CORRECTION OF SPASTIC ENTROPION 657

oval and also the fine very opaque radiate stripes, in relation to these spots, have diminished in number.

d. Circular patterns no longer pre­dominate, but radiate patterns frequently occur; indeed, radiate canalicular and slightly tortuous stripes appear. They are strongly white because of the very heavy contrast-intensity (fig. 2) .

We may wonder if these stripes are col­lector channels of enlarged clefts that de­bouch into the orifices previously described (white spots), or if they represent a change in the direction of the trabecular clefts fol­lowing a structural modification. The first hy­pothesis seems to us to be the more plausible.

The treatment of spastic or senile entro­pion, though occupying a small place in the field of ophthalmology and ophthalmic sur­gery, is nevertheless a perplexing, and often disappointing, challenge to the ophthalmolo­gist. The procedure for correction of spastic entropion which is here reported, though not widely known, was first described in the fall

* From the Manhattan Eye, Ear, and Throat Hos­pital. Presented before the New York Academy of Ophthalmology, Section of Ophthalmology, March, 1955.

CONCLUSIONS

From our observations, we may conclude : 1. That the trabecular clefts and their

orifices at the level of the inner wall of Schlemm's canal are enlarged but only in a very poor manner.

2. That the permeability of the connective tissue, building up the trabeculae, has in­creased.

3. That there is no evidence that new orifices are added to those already existing, but that the passage of the contrast fluid occurs in a more direct manner.

2, Avenue Pasteur.

of 1953 and later published in June, 1954.1

On the basis of the excellent results re­ported, and in view of the fact that previous methods for the correction of spastic entro­pion have too often been disappointing, an endeavor has been made to collect a series of cases over the past 16 months which were operated by the method proposed by Dr. F. A. Wies.

Though many factors are involved in the production of senile or spastic entropion, it is reasonable to conclude as Kettesy2 pointed

REFERENCES

Bârâny, E. H. : In vitro studies of the resistance to flow through the angle of the anterior chamber. Acta Soc. Med. Upsala, 59:260-276, 1954.

Bârâny, E. H., and Scotchbrook, S.: Influence of testicular hyaluronidase on the resistance to flow through the angle of the anterior chamber. Acta Physiol. Scand., 30:240-248, 1954.

Bârâny, E. H. : Discussion to Huggert, A. : Experiments to determine the pore size in the filter of the angle of the anterior chamber. Nordic Congress Goteborg, June, 1954.

Collette, J. M. : Etude radiologique de la circulation plasmo-tissulaire par injection sous-cutanée de substance de contraste. Rev. Méd. de Liege, 8:776-787, 1953.

François, J., Collette, J. M., and Neetens, A. : Etude microradiographique de la paroi interne du canal de Schlemm. J. belge de Radiol., 38:1-15, 1955.

François, J., Neetens, A., and Collette, J. M. : Microradiographic study of the inner wall of Schlemm's canal. Am. J. Ophth., 40:491, 1955.

François, J., Rabaey, M., and Neetens, A. : Perfusion studies about the outflow of aqueous humour in human eyes. Arch. Ophth. In press.

CORRECTION O F SPASTIC ENTROPION*

BY THE METHOD PROPOSED BY W I E S

DONALD C. MCFARLANE, M.D. London, Ontario

658 DONALD C. McFARLANE

out in 1948 that the prime factor is a draw­ing up and accumulation of bundles of the palpebrai portion of the orbicularis muscle in the lid margin, secondary to a slackening and atrophy of the palpebrai connective tissue. The entropion occurs on contraction of the muscle and is not likely to be self-reducing, since the corneal irritation so pro­duced often sets up a secondary spasm which may be severe.

Duke-Elder3 points out that the palpebrai orbicularis forms two arcs as it lies in its normal anatomic relationship against the lower tarsal plate. The concavity of one arc is directed posteriorly, that of the other superiorly. Contraction of the muscle, there­fore, has the effect of reducing these two arcs to chords and, in the absence of normal connective tissue support, the muscle bundles accumulate in the lid margin and have a posterior direction of force.

