the conjunctiva and extravasation into the eyelids and beneath the skin
of the face. The use of a firm pressure bandage and the omission of the
suture is usually sufficient to prevent this occurring, but the
blood-clot may have to be turned out and the bleeding point sought for
and ligatured.
_Granulations and polypi_ in the socket are usually the result of
leaving some tag of tissue between the margins of the wound, and are
therefore more likely to occur when no suture is used to close the
wound. They should be removed with forceps and scissors.
_Polypoid masses_ sometimes form in a socket as the result of an
imperfect artificial eye causing an œdematous condition of the
conjunctiva. They should not be removed, owing to the contraction caused
thereby, but the artificial eye should be left out, when they will often
disappear.
_Contracted socket_ is usually the result of an imperfectly performed
enucleation or loss of large portions of the conjunctiva; for the
operations for its relief, see p. 261.
EVISCERATION
Evisceration is the removal of the intra-ocular contents.
=Indications.= It is the ideal operation for a suppurating globe; in
these cases enucleation is contra-indicated because the lymph-space
round the optic nerve is opened up by the division of the latter and the
inflammation may spread directly to the meninges.
=Instruments.= Speculum, fixation forceps, Beer’s knife, scissors, scoop
and stitches.
=Operation.= A general anæsthetic is necessary.
_First step._ The eye is transfixed about 4 mm. behind the
corneo-sclerotic junction with a Beer’s knife, which is made to cut out
upwards (Fig. 135). The flap of corneal and scleral tissue is then
seized with forceps and the cornea removed entirely by completing the
incision in the sclerotic round it with scissors (Fig. 136).
_Second step._ The contents of the globe are then eviscerated by means
of a spoon, and the cavity flushed out with 1 in 4,000 perchloride of
mercury lotion. Great care should be taken to remove all portions of the
uveal tract; this is best ensured by visual inspection after the
hæmorrhage has ceased. The interior of the sclerotic should appear
perfectly white.
[Illustration: FIG. 135. MULES’S OPERATION. _First step._ Excision of
the cornea.]
[Illustration: FIG. 136. MULES’S OPERATION. The completion of the
excision of the cornea with scissors.]
_Third step._ Although not absolutely necessary, and inadvisable in the
case of a septic globe, a single suture may be passed through the centre
of the wound in the conjunctiva and sclerotic.
=Complications.= As the operation is not infrequently performed for
panophthalmitis, much swelling of the lids and discharge from the socket
may take place after the operation; these symptoms usually subside in
the course of a few weeks without further trouble. The interval which
must elapse before an artificial eye can be worn is considerably longer
than after enucleation.
MULES’S OPERATION
Mules’s operation is the insertion of a celluloid globe into the
sclerotic after evisceration, followed by closure of the scleral wound
over it. In both this and Frost’s operation a better stump is formed, so
that more movement may be obtained in the artificial eye which is
subsequently worn over the inserted globe.
=Indications.= (i) The operation is especially suitable for anterior
staphyloma following ophthalmia neonatorum. In young children the
presence of the ball in the orbit assists the development of that
structure.
(ii) It is also suitable for large, recently made, fairly aseptic wounds
in the globe.
=Operation.= The _first two steps_ are the same as for evisceration.
_Third step._ A glass or, better, a celluloid or gold-plated ball is
inserted into the sclerotic, which is closed over it by two rows of
interrupted sutures, one of catgut passing through the sclerotic, the
other of silk closing over the conjunctival wound. To facilitate the
closure of the conjunctival wound it is advisable to dissect the
conjunctiva back from the limbus before excising the cornea. The ball
inserted in the sclerotic should fit the cavity loosely.
=Complications.= In about 17% of the cases the ball is not retained;
this is not infrequently due to too large a size being used, or to the
wound being imperfectly closed by the sutures. If two rows be used, as
described above, extrusion of the ball is far less frequent than if one
only be inserted. If the globe be extruded the patient is in the same
position as if he had had evisceration performed.
FROST’S OPERATION
In this operation the eye is enucleated, a celluloid globe is inserted
into Tenon’s capsule, and the conjunctiva is closed over it by means of
sutures passing through Tenon’s capsule and the conjunctiva.
=Operation.= The first four steps in the operation are similar to those
described under enucleation.
_Fifth step._ A small, loosely-fitting glass globe is inserted into
Tenon’s capsule. A purse-string suture of strong catgut is then inserted
into the cut margin of Tenon’s capsule, taking care to include in the
sutures the cut ends of the tendons of the recti muscles. The suture is
drawn tight and tied so that Tenon’s capsule and the muscles are thereby
drawn over the globe. The conjunctival wound is closed over this by a
separate suture of silk.
The advantage of this operation over the other substitutes for simple
enucleation is that it can be used after any enucleation. The chief
disadvantages are that the globe is sometimes extruded unless the wound
be carefully closed by sutures, and occasionally it may become
dislocated from Tenon’s capsule beneath the conjunctiva, thus preventing
an artificial eye from being worn, and requiring removal. These
disadvantages are largely done away with if the method of suture
described above be used.
OPERATIONS UPON THE SOCKET AFTER THE REMOVAL OF THE EYE
PARAFFIN INJECTION
=Indications.= Occasionally after an eye has been removed the movements
in the socket are not communicated sufficiently to the artificial eye
which is placed over it, so that the glass eye has a fixed, staring
appearance. As a rule, this can be remedied by the use of a Snellen’s
improved eye, which has a rounded posterior surface and fits well on to
the stump. If this be not satisfactory, the injection of paraffin into
the stump will often improve the movements considerably. The injection
should be made by what is known as the ‘cold method’.
=The ‘cold method’= of paraffin injection is by far the most
satisfactory, for the following reasons:--
(_a_) The temperature need not be so high, and no damage is therefore
done to the tissues.
(_b_) It is more easily regulated (see Vol. I, p. 682).
(_c_) Embolism is less likely to occur.
=Instruments.= Fixation forceps, tenotomy knife, speculum, a large
paraffin syringe, and a short needle having a big bore.
=Operation.= This may be performed under adrenalin and cocaine.
_First step._ The stump is drawn forwards with forceps. A tenotomy
knife, inserted well to the outer side of the stump, is then swept
freely round and a pocket is formed in the centre of the orbit into
which the injection can be made. The tenotomy knife is then withdrawn.
_Second step._ The sterile melted paraffin (melting-point 115° F.)
should be poured into the syringe, which should have been previously
kept in a hot-water bath. The paraffin is then allowed to cool slowly
until it just becomes opalescent. The injection should be made through
the hole made by the tenotomy knife, sufficient paraffin being inserted
to obtain the desired result. The operation is usually followed by
considerable swelling of the tissues, which will subside in three or
four weeks.
OPERATIONS FOR THE RESTORATION OF A CONTRACTED SOCKET
As the result of wearing badly-formed artificial eyes or of subsequent
inflammation in the conjunctival sac, the socket not infrequently
becomes so contracted that the prosthesis cannot be retained.
Enlargement of the sac may be obtained by two methods:--
(_a_) Skin-grafting (Thiersch’s method).
(_b_) Transplantation of skin from the surrounding structures (Maxwell’s
operation).
SKIN-GRAFTING
=Indications.= This procedure is especially suitable for cases in which
the base of the socket opposite the palpebral aperture has to be
enlarged, and it is usually performed prior to Maxwell’s operation for
the restoration of the fornices in severe cases.
=Instruments.= Scalpel, speculum, skin-grafting razor, probes, and a
piece of thick style wire.
=Operation.= _First step._ The base of the socket is freely divided in a
horizontal direction opposite the palpebral aperture so as to produce a
gaping wound.
_Second step._ This gaping wound is put on the stretch in the following
way: A thick piece of style wire is bent round to fit into the fornices
of the socket, the ends being brought out over the lid at the inner
canthus. The circle of wire is opened out as far as possible so as to
put the wound at the bottom of the socket on the stretch to its fullest
extent.
_Third step._ Skin grafts are then cut from the inner surface of the arm
(see Vol. I, p. 670), applied by means of probes, and pressed down on to
the raw surface. No dressings should be applied directly to the grafts,
but a watch-glass may be placed over the palpebral aperture and
dressings applied over it. The style wire should be removed on the
fourth day.
INCLUSION OF FLAPS. MAXWELL’S OPERATION
=Indications.= It is especially useful for the enlargement of the socket
by the formation of new fornices. As a rule it is performed for the
reproduction of the lower fornix, as it is frequently due to the
obliteration of this cul-de-sac that the artificial eye cannot be
retained. The operation, however, may be modified and applied to the
formation of both the upper and outer culs-de-sac.
=Instruments.= Scalpel, forceps, scissors, and sutures.
=Operation.= A general anæsthetic is required.
_First step._ An incision is made in the lower fornix throughout its
whole length and carried downwards for a distance of about half an inch
(Fig. 137, A).
_Second step._ A crescentic piece of skin is marked out on the lower lid
by two incisions which have their concavity directed upwards. The upper
one is parallel with the margin of the lower lid and about 5 millimetres
below it. This crescentic flap is then dissected up from the deeper
tissues all round, except for a small pedicle at its centre (Fig. 137,
B).
_Third step._ The incision forming the upper margin of the crescentic
piece of skin is deepened until it meets the incision made in the
fornix, so that the lower lid is converted into a band of tissue
attached only at each end.
[Illustration: FIG. 137. MAXWELL’S OPERATION FOR CONTRACTED SOCKET.
_First step._ A is the incision through the conjunctiva. The flap of
skin from the outer surface of the lower lid is entirely raised from the
subcutaneous tissue, except for the pedicle B which holds the new fornix
in position.]
[Illustration: FIG. 138. MAXWELL’S OPERATION. _Final step._ Showing the
flap of skin from the outer surface of the lower lid turned in to form
the new lower fornix. The surface wound has been closed by sutures.]
_Fourth step._ The upper margin of the incision in the fornix is
stitched to the upper margin or concavity of the crescentic piece of
skin after the latter has been displaced upwards beneath the band of
tissue carrying the lashes, and the lower margin of the crescentic piece
of skin is stitched to the conjunctival edge of the band, so that the
crescentic piece of skin is folded on itself and forms the new lower
fornix, being held down in its position by the pedicle (Fig. 138). The
sutures should be of catgut, as their subsequent removal is somewhat
difficult.
_Fifth step._ The surface wound is closed by silkworm-gut sutures. The
socket should be packed with gauze, or else a piece of style wire should
be inserted, as in the previous operation, so as to maintain the groove
in the new lower fornix.
CHAPTER VIII
OPERATIONS UPON THE EYELIDS
SURGICAL ANATOMY
The eyelids consist of well-marked planes of tissue, which are, from
without inwards--
1. Skin with very little subcutaneous fat.
2. Orbicularis muscle.
3. Tarsal plates, which are attached to the orbital margins by the
palpebral ligaments and which thereby form a barrier to the passage of
infection backwards into the orbit.
4. Subconjunctival tissue and conjunctiva.
It is most important for successful results that flaps and incisions
should be made accurately down to and in the correct layer of the lid.
Along the lid margin, between the eyelashes and the posterior border of
the eyelid, is a white line (intermarginal line) formed by the edge of
the tarsal plate. In the many operations in which the lid is split the
incision is carried along this line.
The blood-supply to the eyelids is derived from arterial arches--two in
the top lid, and one in the lower--which run parallel to the margins. As
far as possible, therefore, flaps should be planned with their bases at
right angles to the course of the vessels. The extreme vascularity of
the lid, together with the small amount of subcutaneous fat, allows of
almost complete detachment of flaps of skin without fear of necrosis,
but at the same time every care should be taken to avoid injuring these
flaps when manipulating them. Hæmorrhage is controlled during the
operation by means of clamps or by direct pressure of the lid between
the finger and thumb. As a rule a general anæsthetic is required for
most of the operations.
SUTURE OF WOUNDS OF THE EYELIDS
_Wounds which involve the skin only_ are brought together in the
ordinary way with a few fine sutures. In wounds of the upper lid care
should be taken to suture the levator palpebræ, if divided, as otherwise
traumatic ptosis may result.
_Suture of wounds involving the lid margin._
(_a_) In _simple division_ the margins of the lids are brought together
by means of a fine suture; the conjunctival surface is first
approximated, and then the skin by a deep suture which includes the
tarsal cartilage. Accurate apposition of the lid border is very
essential. Unfortunately a certain amount of ectropion frequently
follows, which may require for its relief one of the operations given
below (see p. 284).
(_b_) _Occasionally the lid margin carrying the lashes may be torn off._
As a rule, the strip remains attached to the lid. It should then be
accurately sutured in position, taking care that the lashes take their
correct turn outwards. In cases where the strip is torn off entirely,
the skin and conjunctiva should be sutured together. When large portions
of the lid are lost, some form of plastic operation, such as is
performed for making a new lid, is required (see p. 287).
(_c_) _When the canaliculus has been divided_ the end attached to the
lachrymal sac should be sought for and divided for a short distance
inwards from the wound (see p. 291), the entrance being kept open daily
by a probe to prevent traumatic stricture.
OPERATIONS FOR ANKYLOBLEPHARON
Fusion of the eyelids together is either a congenital condition or the
result of injury, and may take the form of bands or firm fibrous union.
It is rarely complete and is often associated with symblepharon. The
union should be divided on a director, or by careful dissection, taking
care not to wound the underlying globe. The raw surfaces are kept apart
by daily dressing until they are covered by epithelium. No externa[l]
dressing should be applied.
OPERATIONS FOR SYMBLEPHARON
_Partial adhesion of the lid to the globe_ in which a few bands pass
from the lid to the globe are best treated by division followed by union
of the ocular conjunctiva over the raw surface; no external dressing
should be applied. Any tendency to fresh adhesion may be prevented by
daily inspection.
_In extensive adhesion of the lid to the globe_, where the lids are
entirely adherent to the globe and the cornea is destroyed, interference
is inadvisable. In less extensive adhesion, the lid is first separated
from the globe, reunion being prevented by covering the denuded area on
the globe with a flap of bulbar conjunctiva transplanted from an area
that does not come in contact with the raw surface on the eyelid
(Teale’s operation), or by Thiersch’s grafts from a situation where
there are no hairs; or by grafting mucous membrane from the mouth of the
patient or a frog. Teale’s operation, or some modification, is by far
the most satisfactory, but unfortunately it cannot always be carried out
when the loss of conjunctiva is large.
OPERATIONS UPON THE PALPEBRAL APERTURE
CANTHOPLASTY
=Indications.= In contraction of the palpebral aperture, either due to a
congenital condition, or the result of a wound, trachoma, or other
cicatricial contraction.
=Instruments.= Speculum, forceps, scissors, and three sutures.
=Operation.= The speculum is inserted and opened as widely as possible.
One blade of the scissors is passed into the cul-de-sac at the outer
angle of the lid and the palpebral aperture enlarged by dividing the
outer canthus horizontally. The external tarsal ligament which is split
longitudinally is then cut across with scissors passed into the upper
and lower wound. The conjunctiva is drawn up into the wound and stitched
to the skin at the margin to prevent reunion. The stitches should be
removed about the sixth day.
CANTHOTOMY
Canthotomy is simple division of the outer canthus without stitching the
conjunctiva into the wound. It is useful in some cases of blepharospasm
associated with fissure at the outer canthus.
CANTHORRHAPHY
Union of the eyelids, usually at the outer canthus.
=Indications.= (i) When the eyelids do not cover the globe as the result
of--
(_a_) Cicatricial contraction of wounds, burns, &c., about the lid.
(_b_) Long-standing facial paralysis.
(_c_) Exophthalmic goître.
(ii) To help maintain the lid in position after ectropion operations.
=Instruments.= Beer’s knife, fixation forceps, spatula, and sutures.
=Operation.= _First step._ The position for the new external canthus is
determined by holding the lids together at the outer canthus, and is
marked on the upper and lower lids. From these points incisions are
carried outwards to the external canthus along the intermarginal line in
the top and bottom lids. These incisions are deepened to about 5
millimetres.
_Second step._ From the inner end of the incision in the lower lid a
vertical one is made downwards for about 5 millimetres, and is then
carried out to the external canthus. The tissue thus marked out, bearing
the lashes, is then removed.
_Third step._ A corresponding, slightly larger, area is similarly
removed from the under or conjunctival surface of the upper lid (Fig.
139).
[Illustration: FIG. 139. CANTHORRHAPHY.]
_Fourth step._ These two areas are brought into apposition by means of a
strong suture passed through their centre. The suture should have a
needle at either end, and these should be passed from the conjunctival
surface and brought out through the middle of the raw area in the lower
lid, about 2 millimetres apart, and then through the middle of the raw
area in the upper lid and out through the skin. The suture is tied so
that the two raw areas are brought into accurate apposition. The margins
of the wound may then be brought together by sutures if necessary. The
main suture should be left in for at least ten days.
TARSORRHAPHY
=Indications.= (i) Complete union of the eyelids may be required when an
eye has been removed and for some reason an artificial one cannot be
worn.
(ii) Partial union is effected in cases of paralysis of the first
division of the fifth nerve when corneal ulceration threatens. A similar
union is also useful in keeping the lower lid in position during the
process of cicatrization in many of the operations for ectropion
described below. The adhesions produced can be subsequently divided when
contraction has ceased.
=Instruments.= Knife, forceps, scissors, spatula.
=Operation.= _Complete._ As narrow a strip of tissue as possible is
removed from the lid borders behind the eyelashes. This is best
performed by everting the upper lid and shaving off the posterior margin
with a sharp knife; the lower lid is then treated similarly. The raw
areas are brought into apposition with fine sutures.
_Partial._ When only a temporary adhesion is required, as after
ectropion operations, it is sufficient to make raw corresponding areas
of about 2 millimetres on the posterior margins of the top and bottom
lids on either side of the central position of the cornea and unite them
with sutures, which may be removed about the end of the first week.
PTOSIS OPERATIONS
The following operations are usually only undertaken for congenital
ptosis, but they are occasionally required for the paralytic and
traumatic varieties. All the operations are far from satisfactory, and
should only be undertaken when the lid covers the pupil completely or so
nearly that the head has to be thrown back to see objects directly in a
line with the eyes. The relative value of the various operations apart
from their indications is a matter of opinion amongst ophthalmic
surgeons; therefore the various types of operations which are performed
are given below.
There are four types of operation, which respectively aim at--
1. Shortening the eyelid by excision of a portion of the tarsal plate.
2. Attachment of the lid to the occipito-frontalis muscle.
3. Advancement of the levator palpebræ muscle.
4. Grafting of part of the superior rectus muscle into the lid to take
the place of the levator palpebræ superioris.
SHORTENING THE EYELID BY EXCISION OF A PORTION OF THE TARSAL PLATE
=Fergus’s operation (modified).= The object of this operation is to
shorten the eyelid by removing the upper portion of the tarsal plate,
the cut margin of which is subsequently sutured to the tendon of the
levator palpebræ and the palpebral ligament.
The results of the operation are satisfactory, especially in cases in
which there is some movement in the eyelid. The author, who has
performed most of the ptosis operations on several occasions, has had
most uniform results by this method, the modification of which was first
suggested to him by Mr. Treacher Collins.
It has the advantage that the amount of retraction required may be more
easily estimated, the corneal complications are of much rarer
occurrence, and the resulting scar forms a natural fold in the lid. It
is obviously not applicable to cases in which the eyelid is already
short, as in the cases of ‘Chinese eye’ in which little can be done
beyond enlarging the palpebral aperture.
=Instruments.= Spatula, scalpel, artery and dissecting forceps,
scissors, and sutures.
=Operation.= _First step._ The spatula is inserted into the superior
fornix. A curved incision is made directly below the orbital margin
throughout its whole length. The skin and orbicularis muscle are divided
and dissected downwards so as to expose the upper surface of the tarsal
plate. A suture is then passed through this flap so that it may be drawn
down by an assistant.
_Second step._ A narrow strip about 3 millimetres broad is excised from
the whole length of the tarsal plate; in doing this care must be taken
not to button-hole the conjunctiva or flap of skin.
_Third step._ The cut margin of the tarsal plate is sutured to the
levator palpebræ and palpebral ligament by two sutures passed in the
following manner: A thick catgut suture armed with a curved needle is
passed through the upper cut margin of the orbicularis palpebrarum,
palpebral ligament, and levator palpebræ (if the latter be present) at
about the junction of the middle and inner thirds of the wound, a firm
hold being taken on these structures. The needle is then passed through
the tarsal cartilage parallel to the lid border for a distance of about
3 millimetres and out again on to its anterior surface. The needle is
then again carried through the levator palpebræ, palpebral ligament, and
orbicularis in the upper part of the wound. A similar suture is passed
about the junction of the middle and outer thirds of the wound. When
both sutures are in position they are tied sufficiently tightly to
produce the retraction of the lid desired, slight over-correction being
necessary. The skin wound is then closed with sutures.
ATTACHMENT OF THE LID TO THE OCCIPITO-FRONTALIS MUSCLE
There are three chief methods of affecting this attachment:--
(_a_) By cicatricial bands (_e.g._ Hess’s operation).
(_b_) By a suture left permanently in position (_e.g._ Harman’s
operation).
(_c_) By the attachment of the skin of the lid to the muscle (_e.g._
Panas’ operation).
=Indications.= In the majority of the cases of congenital ptosis the
levator palpebræ is completely absent, as shown by the want of upward
movement in the lid, and it is for this condition that one of the
operations of this type is performed. In rare cases the
occipito-frontalis muscle is also absent or imperfectly developed, and
in these cases these operations should not be undertaken.
=Hess’s operation.= The object of this operation is to insert silk
stitches between the eyelid and the occipito-frontalis muscle, and to
leave them in long enough for a fibrous band of union to form along the
stitch tracks.
=Instruments.= Scalpel, dissecting forceps, needle and holder, spatula,
artery forceps.
=Operation.= _First step._ The eyebrow having been shaved, an incision 2
inches long is made about in the line of the brow, and the skin is
dissected down almost to the lid margin.
_Second step._ Three sutures are passed, one in the middle, and one at
each end of the lid; each suture carries two needles. The needles are
inserted in the intermarginal line of the lid about 3 millimetres apart
and brought out into the wound above, so that the lid margin is held by
the loops. These threads are then carried deeply beneath the upper edge
of the wound into the substance of the occipito-frontalis muscle,
brought out through the skin well above the eyebrow and tied over a
piece of drainage tube. The sutures should be drawn tight enough to
produce an undue amount of retraction of the lid, as this tends to drop
again after removal of the sutures. The skin wound is then closed and a
small dressing is applied to cover the drainage tube on the forehead.
The eye itself should be covered with a celluloid shield, as it is
usually impossible for the patient to close the palpebral aperture, and
the cornea is liable to be injured by exposure. The deep sutures should
be left in for at least three or four weeks, so that they may bring
about a fibrous band between the muscle and the eyelid by their
irritation. The immediate result of the operation is usually excellent,
but the lid is very apt to drop again in the course of six months or a
year after removal of the stitches.
=Harman’s operation.= The aim of this operation is to insert a fine
metal chain between the occipito-frontalis and the lid, the chain being
left permanently in position. The operation has not yet been performed
sufficiently often to allow any definite statement about the final
results to be made.
The results have not been very satisfactory in three cases in which the
author has performed this operation.
=Instruments.= A 4-inch straight surgical needle, to which is attached
the fine wire chain such as is used by spectacle makers to attach
glasses to the dress. It measures about O.75 millimetre in diameter. It
is attached to the needle by a soldered ring or by means of a piece of
silk doubly looped through the needle without a knot.
=Operation.= Under a general anæsthetic. ‘The method of implanting the
chain will be followed readily by reference to Fig. 140. The
chain-needle is inserted above the external angular process at A, is
passed inwards, and with a slightly upward inclination deeply beneath
the tissues of the forehead, to be withdrawn at B; as much of the chain
is drawn through as desired. The needle is reinserted at B, passed
beneath the brow close to the orbital margin and through the tissues of
the lid to C, where it is withdrawn and the chain after it. In like
manner it is passed from C to D through the substance of the tarsus and
withdrawn. It is now returned from D to E above the brow and withdrawn,
and a final length embedded above the brow from E to F, which is just
above the internal angular process. The chain should be buried
completely and stretched evenly between the points A, B, C, D, E and F;
and by traction the loop BCDE should be adjusted at B and E; when the
lid is at the desired height the slack at B and E is taken up by
traction on A and F.
‘The position of the points E and B is of importance; they must be
situated in the region of the most effective elevation of the brow by
contraction of the frontalis muscle, as determined by experiment before
the commencement of the operation (and they should be placed well above
the eyebrow).
[Illustration: FIG. 140. HARMAN’S OPERATION FOR PTOSIS.]
‘The lengths of chain lying buried above the brows from A to B and E to
F, and the angles A B C and D E F, are arranged so that there is
sufficient holding power to prevent the subsequent drop of the lid, but
will not prevent adjustment to forcible traction on the lid until the
links of the chain have become interwoven and surrounded by the growth
of connective tissue. This growth should be sufficiently vigorous by the
end of a week to securely fix the chain against all the force of
traction of the orbicularis muscle. (In one case in which the author
removed the chain after two weeks there was no connective tissue in the
links and it was easily withdrawn.) Until this time the free ends of the
chain should be turned towards each other over the skin of the brow and
cemented in position by a cotton-wool and collodion dressing, after
which time the free ends, A and F, are cut off and the free extremities
pushed beneath the skin.’
=Panas’ operation.= In this operation a direct adhesion of the skin of
the lid to the occipito-frontalis muscle is aimed at.
=Instruments.= Lid spatula, scalpel, dissecting forceps, scissors,
sutures.
=Operation.= Under a general anæsthetic.
_First step._ An incision, 2 inches long, is made in the line of the
brow, and an incision of a similar length is made into the skin of the
lid about half an inch below it. The tissue between these two incisions
is undermined so as to produce a band of skin and subcutaneous tissue.
From the ends of the lower wound vertical incisions are made into the
lid, running slightly outwards and inwards respectively towards the
outer and inner canthus (Fig. 141).
[Illustration: FIG. 141. PTOSIS OPERATION. PANAS’.]
_Second step._ The flap, C (Fig. 141), thus produced is raised, and
doubly armed sutures, D D, are passed 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 passed deeply into the
substance of the tarsus both ends are then passed beneath the band and
brought through into the upper wound, whence they are passed 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 stitches are removed on
the tenth day. A small depression is usually seen where the skin of the
lid passes beneath the band.
