Ankyloblepharon is an adhesion of the ciliary margins of the eyelids. It may be complete or partial, often combined with symblepharon, and is acquired from burns or wounds, or congenital. The treatment is by inserting a grooved director behind the lids and dividing the adhesions, or, when extensive, by canthoplasty with sutures in the conjunctiva to present re-adhesion.
Lagophthalmos, is an incomplete closure of the palpebral fissure when the lids are shut together, and in the most cases there is inability to close the eyelids. It may result from a paralysis of the orbicularis, cicatrices in the skin of the lids, exophthalmos, staphyloma, etc. The danger of this condition is from ulceration of the cornea, due to its exposure to air and external irritants, owing to the inability to remove foreign substances by winking.
TREATMENT-In paralytic cases galvanism, with remedies directed to the cause of the paralysis ( such as syphilis, rheumatism, etc.) will often result in a cure. Cases that do not yield to this treatment require the operation of tarsorrhaphy to reduce the size of the opening of the eyelids.
Epicanthus is a congenital deformity in which a crescentic fold of skin projects in front of the inner canthus. It may also be seen in persons with flat noses, such as Mongolians, or syphilitics. As the child grows it disappears altogether, or becomes much less noticeable, so that operative interference is only called for in high degrees for cosmetic purposes. The operation is to remove an elliptical piece of skin from the bridge of the nose and uniting the edges of the wound together with sutures, care being taken to secure union by first intention by preventing any dragging on the stitches.
Trichiasis and Distichiasis- Where there is an irregularity in the shape and position of the eye-lashes so that they become curved in and in contact with the eye, it is called trichiasis, and where there is a double row of lashes, one of which is in contact with the eye, it is called distichiasis. Inverted cilia may affect part or the whole of the lid, and are usually thin pale or stunted. They cause more or less irritation of the eye, sometimes ulcers, pannus, etc., and are usually due to blepharitis, trachoma, injuries, burns, etc.
TREATMENT-Where there are but a few ingrowing lashes, epilation, if often repeated, may cause an atrophy of the hair bulbs and in this way cure the case (Fig.34 ).
Electrolysis, as a curative measure, is most serviceable when the lashes to be destroyed are not too numerous. This is done by inserting a needle into the hair follicle and then connecting it with the negative pole of the battery, the positive being applied to the temple.
Arlt’s operation, when modified to meet the emergencies of the case, seems to be the most generally advisable method of operating for the severe cases and is shown in the illustration (Fig.35). An incision two or three mm. in depth is made along the free border of the lid, splitting it into two layers.
A narrow strip of skin is then excised from the lid, cutting down to the first incision, as shown in the dotted lines in Fig. 35, so that the cilia remain in a bridge of tissue, which is shifted upward and its upper edge attached by sutures to the skin of the lid-its lower margin being left free. To avoid cicatricial contraction drawing the cilia down again, some transplant a narrow strip of the skin removed from the lid into the space that the gapes open in the free border of the lid.
Entropium is an inversion of the eyelid. We find two varieties of entropium; first the spastic, which is usually of the lower lid and is due to a spasmodic contraction of the orbicularis muscle. It is often met with in old people, sometimes coming on after operations, and is due to the lax condition of the skin. It may also be due to irritation from a foreign body, from keratitis, etc. The second variety of entropium is the cicatricial, which gradually comes on during the process of cicatrization and is the result of granular and diphtheritic conjunctivitis, burns, etc., where there has been loss of substance in the conjunctiva. Entropium results in much irritation and pain in the eye. From the continuous scratching of the cornea from the inverted lashes, ulcers and pannus finally ensue.
TREATMENT- In the spasmodic entropium a cure may often be effected by painting the parts with collodion, which should be renewed every two or three days, or oftener, in order to keep the lid in position. Adhesive strips may be applied for the same purpose. If these measures do not suffice, and always in the cicatricial entropium, operative interference must be resorted to before a cure can be made. Owing to the excessive vascularity of the lids, free haemorrhage occurs from any operation upon the lids unless controlled by the use of entropium forces (Fig. 36). There are various operations for the relief of entropium, of which perhaps Green’s is the most serviceable in the majority of cases. This is made by everting the lid and making an incision from the conjunctival side, parallel to and about two mm. above its free border through the entire thickness of the tarsus, the incision to extend from one canthus to the other. A strip of skin about two mm. above the cilia is then removed.
Three sutures are then passed from the conjunctival side of the cilia through the free edge of the tarsus to just above the lower border of the skin wound; from there they pass through the muscular fibres on the outer surface of the tarsus and emerge from the skin about half an inch above the upper border of the wound. On lying these sutures the ciliary border is everted and the skin wound closed.
Streatfeild’s operation is the removal of a strip of skin with subjacent muscular fibres and a portion of the tarsus, just above the border of the lid, by cutting a deep V-shaped groove in its outer surface.
Other operations are Arlt’s, already described, and those of Hotz, Snellen, Pope and others.
Remedies may possibly be useful, if the inversion is recent and only slight in degree. The following are suggested: Aconite, Argent. nit, Calcarea and Natrum mur.
Ectropium is an eversion of the eyelids. The eversion may be slight or so great as to expose almost the whole of the palpebral conjunctiva. Ectropium is also divided into two classes, the spastic, due to chronic inflammation and swelling of the conjunctiva, which separates the lid margin from the eye, and this separation serves to increase the trouble by causing the tears to flow over the lid, which, in its turn by this irritation, aggravates the existing trouble. This form is also sometimes seen in children due to the swelling and inflammation of the conjunctiva, with contraction of the orbicularis. There is also in some cases a drooping of the lower lid from paralysis of the orbicularis, or from a defective innervation of this muscle in old people, which allows the tears to flow over the lid and cause ectropium. The cicatricial ectropium is due to a contraction after loss of the skin of the lids or of the face, following burns, wounds, abscesses, caries of the edge of the orbit with adhesions of the skin, etc.
TREATMENT-In cases of spastic ectropium we may sometimes give relief by replacing the lid and retaining it there for several days by the use of the compress bandage. Scarification or removal of a strip of the conjunctiva to reduce the obstruction from thickening of the conjunctiva, together with the slitting up of the canaliculus, to permit the passage of the tears through the normal channels, may be tried. Other operations recommended to correct this affection are legion, and, as they must necessarily vary in nearly every case, according to the cause, degree and position of the eversion, but two will be detailed.
No plastic operations should be attempted until all tendency to contraction of the cicatrices has disappeared. In all flap operations allowance must be made for shrinking.
In Wharton Jones’s operation a V-shaped (Fig.37) incision is made to include all the cicatricial tissue possible; the flap thus formed is to be dissected from the underlying tissues, and the skin at either side undermined sufficiently to allow of the lid being returned to its normal position. The exposed surface is then to be covered by bringing together the edges of the V- shaped wound with sutures so that it becomes Y-shaped(Fig.38)
Dieffenbach’s operations is especially useful in the cicatricial form of ectropium and is made by dissecting away the diseased tissue by triangular incision. A flap of skin is then loosened by careful dissection from the immediate neighborhood and shifted up on the exposed surface, where it is kept in position by pins and sutures (See Figs. 39 and 40) The surface from which the flap was removed, if small, will become covered by growth of the integument from the edges of the wound; but, when large, it should be filled with grafts of skin from other parts of the body. The ectropium may also be corrected by skin grafting from other parts.
Professor of Ophthalmology in the College of the New York Ophthalmic Hospital; Surgeon to the New York Ophthalmic Hospital. Visiting Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological, Otological and Laryngological Society. First Vice-President American Institute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc.