ECTROPION AND ENTROPION OF THE EYELIDS

WEBB w. WEEKS, M.D.

Professor of Ophthalmology, New York University School of Medicine

NEW YORK CITY

ECTROPION

W HEN an eyeIid has acquired or assumed during its deveIopment a position which interferes with

its functiona activities, or if such a condi- tion has resuIted from disease processes or injury, especiaIIy if pathoIogic changes have set in, surgica1 measures are indicated.

A spastic roIIing outward of the eyeIids occurs through irritative inff ammatory changes in the eyeIid structures or parts adjacent. Unless reIieved, structura1 changes occur in the skin, muscuIar, fibrous (tarsa1) eIements, and conjunctiva, which give a permanency to the deformity and cause the Ioss of function of the eyeIid.

Preceding the surgica1 procedures ad- vised, aseptic preparation of the parts invoIved have been carried out and IocaI anaesthesia instituted. For the conjunctiva IocaI instiIIations of pontocaine 1 per cent is used and an infiItration of the eyeIid is made with 2 per cent novocaine with adrenaIin added.

ShouId the ectropion be more or Iess recent, yet faiIing to be reIieved by IocaI non-surgica1 measures, cautery punctures shouId be tried. The miIIimeter tip of an eIectric cautery needIe at a duI1 red gIow is carried through the conjunctiva and into the tarsus 3 mm. from the sharp posterior margin of the eyeIid, spaced 6 mm. apart aIong the Iength of the tarsus tempora1 to the punctum IacrimaIia. A second row 3 mm. further posteriorIy may be made.

Another procedure of vaIue is pIacing two doubIe armed No. 3 twisted bIack siIk sutures, starting high on the exposed con- junctiva1 curve: one at the junction of the middIe and inner thirds; the other at the junction of the outer and middIe thirds of

the eyeIid. The needIes are carried down to the tarsus, aIong whose posterior surface they trave1 to its inferior border, then for- ward through the eyeIid structures to the orbit margin. Here the needIes pick up the periosteum and continue on through the skin. The sutures are then tied over smaI1 gauze roIIs firmIy enough to invert the roIIed out portion of the eyeIid.

ShouId the conjunctiva be markedIy thickened, an eIIiptica1 4 mm. portion, 3 mm. posterior to the posterior sharp margin of the eyeIid and extending the Iength of the tarsus, may be excised. The cut edges are approximated by interrupted bIack siIk sutures.

A reIaxed, stretched out Iid occurring in an oId ectropion with atonic and atrophic structura1 changes requires shortening and drawing up the eyeIid so that the sharp posterior Iip hugs the eyebaI1. Such con- ditions are seen in seniIe atonic states and eyeIid conditions foIIowing facia1 nerve paraIysis. The Kuhnt-Szymanowski opera- tion wiI1 correct this condition:

First Stage. IntermarginaI incision, spIitting of the Iid, either with a U-shaped Iid cIamp or between the fingers, beginning at the junction of the middIe and inner thirds of the margin and running to the externa1 cantha angIe, through the depth of the Iid.

Second Stage. Two forceps, grasping the tarsus in the middIe area, foId it to determine the width necessary to remove to bring about the desired correction. This section, 5 or more mm. in a v shape incIuding onIy tarsus and conjunctiva, is cut out.

Third Stage. An incision through skin starting at the externa1 angIe is then cut 5 mm. or more obIiqueIy up and outward; another incision twice this Iength is cut

NEW SERIES VOL. X1.11. No. I Weeks-Ectropion and Entropion American Journal of Surficry 79

from the externa1 angIe down and sIightIy Iid, depending on the amount and position perpendicuIar to Iine of first incision. The of the variant from the norma position- extremities of these two incisions are united IO to 16 mm.

FIG. 2. PIacement of SneIIen sutures.