ADVANCEMENT OF THE LEVATOR PALPEBRÆ MUSCLE
This is especially suitable for cases in which the levator palpebræ 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 palpebræ is best
estimated by eliminating the action of the occipito-frontalis by holding
down the brow and asking the patient to raise the lid.
[Illustration: FIG. 142. PTOSIS OPERATION. ADVANCEMENT OF THE LEVATOR
PALPEBRÆ. Showing the suture passed through the tendon; the difficulty
of the operation is to find it. (_Diagrammatic._)]
=Instruments.= Lid spatula, knife, forceps, scissors, sutures.
=Operation.= Under a general anæsthetic.
_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 quantity of fat, will be found the tendon of the
levator palpebræ 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 passed 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.
[Illustration: FIG. 143. PTOSIS OPERATION. ADVANCEMENT OF THE LEVATOR
PALPEBRÆ. _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 stitches.
=Operation.= A general anæsthetic 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 passed beneath it;
its middle portion is isolated and two silk sutures, with a needle at
each end, are passed 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 stitches passed 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
passed 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 palpebræ.
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.
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.
[Illustration: FIG. 144. TREACHER COLLINS’S ENTROPION FORCEPS.]
=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.
[Illustration: FIG. 145. LID CLAMP.]
[Illustration: FIG. 146. STREATFIELD’S ENTROPION OPERATION.]
=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.
[Illustration: FIG. 147. ARLT’S OPERATION FOR TRICHIASIS.]
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.
[Illustration: 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 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.
[Illustration: 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 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.
[Illustration: 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.]
[Illustration: 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.
=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.
[Illustration: FIG. 152. ARGYLL ROBERTSON’S OPERATION FOR ECTROPION.
_Second step._ Showing the method of shortening the lid and the strap of
skin reflected. The upper convex line shows the piece of skin to be
removed so that the lid may be pulled upwards into position.]
[Illustration: FIG. 153. ARGYLL ROBERTSON’S OPERATION FOR ECTROPION.
_Final step._ The strap of skin has been sutured in position after
pulling it upwards sufficiently to reduce the deformity and enlarging
the raw area upwards to allow this to be done.]
=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.
[Illustration: FIG. 154. VY OPERATION FOR ECTROPION OF THE LOWER LID DUE
TO A SCAR. _First step._ Showing incision.]
[Illustration: FIG. 155. VY OPERATION FOR ECTROPION. _Final step._
Showing the lid in position.]
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.
[Illustration: FIG. 156. DENONVILLIER’S OPERATION FOR ECTROPION OF THE
LOWER LID. By reversed flaps at the outer angle. _First step._ The flap
B C D is brought down to form the outer part of lower lid.]
[Illustration: FIG. 157. DENONVILLIER’S OPERATION FOR ECTROPION. Showing
the operation completed after transposition of the flaps.]
=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.
[Illustration: FIG. 158. FRICKE’S OPERATION. To replace the loss of
portions of the skin of the upper lid.]
(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.
[Illustration: FIG. 159. DE VINCENTIIS’ OPERATION TO REPLACE THE LOSS OF
THE INNER PORTION OF THE LOWER LID. Showing the inner portion of the lid
removed by a V-shaped incision and the relief incision made outwards
from the external canthus.]
[Illustration: FIG. 160. DE VINCENTIIS’ OPERATION COMPLETED. The lower
lid has been pulled inwards and united to the opposite side of the gap
left by the V-shaped incision. The incision outwards from the outer
canthus, now much diminished in length, is also sutured.]
=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.
[Illustration: FIG. 161. MODIFIED DIEFFENBACH’S OPERATION TO REPLACE THE
LOSS OF THE WHOLE LOWER LID. _First step._ The whole lower lid, together
with the growth, is removed by the V-shaped incision and the flap to
form the new lid is dissected up from the outer canthus. The diagram
shows the incision marking out the flap.]
[Illustration: FIG. 162. MODIFIED DIEFFENBACH’S OPERATION. _Third step._
Showing the flap turned down, to the free border of which is attached
the flap of skin and ear cartilage. The inset shows the proportion of
skin and cartilage (light area) to be removed from the back of the ear.]
_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.
CHAPTER X
OPERATIONS UPON THE LACHRYMAL APPARATUS
Operations upon the lachrymal apparatus are divided into--
I. Operations upon the lachrymal canals.
II. Operations upon the lachrymal gland.
The majority of operations are undertaken for the relief of obstruction
to some portion of the canal which leads from the conjunctival sac to
the nose, obstruction to which causes an overflow of tears (epiphora)--a
condition which must be distinguished from hypersecretion
(lachrymation).
The obstruction may occur in any part of the canal, that is to say, in
the puncta, canaliculi, lachrymal sac or duct; and it is most important
to determine the cause and position of the obstruction in every case
before undertaking an operation for its relief. Hence it need hardly be
said that the nose should be carefully examined in every case unless the
cause is obvious. The operations are divided into two classes:--
1. Those which are undertaken for the relief of the obstruction.
2. Those which are undertaken for the obliteration of the canals.
Except under exceptional circumstances, the latter operations are only
undertaken when a cure cannot be brought about by the former.
The presence of a septic focus, such as a distended lachrymal sac, apart
from the irritation and increased lachrymal secretion caused thereby, is
a source of grave danger to the eye if not relieved, as it is a frequent
cause of serpiginous corneal ulceration.
OPERATIONS FOR THE RELIEF OF LACHRYMAL OBSTRUCTION
DILATATION OF THE CANALICULUS
=Indications.= (i) Contraction of the puncta following marginal
blepharitis, especially when associated with ectropion.
(ii) Preparatory to syringing or probing.
(iii) To dilate a stricture of the canaliculus.
=Instruments.= Nettleship’s canaliculus dilator (Fig. 163).
=Operation.= The operation is performed under adrenalin and cocaine, a
little solid cocaine being rubbed in over the canaliculus.
The lid is slightly everted and put on the stretch by pulling it
downwards and outwards with the thumb. The depression caused by the
punctum is seen on the top of a small elevation. The point of the
dilator is entered vertically into the punctum and then turned parallel
with the lid margin and passed onwards with a steady pressure. At the
same time it should be rotated between the finger and thumb, until the
inner bony wall of the lachrymal sac is felt. The only difficulty which
may be experienced is in entering the dilator into the punctum, owing to
the small size of the latter. For this reason the fine point of
Nettleship’s dilator is more suitable than the form modified by Lang.
Even Nettleship’s dilator is too large in a few cases, and here a large
sharp-pointed pin is sometimes of use in defining the punctum before
using Nettleship’s dilator.
[Illustration: FIG. 163. CANALICULUS DILATOR]
SLITTING THE CANALICULUS
=Indications.= To enlarge the punctum and direct the entrance to the
canaliculus inwards. This is especially desirable before ectropion
operations and for the removal of concretions (leptothrix) from the
duct. In former days the canaliculus used to be slit with the idea of
passing very large probes down the lachrymal duct; this has now been
abandoned, since slitting the canaliculus throughout its whole length,
as is required for this treatment, does away with the capillary
attraction.
[Illustration: FIG. 164. CANALICULUS KNIFE.]
=Instruments.= Dilator, canaliculus knife (Fig. 164), straight iris
forceps, sharp-pointed scissors.
=Operation.= It is usually performed on the lower canaliculus. The eye
is cocainized as in the previous operation and the patient is made to
look up.
_First step._ The canaliculus is first dilated. The knife is inserted
for a short distance with the handle parallel to the lid margin. The
lower lid being held on the stretch by the thumb, the handle of the
knife is raised towards the brow, thus dividing the canaliculus. The
blade of the knife should be directed upwards and slightly backwards.
_Second step._ As the lips of the wound are liable to reunite, it is
better to remove the posterior lip of the groove. This is performed by
seizing the latter with forceps and dividing it with scissors. The
entrance to the canaliculus should be kept open by means of the dilator
passed twice a week for a month.
SYRINGING THE LACHRYMAL DUCT
=Indications.= (i) To test whether the lachrymal canals are patent.
(ii) By constantly cleansing the sac and washing away all purulent
discharge the mucous membrane may regain a more healthy condition, and
so an obstruction due to an alteration in the mucous lining may be
relieved. In cases with a purulent discharge a small quantity of
protargol (10% solution) may be left in the sac after syringing.
[Illustration: FIG. 165. LACHRYMAL SYRINGE.]
(iii) The injection of adrenalin and cocaine into the sac before its
excision.
=Operation.= The eye is cocainized and the patient made to look up. The
punctum is everted by pulling down the lower lid. The canaliculus is
then dilated. The nozzle of the lachrymal syringe (Fig. 165) should be
passed until it is felt to impinge on the bony outer wall of the sac.
Withdraw the syringe slightly and apply gentle pressure to the piston.
The fluid will either regurgitate through the upper canaliculus or, if
the duct be patent, pass down into the nose and so into the throat.
=Complications.= If too forcible syringing be used extravasation of the
fluid may take place. This is accompanied by pain and swelling in the
lachrymal region. It usually subsides under hot fomentations, but
suppuration and even cellulitis of the orbit have been known to occur.
