Part 45 (1/2)

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 pa.s.sed alongside each lash into the follicle, and a constant current of about 5 milliamperes allowed to pa.s.s 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 p.r.o.nounced 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.

[Ill.u.s.tration: FIG. 144. TREACHER COLLINS'S ENTROPION FORCEPS.]

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

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

_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 st.i.tched 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.

[Ill.u.s.tration: FIG. 145. LID CLAMP.]