FIG. I. SeniIe ectropion. Second Stage. At the nasa1 end of this by an incision and the incIuded skin flap spIit cut out a triangIe of tarsus and con- excised. junctiva with the base 3 to 6 mm. on the

Fourth Stage. Five mm. or more of the outer margin of the Iower Iid is denuded of its ciIia and ciIiary foIIicIes. An assistant grasps the Iid margin in the middIe and partIy everts it. SiIk sutures are then pIaced in the tarsus from beIow up, run- ning from without inward; they are three in number, the top one catching tarsa edges quite near the upper margin. These sutures are tied, aIIowing the Iid to stand upward. A suture now joins the apex of the Iower Iid flap with the upper end of the triangIe of excised skin. Subsequent sutures unite the skin edges where necessary. If the parts have been removed equaIIy, the Iid stands up in position, drawn up against the eyebaI1 and outward. It may be neces- sary to cIose a sIight gaping of the margin wound, which can be done by a suture pIaced just beIow the ciIia, 4 mm. away from the tarsa wound and run from without it, coming back out 3 mm. away and tying over a pig. A firm dressing is appIied.

For a partia1 ectropion of some standing FIG. 3. ParaIytic ectropion.

the procedure of Imbrb is advised, as Iid margin and an apex 5 mm. toward the foIIows : cuI-de-sac.

First Stage. SpIit the Iid in the gray Iine Third Stage. At the tempora1 end of in the area of most prominent sag of the the spIit Iid margin make a vertica1 cut

80 A me&an Journd of Surgery Weeks-Ectropion and Entropion OCTOBER, 1938

through the ciIiated portion 3 mm. Iong. as to overrap the tempora1 end of the Iid From this vertica1 cut running nasaIIy spIit. This overIap is excised and the flap make a cut through the skin and orbicuIaris edges closed by interrupted siIk sutures.

A

FIG. 4. Kuhnt-Szymanowski operation, fourth stage. A, tarsa sutures. By suturing of skin ffap.

muscIe paraIIe1 to the Iid margin IO to 16 mm. Iong. A triangIe of skin and muscIe, with 3 to 6 mm. at the base is cut, with the apex downward 5 mm.

ShouId the ectropion foIIow a cicatricia1 contraction due to a second degree burn, injury, or structura1 changes occurring in eczematous or Iupoid disease of the skin,

FIG. 5. CicatriciaI ectropion.

Fourth Stage. The tarsa triangIe is cIosed with three interrupted siIk sutures tied on the conjunctiva1, side. The top suture is close enough to the margin to approximate it accurateIy.

Fifth Stage. The skin and muscIe tri- angIe is then cIosed with three interrupted sutures. This causes a sIiding of the 3 mm. ciliated skin and muscIe margina strip so

FIG. 6. Spastic entropion with trichiasis.

the Ioss of skin has to be made up by skin grafting. The skin of the upper Iid of the same or opposite side, when avaiIabie, is the best for this purpose. When not avail- abIe, a Thiersch graft from the inner aspect of the upper arm or thigh, scrotum or prepuce may be used.

NEW SERVES VOL. XLII, No. I Weeks-Ectropion and Entropion American ~~~~~~~ oc surgery 8 I

FoIIowing the eyeIid anesthesia the scar conjunctiva1 condition with a spasm of the area is excised, care being taken to remove margina orbicuIaris paIpebrae muscIe over- a11 the cicatricia1 tissue and to unite the coming an atonic or pathoIogicaIIy weak

A B

FIG. 7. Birch-HirschfeId operation. A, movable orbicuIaris muscIe slips. B, insertion of muscIe sIip sutures.

eyeIid margins by two or three partia1 tarsorrhaphys. This opens up the excised area, giving a fuI1 sized bed for the graft and assures that the graft wiI1 be heId in this position. If the skin of the upper eye- Iid is used, it is cut the exact size of the opening into which it is to be pIaced. The bed shouId be cIean and free of bIeeding points. The graft should have as Iittle sub- cutaneous structure as possibIe and be handIed without pinching with forceps. It is sutured in pIace by frequent inter- rupted No. ooo bIack siIk sutures, with the same care as to trauma. ShouId a Thiersch graft be used, a sIight Iarger graft is pIaced, to aIIow for cicatricia1 contraction. The dressing appIied shouId be, first, a rubber tissue with grain running in two directions and IightIy vaseIined, next, an evenIy appIied gauze dressing and firmIy appIied adhesive pIus a bandage, heId by we11 pIaced adhesive strips. This is to spread the graft evenIy and firmIy against its bed, preventing a11 movements of parts con- taining the graft or immediateIy adjacent to it, or possibIe secondary hemorrhage under the graft. First dressing is done five days Iater.

ENTROPION

When a spastic roIIing inward of the eyeIid margin occurs from an irritative

orbita portion of this same muscIe, or from Iack of support received from the eyebaI1, surgery is indicated if unreIieved second- ary permanent pathoIogica1 changes occur which simpIer measures cannot relieve. The condition is exaggerated by the con- tinua1 irritative reaction due to the eye- Iashes’ brushing against the cornea and conjunctiva.

After eyeIid anesthesia, the cautery punctures as for ectropion may be done, observing the same technique onIy from the skin side, the needIes passing through the eyeIid structures just down into but not through the tarsus. Sutures simiIarIy pIaced foIIowing the same steps as men- tioned for ectropion, again from the skin side, may be used. For a hypertrophied, over-powerfu1 margina portion of the orbicuIaris palpebrae muscIe, the CeIsus operation makes an incision through the skin 3 mm. beIow the ciIia, cutting a 3 mm. strip of the orbicuIaris muscIe from the ciIia foIIicIes inferiorIy, the Iength of the tarsus. The skin incision is cIosed by interrupted bIack siIk sutures. Birch-Hirschfeld, in- stead of excision through a simiIar skin incision, outIines the 3 mm. strip by inci- sions down to the tarsus. He incises through the center and inserts a doubIe armed suture in each cut end. The tempora1

82 A me&an JournaI of Surgery Weeks-Ectropion and Entropion OCTOBER, ,938

end is carried up and toward the nose, the out immediateIy; reinsert 3 mm. apart, nasa1 end down and temporaIIy, catching catching topmost edge of Iower tarsa cut the tarsa surface. Then it is taken out edge, continuing onward up through lower

through the skin separate from the skin incision. The skin incision is cIosed sepa- rateIy by interrupted bIack siIk sutures.

If the entropion is partia1 and at the outer one-third of the eyeIid, the Spencer- Watson procedure reIieves the roIIing in and the trichiasis as welI.

When the entropion is due to cicatricia1 contraction with tarsa deformity and trichiasis, the StreatfieId-SneIIen procedure is to be used foIIowing the steps indicated:

I. Insert Iid pIate. After an incision through the skin, 2 mm. above the lashes, paraIIe1 to and extending the Iength of the Iid margin, the upper skin ffap is undermined.

2. The orbicuIaris muscIe is excised over the tarsus for a width of 2 mm. imme- diateIy under this skin incision.

3. A wedge of 1.5 mm. base with apex toward the conjunctiva is excised from the entire Iength of the tarsus, care in cutting through conjunctiva being taken.

4. Three doubIe armed sutures are inserted as foIIows: through needIes in- serted 3 mm. apart, septum orbitaIe, sponeurosis of Ievator muscIe, and partIy through upper border of the tarsus, coming

skin ffap above Iashes; tie over rubber pigs. Unite skin wound edges with interrupted skin sutures.

5. Dressing. Redressed on second day and daiIy thereafter. Sutures are removed on the fifth or sixth day.

ShouId the entropion foIIow a second degree burn of the Iower conjunctiva with cicatricia1 contracture, excision of this area, foIIowed by a mucous membrane graft from the Iip or cheek, may be done with success.

SUMMARY

SurgiGaI experience deaIing with spastic ectropion or entropion where earIy eyeIid structura1 changes have set in, has shown that the simpIer operative procedures are quite uniformIy successfu1; and that where permanent damage has occurred the pIastic operative procedures described give exceI- Ient cosmetic and functiona resuIts.

REFERENCES

I. VON BLASKOVICS, L., and KREIKER, A. Eingriffe am Auge. Stuttgart, 1938. Ferdinand Enke Verlag.

2. THIEL, R. AtIas der Angenkraukheiten. Leipzig, 1937. Georg Thieme VerIag.

3. WEEKS, W. W. Surgery of the Eye. 1938. BIanchard press.