PROBING THE LACHRYMAL DUCT
=Indications.= (i) In cases of congenital lachrymal obstruction due to
débris blocking the duct.
(ii) When syringing has failed to bring about a cure, a probe may be
passed once or twice to see if dilatation causes any improvement. It is
especially useful in children.
(iii) As a preliminary to the insertion of styles.
Various forms of probes are employed, those of Bowman being in general
use. Too fine a probe should not be used, otherwise a false passage is
liable to be made.
=Operation.= This is performed under adrenalin and cocaine, which should
be injected into the lachrymal sac.
The lower punctum is dilated and the probe passed parallel to the lid
margin until it is felt to impinge upon the lachrymal bone. Keeping the
point applied to the bone, the handle of the probe is rotated upwards
through rather more than a quarter of a circle and passed by a gentle
pressure downwards and slightly outwards into the duct, keeping the
point of the probe close to the bone the whole way. The direction of the
probe after entering the duct should be downwards, outwards, and
backwards in the direction of the first molar tooth on the same side.
The backward direction of the duct is much more marked in young children
than in adults.
=Complications.= A false passage may be made into the antrum of
Highmore. If such an accident should occur, no further attempt should be
made to pass a probe for a few days until the wound has healed.
THE INSERTION OF STYLES
A few surgeons still insert styles into the lachrymal duct with the idea
of continuous dilatation. The hollow styles used by Bickerton are the
ones most frequently employed.
=Instruments= for dilating, slitting the canaliculus, probing, and
styles. Also Stilling’s knife.
=Operation.= A general anæsthetic is desirable.
_First step._ The canaliculus is dilated and slit up, the posterior lip
being removed (see p. 29).
_Second step._ The duct is dilated by probing (_vide supra_) or enlarged
by passing Stilling’s knife down it.
_Third step._ A style is passed down the dilated duct. The lower end of
the style should rest upon the floor of the nose, otherwise there is a
tendency for the style to slip into the duct and disappear. Care should
be taken that the upper end does not rub on the globe. Styles should
generally be left in position from three to six months. A style should
at first be made of lead wire and moulded until a suitable pattern is
obtained, from which a hollow gold style can be made subsequently.
=Complications.= 1. _Dacrocystitis_ may follow the insertion of a style,
which should then be removed until the inflammation has subsided.
2. _The style may slip down the duct._ If this should occur an attempt
should be made to grasp it through the slit canaliculus. The lower end
may present in the nose and the style can then be withdrawn with
forceps. Occasionally styles lodge in the antrum of Highmore, in which
case they must be removed after localization by the X-rays through an
opening from the mouth above the canine tooth.
OPERATIONS FOR THE OBLITERATION OF THE CANALS
When syringing and probing have failed to relieve the lachrymal
obstruction, one of the following operations for the obliteration of the
lachrymal passages may be employed.
OBLITERATION OF THE CANALICULI
=Indications.= In cases of lachrymal obstruction in which an immediate
operation upon the globe is required.
=Operation.= Under cocaine. Fine sutures armed with a small curved
needle are passed beneath both the upper and lower can[al]iculus and
tied so as to include them in the ligature. Permanent obliteration may
be caused by the destruction of the lining membrane with the actual
cautery.
EXCISION OF THE LACHRYMAL SAC
=Indications.= (i) For mucocele in cases of lachrymal obstruction which
have failed to yield to other treatment.
(ii) In all cases of tuberculous disease of the sac.
(iii) For a recurrent lachrymal abscess after subsidence of the acute
inflammation.
(iv) For hypopyon ulcer associated with lachrymal obstruction.
(v) Before operation on the globe in cases of lachrymal obstruction.
(vi) For lachrymal fistula.
=Instruments.= Small scalpel, forceps, Muller’s speculum (Fig. 166),
Axenfeld’s retractor (Fig. 167), straight scissors, horsehair sutures.
=Operation.= Hæmorrhage is the most troublesome part of this operation;
it is best controlled by injecting adrenalin (made from the dried gland,
ʒj, and ℥j of water) and cocaine, 10%, into the sac a quarter of an hour
before operating. Swabs on the end of a glass rod dipped in adrenalin
and cocaine may also be used during the operation. A general anæsthetic
is desirable, but many surgeons perform the operation under local
anæsthesia, produced by injecting 5% cocaine with 1 in 1,000 adrenalin
into the tissue surrounding the sac; but the latter plan has the
disadvantage that the mixture may cause severe toxic effects, and the
patient usually experiences some pain while the upper portion of the
incision is being made and the lower end of the sac is being divided.
_First step._ The internal tarsal ligament is first defined by putting
the lids on the stretch. An incision should be made, 15 millimetres in
length (5 millimetres of which should fall above the tarsal ligament),
backwards and inwards directly over the lachrymal sac. Muller’s
retractor is then inserted to retract the wound laterally, the hooks
being made to engage the margins of the incision by means of forceps.
The superficial fascia and the fibres of the orbicularis muscle are then
divided. The internal tarsal ligament in the upper part of the wound,
together with the glistening deep fascia, is exposed and divided
carefully so as not to injure the lachrymal sac, which is found directly
beneath it (Fig. 168).
[Illustration: FIG. 166. MULLER’S RETRACTOR FOR EXCISION OF THE
LACHRYMAL SAC.]
[Illustration: FIG. 167. AXENFELD’S RETRACTOR FOR EXCISION OF THE
LACHRYMAL SAC.]
_Second step._ With scissors the sac-wall is then separated from the
deep fascia which encloses it, first externally and then internally, the
canaliculi being divided. Axenfeld’s retractor is then inserted in the
longitudinal axis of the wound (Fig. 167). The middle of the sac is
grasped with forceps and pulled forward, and the top of the sac is
defined and detached. This is frequently difficult owing to the
troublesome hæmorrhage which often occurs. The sac is pulled well
forward, and the posterior wall is separated, the neck of the sac being
divided as far down the duct as possible by means of scissors. A large
probe is passed down the duct into the nose. Some surgeons remove the
periosteum of the lachrymal bone as well as the sac, which is
unnecessary. The wound is closed by three sutures, the middle one
including the divided ends of the internal tarsal ligament. A firm
dressing should be applied so as to keep the walls of the cavity in
contact. In tuberculous cases it is desirable to curette the lower end
of the duct after removal of the sac. The stitches are removed on the
seventh day.
=Complications.= These may be immediate or remote.
=Immediate.= 1. _Inability to find the sac._ This may happen to a
beginner, and is generally due to the fact that the dissection is
carried too much inwards towards the nose. It should not occur if the
guides to the sac carefully borne in mind, namely, the internal tarsal
ligament and, on the inner side, the lachrymal crest, which can easily
be felt with the finger or forceps in the wound.
[Illustration: FIG. 168. EXCISION OF THE LACHRYMAL SAC. Showing the
internal tarsal ligament in the upper part of the wound with the sac
lying beneath.]
[Illustration: FIG. 169. EXCISION OF THE LACHRYMAL SAC. Showing the
method of defining the upper end of the sac. The internal tarsal
ligament has been divided and the sac is well pulled forward with
forceps.]
2. _Opening the conjunctival sac._ This may take place when dividing the
canaliculi. It is more likely to occur if the deep fascia has been
imperfectly divided before carrying out the dissection to the inner
side. As a rule the opening heals readily.
3. _Opening of the orbit_, due to the division of the fascia attached to
the posterior lip of the lachrymal groove. It is recognized by the fact
that orbital fat presents in the wound, and for this reason it makes the
operation more difficult. It is most likely to happen when the lower end
of the sac is being divided. It lays the orbit open to the possibility
of septic infection. The internal rectus has been divided, no doubt due
to the fact that the fascia, which passes from the outer surface of this
muscle, is attached to the posterior lip of the lachrymal groove, and
the muscle has been thereby pulled up into the wound; with ordinary
caution such an accident is impossible.
4. _Injuries to the cornea._ Corneal abrasions by the clumsy insertion
of retractors may lead to severe corneal ulceration.
=Remote.= 1. _Epiphora._ Normally the lachrymal secretion is largely
removed from the conjunctival sac by a process of evaporation. It is
only when the hypersecretion of tears takes place that the lachrymal
apparatus is called much into use. As a rule, patients who have had the
lachrymal sac excised do not complain of epiphora, except in a cold
wind. Occasionally this epiphora may be so troublesome that removal of
the palpebral portion of the lachrymal gland is desirable for its
relief. There is no fear of the conjunctival sac becoming dry after this
operation, since there are numerous accessory lachrymal glands (glands
of Waldeyer and Krause) opening on to the superior fornix.
2. _A sinus._ The wound may break down and a sinus may form at the site
of the incision. These cases are nearly always of tuberculous origin and
not infrequently have underlying bone trouble. They can usually be made
to heal by the use of iodoform and scraping.
3. _Recurrence of the mucocele or lachrymal abscess._ Occasionally the
mucocele may re-form, or an abscess result after removal of the sac.
