Part 44 (2/2)

[Ill.u.s.tration: FIG. 141. PTOSIS OPERATION. PANAS'.]

_Second step._ The flap, C (Fig. 141), thus produced is raised, and doubly armed sutures, D D, are pa.s.sed 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 pa.s.sed deeply into the substance of the tarsus both ends are then pa.s.sed beneath the band and brought through into the upper wound, whence they are pa.s.sed 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 st.i.tches are removed on the tenth day. A small depression is usually seen where the skin of the lid pa.s.ses beneath the band.

ADVANCEMENT OF THE LEVATOR PALPEBRae MUSCLE

This is especially suitable for cases in which the levator palpebrae 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 palpebrae is best estimated by eliminating the action of the occipito-frontalis by holding down the brow and asking the patient to raise the lid.

[Ill.u.s.tration: FIG. 142. PTOSIS OPERATION. ADVANCEMENT OF THE LEVATOR PALPEBRae. Showing the suture pa.s.sed through the tendon; the difficulty of the operation is to find it. (_Diagrammatic._)]

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

=Operation.= Under a general anaesthetic.

_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 quant.i.ty of fat, will be found the tendon of the levator palpebrae 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 pa.s.sed 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.

[Ill.u.s.tration: FIG. 143. PTOSIS OPERATION. ADVANCEMENT OF THE LEVATOR PALPEBRae. _Showing the sutures in position._ The tendon is shortened by folding it on itself.]

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 st.i.tches.

=Operation.= A general anaesthetic 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 pa.s.sed beneath it; its middle portion is isolated and two silk sutures, with a needle at each end, are pa.s.sed 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 st.i.tches pa.s.sed 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 pa.s.sed 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 palpebrae.

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.

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