Part 46 (1/2)

=Snellen's suture method.= The object of this operation is to pa.s.s 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.

[Ill.u.s.tration: FIG. 148. SNELLEN'S SUTURES.

A B

A. A suture in position.

B. The suture tightened.

=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 st.i.tch 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 anaesthetic is desirable, although not absolutely necessary. The needles belonging to each st.i.tch are inserted about 3 millimetres apart, from the conjunctival surface above the apex of the everted lid, and after pa.s.sing 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 st.i.tched to the lid margin, is sufficient to draw that structure inwards into position.

[Ill.u.s.tration: FIG. 149. FERGUS'S OPERATION FOR SLIGHT ECTROPION OF THE LOWER LID. Showing the lines of the incision.]

=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 anaesthetic 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.

[Ill.u.s.tration: FIG. 150. MODIFIED KUHNT'S OPERATION FOR SEVERE ECTROPION. _Second step._ The outer half of the lid is split and a V-shaped portion of the tarsal plate removed. The triangular piece of skin at the outer canthus is entirely removed.]

[Ill.u.s.tration: FIG. 151. MODIFIED KUHNT'S OPERATION. _Fourth step._ Showing the sutures in position. The outer part of the lid has been undermined and dissected up. The V-shaped gap in the tissues is sutured first.]

_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.