This is due either to a piece of sac-wall being left behind, or to the
relining of the cavity with epithelium from the cut end of the duct. It
is particularly liable to occur in cases of a tuberculous nature. Firm
pressure with the dressings after the operation is the best method of
preventing the cavity relining with epithelium. If the condition has
arisen, the pseudo-sac should be excised.
OPENING A LACHRYMAL ABSCESS
=Indications.= Lachrymal abscess is due to an inflammation around the
sac-wall through which infection of the cellular tissue has taken place.
The abscess should not be opened until pus is present, as even
considerable swelling and œdema will often subside without suppuration;
this is usually about the end of the third day. Further, if the opening
be made too soon, the inflammation takes considerably longer to subside.
=Instruments.= Beer’s knife, forceps, and probe.
=Operation.= Usually performed under gas. An incision is made over the
lachrymal sac and is carried downwards and inwards to the bone by a
single puncture of the knife. The pus is evacuated, and the cavity
stuffed with gauze, which should be changed daily for the first three
days. Hot fomentations should be applied. As soon as the swelling has
subsided, the lachrymal obstruction should be treated by one of the
methods previously described.
OPERATIONS UPON THE LACHRYMAL GLAND
REMOVAL OF THE PALPEBRAL PORTION
=Indications.= For obstinate epiphora after removal of the lachrymal
sac.
=Instruments.= Fixation forceps (two pairs), two sharp hooks, strabismus
scissors, suture.
[Illustration: FIG. 170. EXCISION OF THE PALPEBRAL PORTION OF THE
LACHRYMAL GLAND. The lid is doubly everted and the gland is dissected
out from within outwards.]
=Operation.= Usually performed under adrenalin and cocaine.
_First step._ The upper lid is doubly everted. The eversion is best
carried out by holding the singly everted lid between forceps and then
re-everting it; the forceps are then given to an assistant to hold. With
a syringe a few drops of 5% cocaine are injected through the conjunctiva
into the area to be operated upon.
_Second step._ The gland is seen beneath the conjunctiva at the outer
part of the upper fornix, seized with forceps, and drawn forwards. A
horizontal incision is made with scissors through the conjunctiva, which
is dissected backwards. The edges of the wound are then held apart by
means of sharp hooks (Fig. 170).
_Third step._ The gland, which is seen as a nodule, is drawn forward
with forceps. By means of the scissors the gland is separated from its
attachments along its whole length, starting on the inner side, the
wound being subsequently closed with a few points of catgut suture.
REMOVAL OF THE ORBITAL PORTION
=Indications.= It is usually undertaken for tumours (endotheliomata,
&c.) and retention cysts.
=Instruments.= Knife, artery and dissecting forceps, retractors,
ligatures.
=Operation.= Performed under a general anæsthetic.
_First step._ An incision, three inches long, is made through the skin
immediately below the outer third of the orbital margin. The underlying
orbicularis palpebrarum is divided, and the orbital fascia covering the
gland is defined and incised.
_Second step._ The gland is first separated from the periosteum of the
depression in the bone in which it lies, and is drawn forward and
carefully dissected out from the lid. The wound is then closed with
sutures.
=An abscess in the lachrymal gland= should be opened by an incision
similar to, but not so long as that in the above operation.
OPERATIONS UPON THE ORBIT
EXPLORATION OF THE ORBIT (KRÖNLEIN’S METHOD)
In this operation the bony outer wall of the orbit is divided above and
below, and turned outwards so as to expose the orbital contents without
interfering with the globe; the bony wall, being kept attached to the
overlying tissue, can be replaced subsequently without fear of necrosis.
=Indications.= The operation is performed in cases of a suspected tumour
of the orbit, which, if small and non-malignant, can be removed, the eye
being left _in situ_. If doubt exists as to the nature of the tumour a
piece can be removed and examined microscopically, either at the time of
the operation or later. It is especially suitable for tumours of the
optic nerve and for orbital cysts behind the globe.
=Instruments.= Scalpel, dissecting forceps, artery forceps, scissors,
periosteum detacher, chisel and hammer, or preferably, a motor rotary
saw, and retractors.
=Operation.= Performed under a general anæsthetic.
_First step._ A slightly curved incision with the convexity forwards is
made so as to expose the outer margin of the orbit and carried down to
the bone. The periosteum is separated from the inner surface of the
outer wall of the orbit by means of a periosteum detacher and divided
horizontally, the finger is inserted, and the orbit explored. If a
small tumour or cyst be found it can sometimes be shelled out through
this incision without enlarging the wound further.
_Second step._ The eye and orbital contents are carefully protected with
a large flat retractor. The bone is first divided above, by means of
either a chisel or a saw. The upper incision should pass through the
base of the external angular process of the frontal bone, and run
backwards and slightly downwards to the posterior end of the
spheno-maxillary fissure. The lower incision should run directly
backwards from the lower orbital margin into the spheno-maxillary
fissure. The triangular wedge of bone attached by its outer surface to
the soft tissues in the temporal fossa is then forced outwards. In doing
this care must be taken not to fracture the orbital wall anteriorly,
otherwise the space to work in will be much reduced.
_Third step._ Consists in the removal of the tumour. Care must be taken
to displace the external rectus to one side so as to avoid injury to it
as much as possible. If the case should be one of an optic nerve tumour,
for which the operation is most frequently performed, the optic nerve is
divided close behind the globe. The tumour is freed from the surrounding
ciliary nerves and the ophthalmic artery and brought up into the wound
as much as possible. The optic nerve is then divided at the apex of the
orbit and the tumour removed. The wound in the periosteum of the outer
wall of the orbit is closed with a catgut suture, the bone, together
with the soft parts, replaced in position and the skin wound closed by
sutures. A drainage tube should be inserted for at least twenty-four
hours.
=Complications.= 1. _Proptosis._ The operation is liable to be followed
by great proptosis as the result of hæmorrhage into the orbit. If the
optic nerve has been removed, the globe may be dislocated forwards
between the lids and come in contact with the dressings.
2. _Corneal ulceration._ As the cornea is frequently anæsthetic from
division of the ciliary nerves, ulceration is very liable to follow. It
is, therefore, desirable in many cases to stitch the lids together after
closing the skin wound.
3. _Defective outward movement in the globe_ is of frequent occurrence,
owing either to injury of the external rectus or the sixth nerve, or to
involvement of them in the scar tissue. Stitching the periosteum
together obviates the latter to a certain extent.
4. As the wound cicatrizes a certain amount of _enophthalmos_ is very
liable to result.
EVISCERATION OF THE ORBIT
=Indications.= This operation is usually performed for some form of new
growth originating either in the eye or the orbit.
=Operation.= This may be modified (1) according to the _position_ of the
growth. In severe cases of rodent ulcer and sarcomatous growths, which
involve the lids, it is desirable that the lids should be removed with
the tumour; but in cases of tumour of the optic nerve, or disease
situated far back in the orbit, and not involving the lids or
conjunctiva, these structures may be retained, since a much better
socket is thus obtained. (2) The _nature_ of the growth. In simple
tumours, such as nævi and some cases of arterio-venous aneurism which
have failed to yield to other treatment, the incomplete method, in which
the lids are retained, is all that is necessary, but in malignant cases
they should be removed.
_The Complete Method._ An incision down to the bone is first made,
completely encircling the orbital margin and including any growth that
may be involving the skin. The periosteum is then separated completely,
as near to the optic foramen as possible. Care must be taken in dealing
with the periosteum over the lachrymal bone, as the bone is liable to be
fractured and an opening made into the nose if undue force be used. The
apex of the cone formed by the periosteum is divided, as far back as
possible, with curved scissors, and the whole orbital contents are
removed. The wound is packed with gauze, and skin-grafting is
subsequently performed when the bone has become covered with
granulations; this usually occurs about the end of the second week.
_The Incomplete Method._ The globe is first enucleated and the outer
canthus divided. The lids are well retracted and an incision is carried
down to the bone along the orbital margins. The periosteum is then
stripped up from the walls of the orbit and the apex of the cone divided
as far back as possible, as in the previous operation. The conjunctiva
and outer canthus are then united with sutures. As a rule, skin-grafting
is not necessary after this operation.
OPENING AN ORBITAL ABSCESS
Orbital abscesses should be incised where they point. In the upper lid
care should be taken not to divide the levator palpebræ muscle; the
incision should be placed well to one side. In making an incision over
the inner side of the orbit care should be taken not to detach the
pulley of the superior oblique. The cause of the abscess should be
ascertained if possible. Suppuration in the ethmoidal sinuses coming
through from the nose is the commonest cause, and should be treated
appropriately (see Section V).
SECTION III
OPERATIONS UPON THE EAR
BY
HUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.)
Aural Surgeon to the London Hospital
CHAPTER I
EXAMINATION OF THE EAR: GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS
In order to perform successfully the various operations upon the ear, it
is essential that the surgeon should be familiar with the technique of
its examination, which, for the sake of convenience, will first be
briefly described.
