief vary very considerably for the following reasons:--

1. _The cause of the ectropion._ The active or cicatricial form requires different and more extensive operations than the passive form, such as occurs after facial paralysis, senile ectropion, or that occurring after blepharitis.

2. _The degree of ectropion_, whether it is partial, affecting merely the lid margin; or complete, affecting the whole lid.

Ectropion of the lower lid is always accompanied by epiphora, owing to the want of application of the canaliculus to the lacus lachrymalis. The canaliculus is also apt to become obliterated as the result of marginal blepharitis. Before undertaking any of the operations described below this condition must be remedied, either by dilating the canaliculus or by slitting it inwards for a short distance (see p. 290), otherwise, even if the operation be successful in restoring the deformity, the overflow of tears causes the patient to pull down the lower lid constantly in wiping them away, and this tends to reproduce the condition.

After many of the operations a temporary tarsorrhaphy is required to keep the lid in position during the process of cicatrization. The temporary bands produced by this operation are so placed on either side of the cornea as not to interfere with vision altogether. Canthorrhaphy is also desirable in some cases, especially when the ectropion affects the outer end of the lid.

The deformity to be overcome in ectropion is not only the turning outwards of the lid; in cases which have existed for any length of time the lid border becomes permanently elongated and requires to be shortened before it will keep in position. The exposed conjunctiva, especially in cases secondary to blepharitis, becomes thickened near the lid margin, and, though it may regain a more or less normal appearance after the lid has been replaced in position, the thickened margin frequently prevents the proper apposition of the canaliculus, and in these cases it is often desirable to remove this tissue (see Fergus’s operation).

OPERATIONS FOR PASSIVE ECTROPION

=Snellen’s suture method.= The object of this operation is to pass sutures through the lower lid from rather above the apex of the eversion out on to the cheek, so that when tightened they draw the lid up into position. The inflammation which occurs around the sutures leaves a permanent band of cicatricial tissue which continues the action of the sutures after they have been removed.

=Indications.= Snellen’s sutures are useful in moderate degrees of the senile form of ectropion in which there is not much thickening of the lid margins. Although the results are satisfactory in carefully selected cases, the operation is attended with considerable pain and is very liable to be followed by a marked inflammation along the stitch tracks; indeed, the final results are not very satisfactory unless some inflammation does occur.

=Instruments.= Two, and occasionally three, sutures of thick silk armed at either end with 3-inch straight needles.

=Operation.= A general anæsthetic is desirable, although not absolutely necessary. The needles belonging to each stitch are inserted about 3 millimetres apart, from the conjunctival surface above the apex of the everted lid, and after passing deeply near the lower cul-de-sac on the posterior surface of the tarsus, they are brought out on the cheek low down and tied over a piece of drainage tube. The loops, when drawn tight, draw the lid margin inwards (Fig. 148). Two of these sutures are usually required at such a distance apart as to divide the lower lid into thirds. They should be left in place some two or three weeks.

=Fergus’s operation.= This operation consists in excision of the apex of the everted lid.

=Indications.= It is a most satisfactory operation for cases in which the lid margin has undergone thickening from blepharitis and for cases of slight senile ectropion.

=Instruments.= Beer’s knife, fixation forceps, and sharp-pointed scissors.

=Operation.= Under adrenalin and cocaine, a little solid cocaine being rubbed into the conjunctiva. A strip of thickened conjunctiva and subconjunctival tissue corresponding to the apex of the eversion is removed along the whole length of the lid (Fig. 149). The wound produced is united with sutures. The pull of the conjunctiva, which is stitched to the lid margin, is sufficient to draw that structure inwards into position.

=Kuhnt’s operation= (modified). The object of this operation is the removal of a triangular piece of conjunctiva and tarsal cartilage from the centre of the lower lid, the base of the triangle being placed towards the free margin of the lid so as to produce sufficient shortening of the elongated lid border to hold it in position. The skin of the lid is also shortened by removal of a triangular portion at the external canthus.

=Indications.= It is especially suitable for cases of paralytic ectropion (lagophthalmos) and severe degrees of senile ectropion of the lower lid.

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

=Operation.= A general anæsthetic is required.

_First step._ The lower lid being held between the finger and thumb is split in the intermarginal line along the outer two-thirds of its length, and the incision deepened till the lower border of the tarsus is reached. For this purpose some surgeons use a broad keratome instead of a Beer’s knife.

_Second step._ A triangular piece of conjunctiva and the whole thickness of the tarsus are removed from the centre of the lower lid, the base of the triangle being towards the free margin of the lid and being of sufficient length to produce the shortening desired to bring the lid up into position (Fig. 150); this is best estimated by making the incision forming the inner limb of the V and overlapping the outer flap until the lid is pulled upwards into position.

_Third step._ A triangular piece of skin with its base upwards is excised from the outer canthus in the following manner (Fig. 150). An incision is made outwards and slightly upwards from the canthus. A vertical incision, twice the length of the preceding one, is made directly downwards from its outer end to the outer canthus, and the lower end of this is then joined by an incision completing the triangle. The skin marked out by this triangle is then dissected up and removed. The undermining of the flap formed by the skin and subcutaneous tissue of the outer part of the lid is continued inwards until the flap, when pulled up into place, restores the lid to its proper position.

_Fourth step._ The lid is sutured into position. The V-shaped wound in the conjunctiva and tarsus is sutured, the knots being placed on the conjunctival surface with the exception of the suture at the lid border, which is turned the other way, the ends being brought out through the skin of the outside flap, after the latter has been sutured in position, and the two ends tied over a bead. The outside flap of skin is brought up into position by a suture at its upper angle. As the result of this a few eyelashes project beyond the outer canthus; these should be excised. Additional sutures to hold the flap in position are then inserted. Both eyes should be bandaged after the operation, otherwise the knots in the conjunctiva may rub on the cornea.

=Argyll Robertson’s operation.= The operation aims at shortening the border of the lower lid and at the same time pulling it upwards into position by means of a strap of skin and subcutaneous tissue cut from the outer side, the attached end of the strap being formed by the outer portion of the skin of the lower lid.

=Indications.= It is especially useful for paralytic cases, and as a subsequent measure to the VY operation described below for cicatricial ectropion. The operation is likely to be successful if a marked reduction in the deformity is effected by pulling the skin at the side of the outer canthus upwards.

=Instruments.= Scalpel, dissecting forceps, artery forceps, scissors, sutures.

=Operation.= _First step._ An incision, 2 millimetres below the lid margin and opposite its outer third, is carried through the skin parallel to the border of the lower lid outwards to the canthus; having reached this point the direction of the incision is changed and it is carried more upwards and outwards till the upper end is on a level with the upper orbital margin. The incision is then carried outwards for about 6 millimetres and again downwards, slightly diverging from the former incision, until it is opposite the lower orbital margin. This flap of skin and subcutaneous tissue is dissected up from above downwards (Fig. 152).

_Second step._ A V-shaped portion is removed from the margin of the lower lid near the outer canthus, the base of the V being of sufficient length to produce the shortening of the lid required when the edges of the incision are brought together.

_Third step._ The strap of skin is pulled upwards to the extent required to replace the lid in position, and sutured there. The raw area must be enlarged upwards so as to accommodate the upper end of the strap. It is better to do this than to shorten the strap, since a firm hold is thus obtained (Fig. 153).

OPERATIONS FOR THE ACTIVE OR CICATRICIAL FORM OF ECTROPION

The numerous operations which have been devised for this condition are divided into two groups: (1) the transplantation of flaps in the neighbourhood of the lesion, and (2) the grafting of skin flaps from other parts of the body. The latter method is usually only undertaken when the employment of flaps from the neighbourhood of the deformity is impossible, as the cicatricial contraction which follows the grafting of flaps from other parts of the body is usually attended by considerable shrinkage and therefore does not yield such satisfactory results.