Operations for the correction of spastic entropion should, therefore, be directed toward preventing this upward riding of the muscle bundles over the tarsus. This can be accomplished in one of several ways :

First, by re-establishing the absent pres­sure of the muscle on the convexity of the lower tarsal plate, as exemplified by the Wheeler technique.

Second, by producing fibrous tissue ad­hesions between the muscle and the tarsal plate, which is the primary purpose of the Ziegler cautery and a secondary effect of practically all of the many methods which employ a surgical incision through the muscle.

Third, by producing an actual tissue bar­rier which divides the muscle, and, there­fore, will not permit migration of its lower fibers into the lid margin. This is the pur­pose of the Wies procedure.

Other principles have been proposed, such' as increasing the tone of the tarso-orbital fascia and even complete excision of the palpebrai and part of the orbital portions of the orbicularis. These procedures do not, however, attack the problem directly or, as

WEELER [Zl CASES)

ZIEGLER ( IS CASES )

WIES [18 CASES)

SHTlSFItClORY

56 %

47 %

7β %

UNSnriSFACTORY

44%

5 3 %

22 %

Fig. 1 (McFarlane). Postoperative results in 60 cases of spastic entropion.

in the latter technique, are more severe than is generally warranted.

In order to compare the results using the Wies method, all of the cases of spastic entropion operated on the clinical service of the Manhattan Eye, Ear, and Throat Hospi­tal over the past five years have been re­viewed. Only those cases in which the fol­low-up was six months or more have been recorded for comparative purposes. None of the Wies-procedure cases reported is less than three months postoperative.

This series (fig. 1) shows less than a 60 percent cure rate when the Wheeler method was used and less than 50 percent when Ziegler cautery was employed as compared to better than 75-percent cure with the Wies procedure. The relatively small number of Ziegler cauterizations is due to the fact that only those performed in the operating room are included. Undoubtedly results of many of the less severe cases treated b)r cauteriza­tion in the out-patient clinic would change this figure. I have not included procedures other than those mentioned, since only a small number of cases representing each of numerous and varied other methods of treat­ment could be collected.

WHEEIER

ZIEGISR

WIES

SATISFACTORY

AND COSMCly" RUS-'U

M

5

u

GCGD rUNCnuNAL

RESULT

;

2

3

lAISfttlSfACTOFY.

tlCCUHF-.ENCE

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7

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OVERCORRIXTION

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Fig. 2 (McFarlane). Postoperative analysis of 60 cases of spastic entropion.

CORRECTION OF SPASTIC ENTROPION 659

Fig. 3 (McFarlane). (A) Conjunctival incision made the length of the lower lid. No fixation clamp or ocular protector is shown. (B) Cross section of lid following incision no more than four mm. below the lid margin. Artist's conception of tarsus below incision is exaggerated.

A more detailed analysis of the cases (fig. 2) demonstrates one point clearly. Cases treated by both the Wheeler and Zielger methods show a marked tendency to recurrence, even after several months, while those treated by the Wies method do not. The Wies method, on the other hand, shows a tendency toward overcorrection in an un-selected series, a difficulty which I feel can be largely eliminated by attention to the technique.

METHOD OF OPERATION

The technique recommended by Dr. Wies, and the one which has been followed, can be done as an office procedure if adequate assistance is available.

Under local infiltration anesthesia, a hori-

Fig. 4 (McFarlane). (C) Showing double-armed, 4-0 black-silk suture passed through conjunctiva of the lower part of incision and emerging through skin of the upper part. (D) Deep sutures in posi­tion and secured over rubber pegs. Skin closure with interrupted 6-0 silk.

zontal through-and-through incision, to in­clude skin, muscle, tarsus, and conjunctiva, is made the length of the lower lid and four mm. below its margin (fig. 3). Hemo-stasis is readily achieved by pressure. Three 4-0 black silk, double-armed sutures are placed in the free margin of the conjunctiva (fig. 4) at the lower edge of the incision and brought out through the skin of the upper part, where they are tied over rubber pegs or a continuous rubber strip. The skin edges are then closed with interrupted 6-0 silk sutures. This effectively incarcerates a tongue of conjunctiva within the wound and above the major portion of the lower palpe­brai orbicularis fibers.