EXAMINATION OF THE EAR
For this purpose it is necessary to make use of certain instruments in
order to obtain a clear view of the deeper parts of the auditory canal
and tympanic membrane. Most important amongst these are the following:--
=Mirror.= A head-mirror, such as the ordinary laryngological mirror with
a focus of eight inches, is to be preferred to the hand-mirror, as it
leaves both hands free for manipulation.
[Illustration: FIG. 171. CLAR’S LAMP.]
=Sources of illumination.= Although the light reflected from the sky on
a bright cloudless day is excellent, it can seldom be made use of, and
so for practical purposes the source of light is usually artificial. It
is wiser always to use the same kind of light--for instance,
electric--as in this way a more accurate comparison can be made of the
various pathological conditions seen on examination. In the consulting
room, the lamp recommended by Dr. Greville Macdonald, furnished either
with a thirty-two candle-power frosted burner or with a Nernst light, is
most suitable. As a portable lamp, it is useful to have an electric
bull’s-eye lamp, run off from a dry-celled battery: it can be held in
the position of the ordinary lamp, the light being reflected into the
ear by means of the head mirror. The ordinary surgical head-lamp,
although not well adapted for inspection of the deeper parts of the
auditory canal, is eminently suited for obtaining good illumination
during the performance of the mastoid operations; or in its stead a
head-mirror with lamp attached may be used, as recommended by Clar (Fig.
171).
=Aural specula.= Of the various aural specula employed, Gruber’s is very
good (Fig. 172). A special speculum in which a portion has been removed
from the narrow end is sometimes useful in order to facilitate operative
procedures within the external meatus.
=Forceps.= The best are angular spring forceps with bulbous points (Fig.
173).
[Illustration: FIG. 172. GRUBER’S AURAL SPECULUM.]
[Illustration: FIG. 173. ANGULAR SPRING FORCEPS.]
=Position of the patient.= The patient should sit upright in a chair
with the side to be examined turned towards the surgeon. To prevent
movement, the head should be supported by an assistant or by a head-rest
fixed to the back of the chair. The lamp is placed a little behind and
to the left of the patient’s head, on a level with the head of the
examiner.
=Technique of examination.= To convert the external meatus into a
straight canal, the auricle has to be pulled backwards and downwards in
an infant, backwards in a child, and backwards and upwards in an adult.
The speculum should be warmed and inserted gently into the meatus by the
thumb and index-finger of the left hand, whilst the pinna is held
between and pulled back by the second and third fingers (Fig. 174). This
leaves the right hand free for manipulation. The largest possible
speculum should be used, in order to give the maximum amount of room and
illumination. It should only be introduced into the meatus as far as the
adaptable cartilaginous portion permits--about half an inch in the
adult--and not forced into the bony portion. The utmost gentleness is
essential in order to obtain the confidence of the patient; this is
absolutely necessary for the performance of the various small operations
upon the auditory canal and tympanic cavity under local anæsthesia.
[Illustration: FIG. 174. EXAMINATION OF THE EAR.]
[Illustration: FIG. 175. AURAL FORCEPS HOLDING COTTON-WOOL.]
=Method of cleansing the ear.= Except when the auditory canal is
completely blocked by inspissated pus, cerumen, or epithelial débris, it
is sufficient to mop out the ear with small pledgets of cotton-wool. To
prevent injury to the walls of the meatus and to the tympanic membrane,
the pledget is held between the blades of the forceps in such a fashion
that it partially projects beyond its points (Fig. 175). The forceps is
passed through the lumen of the speculum along the auditory canal and
then quickly withdrawn. This is repeated with fresh pledgets until the
meatus is cleansed. If there is much purulent discharge, only a brief
moment may be given (after the withdrawal of the forceps) in which to
inspect the deeper parts. Such a view, however, should always be
obtained in order to form an accurate diagnosis. If this method fails to
cleanse the ear, syringing becomes necessary.
=Technique of syringing.= The patient should be sitting down, as
syringing may cause giddiness. The fluid should be aseptic, and at a
temperature of 100° F. The patient’s head is inclined to the affected
side, and the auricle is pulled upwards or backwards. The syringe is
inserted a short distance within the meatus, and applied to the upper
posterior wall so that the stream of lotion flows along the roof of the
canal to the drum, and returns along the floor, thus washing out the
contents. The best syringe is one with a metal plunger, as it can be
easily sterilized. After syringing, the auditory canal should be dried
and again inspected. If the inspissated pus or epithelial débris cannot
be removed by simple syringing, an ear-bath of warm hydrogen peroxide
(10 vols. %) should be given, and the ear again syringed after ten
minutes.
[Illustration: FIG. 176. MILLIGAN’S INTRATYMPANIC SYRINGE.]
=Syringing out of the attic.= In certain cases of chronic attic
suppuration, it is advisable to syringe out the attic. For this a
special syringe is necessary. It consists of a fine canula whose point
is turned up almost at right angles to its shaft (known as Hartmann’s
canula), to which is fitted a piece of india-rubber tubing and a ball
syringe. Milligan’s modification of this instrument is now generally
used, as it permits of the canula being held in the hand, and instead of
having a ball syringe, is connected by rubber tubing to a small
irrigator (Fig. 176).
The patient sits upright in a chair in the ordinary position for
examination of the ear; a speculum is inserted into the meatus, and held
in position with the left hand; the canula, together with the ball
syringe (if Hartmann’s is used), is held in the right hand. Under good
illumination the canula is passed inwards along the auditory canal, and
its point inserted through the perforation. By gently pressing on the
syringe, the fluid is forced into the attic, which is thus washed out.
With Milligan’s instrument, the irrigator is fixed about two feet above
the level of the ear. While the canula is being inserted, the escape of
lotion is prevented by compressing the tube against the shaft of the
instrument by means of the thumb. After the canula has been inserted
into the opening, relaxation of this pressure permits of flow of the
lotion. Milligan’s method is better than Hartmann’s, as the surgeon has
more control over the instrument. Pain due to the introduction of the
canula may be greatly minimized by previously inserting within the
margins of the perforation either a pledget of cotton-wool soaked in a
saturated solution of cocaine, or a crystal of cocaine.
After the cavity has been thoroughly washed out, the auditory canal is
carefully dried as a final step, gentle inflation by Politzer’s method
may be performed in order to expel any fluid still remaining within the
attic.
GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS
In this connexion two points must be borne in mind: (1) The surgeon must
have a good view of the part operated upon. For this reason when
operating upon the auditory canal, the tympanic membrane, and tympanic
cavity, he will usually require to work by reflected light.
(2) There must be no movement of the patient’s head during the
operation. If the operation is performed under a local anæsthetic, it is
therefore very important that the patient’s head should be kept fixed by
means of an assistant.
=Preliminary surgical toilet.= If there be no existing suppuration, the
ear should be cleansed, some twelve hours before the operation, by first
giving an ear-bath of hydrogen peroxide lotion. This is done by making
the patient incline the head to the opposite side so that the affected
ear is uppermost. The warm solution is then poured into the meatus.
After ten minutes the ear is syringed out with a 1 in 5,000 aqueous
solution of biniodide of mercury, and a strip of sterilized gauze is
then inserted into the auditory canal. The auricle and surrounding parts
should also be surgically cleansed, and afterwards protected by a simple
aseptic compress. If, as in furunculosis of the external meatus,
syringing or cleansing of the ear is very painful, drops of a 10%
solution of carbolic acid in glycerine may be instilled frequently into
the meatus instead. If there is an existing otorrhœa, it is obviously
impossible to render the field of operation absolutely aseptic. The ear,
however, should be cleansed, but the auditory canal should not be
plugged with gauze. The existence of a purulent discharge is no excuse
for lack of cleanliness. Failure of such precautions may lead to
disaster; for example, to perichondritis of the auricle as a sequel of
the mastoid operation.
Before the actual operation takes place, if necessary after the
anæsthetic has been given, the ear and surrounding parts should again be
carefully cleansed, and the auditory canal syringed out with biniodide
of mercury solution.
In intrameatal operations the head should be wrapped in a sterilized
towel, and a square of sterilized lint, having an aperture in the centre
so as to expose only the auricle and meatus, should be placed over the
side of the head and face. In operations on the mastoid process, and in
those involving a post-auricular incision, the head should also be
shaved for at least two or three inches beyond the region of the ear.
=Anæsthesia.= Both local and general anæsthesia are used. Unless
contra-indicated for some special reason, and unless the operation is a
very trivial one, it is wiser to give a _general anæsthetic_. Of these,
chloroform is the most suitable in adults and infants, and the A. C. E.
mixture in children. Ether, although it may be safer, is frequently a
source of annoyance to the operator, as it tends to increase the
hæmorrhage.
In order to produce _local anæsthesia_ two methods may be employed: (1)
The instillation of fluids into the meatus; (2) subcutaneous injection
of fluids beneath the lining membrane of the meatus and into the
surrounding parts of the auricle.