BY THE TRANSPLANTATION OF FLAPS

=VY operation= (Wharton Jones). =Indications.= This operation is useful for cases of ectropion affecting the middle parts of the lower lid, generally due to a scar such as would result from a healed sinus after tuberculous periostitis of the lower orbital margin.

=Instruments.= Dissecting forceps, scalpel, artery forceps, sutures.

=Operation.= The operation is performed under a general anæsthetic. A V-shaped incision, with the apex downwards, is made to embrace the whole margin of the lower lid. The upper ends of the V should skirt the outer and inner canthus and roughly lie over the lower orbital margin, enclosing the scar, the apex of the V falling rather below the orbit. The incision should include the skin and subcutaneous tissue. The V-shaped flap is dissected up and the lid liberated from the underlying scar tissue. The incision is then sewn up in the form of a Y (Fig. 155). Temporary tarsorrhaphy (see p. 266) is always desirable. Subsequent shortening of the lid margin by the Argyll Robertson method is sometimes necessary.

=Denonvillier’s operation.= This procedure is useful to remedy an ectropion of the outer portion of the lower lid by the transposition of flaps at the outer canthus.

=Instruments.= Scalpel, dissecting and artery forceps, scissors, sutures.

=Operation.= The operation is performed under a general anæsthetic.

_First step._ An oblique incision (Fig. 156), starting from below the inner end of the deformity, A, is carried outwards and slightly upwards for 12 mm. to the point B. From the point B a curved incision B C is carried upwards to and along the orbital margin. This marks out a triangular flap. From C the incision is carried outwards and downwards in a curved direction to D, which is situated about 2 cm. from the external canthus, thus marking out another triangular flap B C D.

_Second step._ Both flaps are dissected up, and, when all bleeding has ceased, the apices of the triangles are transposed and sutured in position, the incision thus forming a _Z_-like figure (Fig. 157). A canthorrhaphy is generally required.

=Fricke’s operation.= This has for its object the transplantation of flaps from the side of the forehead or face into the lid to remedy a loss of tissue resulting from operation or cicatricial contraction.

=Indications.= The operation is usually performed for cicatrices about the upper lid, the flap being turned down from the side of the forehead. A flap may be turned in from the inner side in addition if necessary. The operation may also be applied to ectropion of the lower lid.

=Operation.= When planning the flaps the following points must be taken into account:--

(i) The flap must be cut so that its base contains the main blood-supply of the part made use of.

(ii) It should be at least one-third larger than the area to be covered. This is estimated by cutting a piece of protective the size of the area to be covered and laying it on the skin before the flap is cut.

(iii) The base of the flap should consist of a considerable amount of subcutaneous tissue as well as skin, but the apex may be little more than the skin itself.

(iv) The direction of the subsequent contraction should be taken into account so as to assist the final result.

_First step._ The lid is first freed by dividing all the cicatricial bands, or, if only a small cicatrix be present, by excising that. The lid is then pulled down into position and put fully on the stretch. This is best performed by stitching the margin of the lid to the cheek.

_Second step._ The flap is marked out at least one-third larger than the size required to cover the raw area. The base of the flap should be placed a little below the raw area to be covered, so that the rotation of the flap into position is easily performed without danger of constriction to the base (Fig. 158).

_Third step._ The flap having been raised and all bleeding stopped, it is rotated and sutured in its new position, the wound made by the removal of the flap being brought together by sutures or, if it be too large for this, covered by skin grafts (see Vol. I, p. 670).

BY THIERSCH’S SKIN-GRAFTING METHOD

=Indications.= As has already been pointed out, this method is not so satisfactory as the method by flaps described above, but it is frequently the only one available when the surrounding skin has been destroyed, as after extensive lupus of the face.

=Instruments.= Scalpel, forceps, skin-grafting razor, probes.

=Operations.= _First step._ As for the previous operation.

_Second step._ Grafts are cut from a situation free from hairs, such as the inner side of the upper arm (see Vol. I, p. 671).

_Third step._ After all bleeding has been stopped, the grafts are applied, straightened with probes, and pressed firmly down on to the raw surface. The edges of each graft should slightly overlap the one next to it. Great care should be taken in applying the dressings not to disturb the grafts (see Vol. I, p. 673).

If the whole thickness of the skin be used (Wolff’s method), care should be taken to see that the under surface is free from fat.

THE REPAIR OF LARGE LOSSES OF SUBSTANCE FROM THE EYELIDS

Losses of portions of the lid margins usually result from operations for malignant growths. When the loss is in the _upper lid_, some modified form of Fricke’s operation is the best method of remedying the deformity. When a large area is to be covered, transplantation of a flap from the arm by the Tagliacotian method has to be performed (see Vol. I, p. 679).

Fricke’s operation is also applicable to the outer portion of the lower lid. When the inner end of the _lower lid_ is affected, De Vincentiis’ operation yields satisfactory results. When the whole lower lid has been lost, a modified Dieffenbach’s method with the use of the ear cartilage is indicated.

=De Vincentiis’ operation.= The operation aims at shifting the remains of the lid bodily inwards to cover the gap left by the removal of the growth.

=Instruments.= Scalpel, dissecting forceps, artery forceps, scissors, sutures.

=Operation.= _First step._ The portion of the whole thickness of the lid together with the growth is excised by a V-shaped incision (Fig. 159).

_Second step._ The outer canthus and orbito-tarsal ligament are divided with the scissors. The incision is then carried outwards and upwards with a scalpel, in a line with the lower margin of the lid, the incision being long enough to free the lower lid sufficiently to slide it inwards and to enable the edges of the V-shaped wound to be united (Fig. 160).

=Dieffenbach’s operation= (modified with the use of ear cartilage). This operation consists in shifting inwards a flap of skin and subcutaneous tissue derived from the outer side of the face to take the place of the eyelid which has been removed, the conjunctiva and tarsal plate being represented by a piece of skin and cartilage taken from the posterior surface of the ear and stitched to the inner surface of the flap.

=Operation.= _First step._ The growth, together with the eyelid, is first removed by a V-shaped incision, the base of the V being formed by the margin of the lower lid.

_Second step._ An incision is carried directly outwards from the external canthus. The length of this incision should be 1-1/4 times the length of the lid margin. An incision is then carried downwards from its outer end parallel to the outer limb of the V by which the lower lid has been excised. This flap is then raised freely (Fig. 161).

_Third step._ The ear is turned forward and a semilunar portion of the skin is marked out and deepened down to the cartilage. The base of this semilunar portion should be equal in length to the upper margin of the flap that is to form the new lid (Fig. 162). The skin is then dissected up for about 3 millimetres from the crescentic part of the incision back towards the straight one forming the base of the semilune. When this part of the skin has been raised the cartilage is divided, first by a curved incision, 3 millimetres behind that through the skin, and then along the straight incision joining the ends of the curved one. It is separated from the skin on the anterior surface of the ear, and the semilunar piece of skin and cartilage is thus removed. The portion of cartilage removed with the skin is smaller than the latter; the two portions coincide in length along their straight margins, but the depth of the crescent of cartilage is considerably less than that of the skin (Fig. 162). The cartilage is usually too thick to form the new tarsus and must be pared down until the right thickness is obtained. It is then applied to the inner surface of the flap to form the new lid, the skin surface being directed inwards to help to form the lower conjunctival sac. It is fixed firmly by sutures at its margin, which are passed through the whole substance of both flaps, and tied on the outer surface of the new lid.

_Fourth step._ The flap forming the new lower lid is sutured in position. The surface from which the flap is taken is closed as far as possible with sutures after undermining the edges, any raw area being covered by skin grafts taken from the arm.