244 CLARK: Modification of Operation for Canthopzsty.
A MODIFICATION OF THE OPERATION FOR CANTHOPLASTY. BY C. F. CLARK, M.D., COLUMBUS, OHIO.
There are many cases of entropion and blepharophimosis which, owing to neglect, have become so desperate as to defy every effort made to restore the lids to their proper position, and, in my own experience at least, there has occasionally been a case in which the usual operation for canthoplasty has proven a dismal failure. Thorough division of the palpebral ligaments and careful approximation and suturing of the. conjunctiva to the skin is at C~~
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~
C
times rewarded only by a degree of cicatricial contraction which seems to render the patient's condition worse than before the
operation. A case of entropion of high degree, with narrowing of the palpebral fissure following many years of neglect of trachoma, reported to me some months ago at St. Francis Hospital. She had been operated upon for entropion some ten years before in Canada, but had had little treatment since that time. The left eye was extremely defective, owing to pannus, while the right was practically useless, having only light perception. She was subjected to the usual treatment for trachoma, and, after a few weeks, I operated upon the upper and lower lids of one eye, doing an entropion operation and a canthoplasty at .the same time. This was followed in a short time by a similar operation upon the other eye. I was rewarded by great improvement of vision in the left and permanent restoration of the ciliary margins to a position
CLARK: Modification of Operation for Canthopiasty. 245 no longer menacing the cornea in both eyes, with the exception of a portion of the upper lid of the right. Here the lashes again turned in, and after a few weeks it became apparent that, in spite of the fact that no granulation tissue had appeared, the cicatricial contraction at the outer canthus was sufficient to render her condition at this point as bad as before. While the conjunctiva was possibly sufficiently lax to have allowed me to repeat the usual operation, it occurred to me that much more would be gained for the patient if instead of sacrificing a part of the already scant inter-palpebral membrane, I could add to it. I therefore undertook to transplant a spearhead shaped flap of integument from the temple to fill the gap created by division at the external canthus. The inter-tarsal ligament and the tarsal ligaments were divided, 'as was also the conjunctiva from the external canthus inward for a distance of about six to eight millimeters. From the outer extremity of this incision, that is, from the junction of conjunctiva with skin at the external canthus, two incisions six to seven mm. long were made in the skin at an angle of about eighty degrees with one another. At their outer extremities they were turned at an angle and continued in curved lines for about twelve mm. to complete the figure of a spear-head, the shaft of which consisted of a strip of skin about three mm. wide. (See Figure.) After carefully dissecting up this thin spear-head shaped flap, it was found to be an easy matter to slide it forward and attach its apex (B) to the inner extremity of the conjunctival incision (A) and its angles (C and D) to the extremities of the palpebral margins (E and F). Two additional sutures at the points occupied by the angles (C and D), uniting these points to the narrow portion of the flap at the neck of the spear-head, gave security against retraction by contraction of the flap in its long axis. After doing, in addition to the above, an entropion operation on the upper lid, I applied an antiseptic dressing, which was renewed after two or three days. The wound healed without accident, and, instead of a trifling
246 CLARK:
Modification
of Operation for Canthoplasty.
advantage such as so frequently follows the usual operation when the conjunctiva begins to shrink as it assiumes the character of skin, I was gratified, after many weeks, to find the result excellent. The eye gradually cleared, and vision was soon sufficient to allow the patient to go about the ward by the aid of this eye alone. An advantage of this operation that is well worth considering is the absence of the unsightly break in the continuity of the palpebral edges so often seen where sufficient effect has been obtained by thevold method. In reviewing to some extent the literature of the subject, I had the usual fate of would-be devisers of new operations and found that others had attempted to obtain relief foiblepharophimosis in a manner very similar to that which I have described. There were, however, some essential differences. The operation which most nearly resembled the one suggested was one devised by Kuhnt. He brought the flap from the upper lid and avoided the necessity of suturing to the membrane by inserting its point beneath the conjunctiva.
A MODIFICATION OF THE OPERATION FOR CANTHOPLASTY. BY C. F. CLARK, M.D., COLUMBUS, OHIO.
There are many cases of entropion and blepharophimosis which, owing to neglect, have become so desperate as to defy every effort made to restore the lids to their proper position, and, in my own experience at least, there has occasionally been a case in which the usual operation for canthoplasty has proven a dismal failure. Thorough division of the palpebral ligaments and careful approximation and suturing of the. conjunctiva to the skin is at C~~
~
~
~
~
C
times rewarded only by a degree of cicatricial contraction which seems to render the patient's condition worse than before the
operation. A case of entropion of high degree, with narrowing of the palpebral fissure following many years of neglect of trachoma, reported to me some months ago at St. Francis Hospital. She had been operated upon for entropion some ten years before in Canada, but had had little treatment since that time. The left eye was extremely defective, owing to pannus, while the right was practically useless, having only light perception. She was subjected to the usual treatment for trachoma, and, after a few weeks, I operated upon the upper and lower lids of one eye, doing an entropion operation and a canthoplasty at .the same time. This was followed in a short time by a similar operation upon the other eye. I was rewarded by great improvement of vision in the left and permanent restoration of the ciliary margins to a position
CLARK: Modification of Operation for Canthopiasty. 245 no longer menacing the cornea in both eyes, with the exception of a portion of the upper lid of the right. Here the lashes again turned in, and after a few weeks it became apparent that, in spite of the fact that no granulation tissue had appeared, the cicatricial contraction at the outer canthus was sufficient to render her condition at this point as bad as before. While the conjunctiva was possibly sufficiently lax to have allowed me to repeat the usual operation, it occurred to me that much more would be gained for the patient if instead of sacrificing a part of the already scant inter-palpebral membrane, I could add to it. I therefore undertook to transplant a spearhead shaped flap of integument from the temple to fill the gap created by division at the external canthus. The inter-tarsal ligament and the tarsal ligaments were divided, 'as was also the conjunctiva from the external canthus inward for a distance of about six to eight millimeters. From the outer extremity of this incision, that is, from the junction of conjunctiva with skin at the external canthus, two incisions six to seven mm. long were made in the skin at an angle of about eighty degrees with one another. At their outer extremities they were turned at an angle and continued in curved lines for about twelve mm. to complete the figure of a spear-head, the shaft of which consisted of a strip of skin about three mm. wide. (See Figure.) After carefully dissecting up this thin spear-head shaped flap, it was found to be an easy matter to slide it forward and attach its apex (B) to the inner extremity of the conjunctival incision (A) and its angles (C and D) to the extremities of the palpebral margins (E and F). Two additional sutures at the points occupied by the angles (C and D), uniting these points to the narrow portion of the flap at the neck of the spear-head, gave security against retraction by contraction of the flap in its long axis. After doing, in addition to the above, an entropion operation on the upper lid, I applied an antiseptic dressing, which was renewed after two or three days. The wound healed without accident, and, instead of a trifling
246 CLARK:
Modification
of Operation for Canthoplasty.
advantage such as so frequently follows the usual operation when the conjunctiva begins to shrink as it assiumes the character of skin, I was gratified, after many weeks, to find the result excellent. The eye gradually cleared, and vision was soon sufficient to allow the patient to go about the ward by the aid of this eye alone. An advantage of this operation that is well worth considering is the absence of the unsightly break in the continuity of the palpebral edges so often seen where sufficient effect has been obtained by thevold method. In reviewing to some extent the literature of the subject, I had the usual fate of would-be devisers of new operations and found that others had attempted to obtain relief foiblepharophimosis in a manner very similar to that which I have described. There were, however, some essential differences. The operation which most nearly resembled the one suggested was one devised by Kuhnt. He brought the flap from the upper lid and avoided the necessity of suturing to the membrane by inserting its point beneath the conjunctiva.