The solution usually employed is a sterilized aqueous solution of
cocaine hydrochloride in varying strengths up to 20%, to which may be
added equal parts of 1 in 1,000 adrenalin chloride solution; the latter
not only increases its analgesic properties, but also acts as a powerful
hæmostatic.
_Instillation._ As the auditory canal and the tympanic membrane are
lined with epithelium which is very resistant to the absorption of
fluids, complete anæsthesia is almost impossible to obtain. This method,
therefore, is practically limited to such trivial operations as the
curetting away or snaring off of granulations or polypi from the
external or middle ear. To render anæsthesia more complete, the affected
part may be finally rubbed over with a crystal of solid cocaine
hydrochloride just before the operation--is begun. On the other hand, if
the raw surface is large--for example, the wound left after a recently
performed complete mastoid operation--the cocaine employed should not be
stronger than a 5% solution in order to minimize the risk of poisoning.
Gray of Glasgow has suggested, as a more penetrating anodyne solution, a
mixture consisting of a 10% solution of cocaine hydrochloride in equal
parts of aniline oil and absolute alcohol, a solution which he
especially advocates in order to produce anæsthesia of the tympanic
membrane before doing paracentesis.
_Subcutaneous injection._ This is a modification of Schleich’s method,
and was first introduced by Neumann of Vienna. It consists in injecting
a very weak solution of cocaine and adrenalin chloride subcutaneously
beneath the periosteum lining the auditory canal. By this method even
the complete mastoid operation has been performed, and in certain
clinics it is used continually in the minor operations of paracentesis
of the tympanic membrane, division of intratympanic adhesions,
extraction of polypi, and ossiculectomy. A solution of beta-eucaine or
novocaine may be used in preference to cocaine, as being less dangerous.
According to Neumann, three solutions are necessary: (_a_) a 1 in 2,000
solution of adrenalin chloride containing a 1% solution of beta-eucaine;
(_b_) a 1 in 3,000 solution of adrenalin chloride containing a 1%
solution of cocaine; (_c_) a 20% solution of cocaine.
The syringe for injecting the solution has a capacity of I cubic
centimetre, and for convenience its needle is fixed at an obtuse angle
to the body of the syringe (Fig. 177). The technique of the injection
depends on whether the operation is to be limited to the auditory canal
and tympanic cavity, or is to involve the mastoid process.
[Illustration: FIG. 177. NEUMANN’S SYRINGE FOR SUBCUTANEOUS INJECTION.]
If the complete mastoid operation is going to be performed, the needle
of the syringe, now filled with the eucaine solution, is thrust through
the skin about the middle point of the mastoid process, and a few drops
of the solution are injected. The needle is then forced upwards towards
the temporal ridge, at the same time being thrust in deeply until it
touches the bone, so that a syringeful of the solution is injected
beneath the periosteum. The needle is then withdrawn and reinserted at
the same point, but in a backward direction, the solution being injected
along the posterior portion of the mastoid process; in a similar manner
the solution is injected downwards towards the tip of the mastoid. The
ear being now pulled well forward, the needle is made to pierce the fold
between the auricle and the mastoid process, just above the posterior
ligament, and is pushed inwards between the anterior border of the
mastoid process and the cartilage of the meatus, and a further
syringeful of the solution is injected. A large speculum is now inserted
into the ear, so that by pressing it against the wall of the meatus the
skin, at the termination of the cartilaginous portion, is made to
project in folds. The needle of the syringe, filled with cocaine
solution, is pushed into this fold, and a few drops of the solution
injected. By degrees the needle is still further pushed inwards, keeping
it in close contact with the bony wall so that the fluid is injected
beneath the periosteum. If the injection has been successful, a white
bulging of the superior wall of the auditory canal will be noticed. To
render anæsthesia complete, further injections may be made into the
inferior and anterior walls of the auditory canal. Finally, a pledget of
cotton-wool soaked in a 20% solution of cocaine is pushed into the
tympanic cavity.
In the case of simple opening of the mastoid, subcutaneous injections
into the auditory canal are not necessary. On the other hand, if the
operation is limited to the auditory canal and tympanic cavity, the
injections into the mastoid process are not required, but a primary
injection of a small quantity of eucaine solution into the
auriculo-mastoid fold considerably diminishes the pain produced during
the act of injection into the auditory canal. Fifteen minutes should be
allowed to elapse before the operation is begun. The anæsthesia lasts
about half an hour.
_Difficulties._ It is by no means easy to inject fluid beneath the
periosteum of the auditory canal, owing to its close adherence to the
bone. The needle by mistake may repierce the skin at a point farther in,
so that the fluid, instead of being injected beneath the periosteum, is
injected into the auditory canal itself. In these cases anæsthesia will
not be obtained, and the operator may possibly blame the principle of
subcutaneous injection, rather than his own faulty technique.
In favour of subcutaneous injection it is urged that most of the minor
operations within the tympanic cavity, including ossiculectomy, may be
performed with the patient sitting up in the chair in the consulting
room, and further, that the patient can afterwards go home; that the
operation is rendered more easy owing to there being practically no
bleeding; and that in the case of the more severe operations, such as
opening of the mastoid antrum, the surgeon, in a case of emergency, may
make use of this method if he cannot possibly obtain the services of an
anæsthetist.
Against subcutaneous injection is the pain of the injection, which may
be so great that the patient will not submit to it, and in consequence
the proposed operation may have to be postponed.
In the case of the mastoid operation, it is difficult to believe that
local anæsthesia, however efficient, will be looked upon with favour
either by the surgeon or by the patient, except when a general
anæsthetic is absolutely contra-indicated. The discomfort produced by
retraction of the parts, the jarring caused by chiselling, and the
consciousness of what is taking place, are far more unpleasant and more
of a shock to the patient, than a general anæsthetic carefully given.
Further, it is not always possible to foretell the extent of the
operation, and if repeated injections become necessary, there is danger
of eucaine or cocaine poisoning being produced.
=Position of the patient and the surgeon=
1. In the minor operations the patient may be operated on whilst in the
sitting posture, whether a local anæsthetic or a general one of gas and
oxygen is employed. The relative positions of the patient and the
surgeon are then the same as for the ordinary routine examination of the
ear. Special care, however, should be taken that the patient’s head is
supported by the anæsthetist or assistant in order to prevent
involuntary movements.
2. If the patient is operated on in the recumbent position, the head may
rest comfortably on an ordinary pillow, but if chiselling is going to
take place, the best support is a loosely filled sand-bag. The head
should be turned towards the opposite side so that the affected ear is
uppermost, and the surgeon stands at the side to be operated on. The
lamp, the source of reflected light, should be held about six inches
above the patient’s shoulder on the opposite side.
CHAPTER II
OPERATIONS UPON THE EXTERNAL AUDITORY CANAL
OPERATIONS FOR FURUNCULOSIS
The operative treatment consists in incising the furuncles and, if
necessary, curetting out their contents.
=Indications.= (1) If, in spite of palliative treatment for two days,
the pain be so intense as to prevent sleep, and be accompanied by
pyrexia.
(2) If there be accompanying œdema of the auricle and surrounding parts.
(3) If the furuncles occur during the course of a middle-ear
suppuration, and occlusion of the external meatus prevents free drainage
of the purulent secretion.
When possible, it is always preferable to operate under a general
anæsthetic, such as gas and oxygen. If, however, the patient objects to
a general anæsthetic, it should be explained that, in spite of the
application of anodynes, the operation, although of momentary duration,
will be excessively painful.
=Operation.= After the ear has been thoroughly cleansed, a large aural
speculum is inserted within the meatus and the auditory canal dried with
pledgets of cotton-wool.
The instrument usually used for this operation is a small and narrow
sharp-pointed knife known as Hartmann’s furunculotome (Fig. 178, C).
Equally suitable, however, is a fine bistoury; or, if necessary, a small
tenotome or the ordinary paracentesis knife.
The surgeon holds the speculum in position within the meatus with the
left hand, and with the right inserts the knife through the lumen of the
speculum along the meatus until its point passes the innermost limit of
the furuncle. It is then quickly withdrawn, at the same time _incising
the furuncle_ freely down to its base. Another method is to _transfix
the furuncle_ by passing the knife through its base and making it cut
outwards through the skin. In a similar manner any other furuncles that
may be present are incised or transfixed.
If the inflammatory process, instead of being localized as a furuncle,
extends to the subcutaneous tissues, and especially if it is
accompanied by much pain, pyrexia, and occlusion of the external
meatus, _linear scarification_ may become necessary.
After incision, the contents of the furuncle are rapidly scooped out
with the curette (Fig. 178, A). Slight hæmorrhage may occur, but can be
arrested at once by plugging the meatus for a minute with a strip of
sterilized gauze. The auditory canal is finally syringed out with a warm
aqueous 1 in 5,000 solution of biniodide of mercury and firmly plugged
with gauze soaked in a 10% solution of carbolic acid in glycerine; a hot
fomentation being afterwards applied to the side of the head.
[Illustration: FIG. 178. BURKHARDT-MERIAN’S AURAL INSTRUMENT.