Experience has taught that the most im­portant part of the procedure is the lid in­cision. This should be made perpendicular to the lid and no more than four mm. below its margin, after first outlining the incision with marking fluid. If local anesthesia is used, it is best to block the lid rather than infiltrate directly into the area of the incision. To facilitate an incision perpendicular to the sur­face of the lid, a fixation device, such as the Erhardt clamp, is extremely helpful. Practi­cally all of the overcorrections encountered have been attributed to an incision which is either too far below the lid margin, or is slanted downward and posteriorly into the lower fornix.

It has not been found necessary to under­mine the conjunctiva which is to be incar­cerated in the wound. The deep sutures are usually removed on the third or fourth day and the skin sutures on the fifth or sixth. Several of our successful cases have shown an apparent early overcorrection which per­sists as long as two or even three weeks. The overcorrections regress, however, without treatment or, if pronounced, it may be advis­able to remove the offending deep suture or sutures at the first dressing. In the event that overcorrection occurs, application of the cautery to the conjunctival surface of the lid, as recommended by Wies, should be sufficient to control the ectropion.

660 A. HAGEDOORN AND D. H. SIEGER

i 'λι·.·

Fig. S (McFarlane). (A) Right eye, showing severe constant spastic entropion. (B) Same patient, nine weeks postoperative, showing lower lid in good position. Upper lid, manually retracted. (C) Nine weeks after operation, showing attempt to produce inversion of lower lid by forced closure, while upper lid is held in position.

SUMMARY

A little known method for the correction of spastic entropion, based on attacking what is believed to be the primary etiologic factors of this condition, has been presented. Results from this operation are gratifying (fig. 5-A, B, and C). Though there is a tendency to overcorrection in an unselected series, proper attention to the details of the pro­cedure, especially as regards the lid incision,

should overcome this fault. No recurrences are reported, despite the fact that many of the procedures were performed on persons with a history of as many as three previous operations for spastic entropion on the same lid. The procedure seems to be an operation of choice in severe and recurrent spastic entropion.

University of Western Ontario, Faculty of Medicine.

REFERENCES

1. Wies, F. A.: Surgical treatment of entropion. J. Internat. Coll. Surgeons, 21:758, 19S4. 2. Kettesy, A.: On genesis and operation of senile entropion. Brit. J. Ophth., 32:311, 1948. 3. Duke-Elder, W. S. : Textbook of Ophthalmology. St. Louis, Mosby, 1952, v. 5.

IDIOPATHIC RETINAL DETACHMENT*

A. HAGEDOORN, M.D., AND D. H. SIEGER, M.D. Amsterdam, Holland

In normal eyes the vitreous adheres to the region of the optic nerve and—more firmly —to the periphery. In other parts of the adult human retina, however, no adhesions between retina and vitreous are generally supposed to exist.

In cases of retinal detachment, neverthe­less, tiny strands may be seen with the ophthalmoscope which are apparently pulling small flaps, even small isolated pieces of the ruptured retina, into the vitreous space.

* From the Department of Ophthalmology, Uni­versity of Amsterdam (Director: A. Hagedoorn, M.D.).

They have been described in pathologic spec­imens as the result of a degenerative or postinflammatory condition of the vitreous body and retina.

In some publications, the suggestion may be found that alterations in the retina and vitreous body might secondarily enforce pré­existent tiny adhesions to firmer connections, which have a pathogenetic significance in the development of retinal tears (Hruby1). However, as far as we know, no histologie evidence was given to substantiate these theories.

In 1952, one of us (Hagedoorn) demon-