Operations Upon The Eyelids | Operating Microscopes

Operations Upon The Eyelids
By F. C. HOTZ, M. D.,
OF CHICAGO.

THE operations upon the eyelids may be divided into two groups. The first group embraces a number of surgical procedures which every, practitioner having a general training in surgery may easily employ. The second group embraces those operations requiring a degree of dexterity and judgment which can be acquired only by special training.

MINOR OPERATIONS.

1. The Removal of Eyelashes. The simplest procedure for removing eyelashes is

(a) collation by means of a cilium forceps.

With the fingers of the left hand a gentle steady pressure is made upon the lid, and with the forceps, held in the right hand, the eyelash is seized as near as possible to the skin and drawn out with a steady traction. Jerking must be avoided, lest the hair shaft break off; also not more than one eyelash must be grasped at one time, because extraction of several eyelashes together is very painful.

Eyelashes so removed usually grow again; epilation, therefore, is the proper procedure only where a temporary removal of cilia is indicated. If a permanent removal is desired, we must have recourse to electrolysis or the scalping operation.

(b) Electrolytic removal of cilia requires a mild galvanic current and an electrolytic needle set in a convenient handle.

The eyelid being well steadied in the manner described above, the point of the needle connected with the, negative pole of the battery is inserted along the shaft of the eyelash until it reaches the root, about 3 mm. under the surface. The other electrode, represented by a moist sponge, is placed upon the temple or the hand of the patient; this closes the circuit, and at once a whitish froth makes its appearance around the needle. After a few seconds the needle is withdrawn, the eyelash seized with forceps, and extracted. If it offers the slightest resistance, the electrolytic needle should be reinserted, for only if the eyelash is perfectly loose are we sure of the complete destruction of its root.

This procedure is quite painful ; hence if a great number of cilia are to be removed, it is advisable to treat three or four eyelashes only at one sitting and to repeat the operation at intervals of' a few days. As the operation produces no scars, it does not disfigure the lid. In this respect it is far preferable to the extirpation of the cilia by the scalping operation.

(c) Scalping consists in the excision of the whole ciliary border. The instruments required for this operation are a fine scalpel, forceps, small curved needles, a needle holder, fine silk, and a lid plate made usually of shell or hard rubber.

The surgeon, putting the thumb of his left hand upon the lid supported by a plate, makes a slight pressure upon it to turn the lid border into full view. With the scalpel in his right hand he then makes an incision all along the lid border just behind the eyelashes (Fig. 339), and deepens this incision by repeated strokes of the scalpel until the bulbs of the cilia are exposed as small black dots in the anterior margin of the wound. This incision is known as the intermarginal incision. Its correct execution requires a steady hand and watchful eye, for it is essential that no hair bulbs shall remain behind in the posterior margin of the incision.

The next step consists of a transverse incision through the skin, made just behind the eyelashes; at both ends this incision is continued into the intermarginal incision, the two incisions thus including a long and narrow strip containing all eyelashes. This strip is seized with fine forceps, and dissected up by deepening the cutaneous wound until it meets the intermarginal incision behind the hair bulbs. After a careful inspection has convinced the operator that no hair bulbs are left behind, the wound is thoroughly cleansed and closed by fine silk sutures, which are removed after three days.

In former years scalping was frequently performed, but since the introduction of electrolysis and improved modern operations for entropion it is seldom required, and fortunately for the patients, as it produces a very hideous and permanent disfigurement of the eyelid.

Abscesses of the lid are opened by a transverse incision through the skin and treated according to the general principles of surgery.

Hordeolum (or stye) is opened by a small incision and its contents are expelled by gentle pressure.

2. Removal of a chalazion (tarsal tumor, Meibomian cyst) can, in the majority of cases, be performed by an incision through the conjunctiva; but if it is very large, causing a decided protuberance of' the skin, it is more, convenient to attack the tumor through the external integument. In either case the use of the lid clamp (Fig. 340) is very advantageous, as it makes the operation practically bloodless.

If the surgeon decides to remove the chalazion by incision through the skin, the lid is secured in a clamp and the tumor is exposed by a transverse incision through skin and muscular laver, and is cut open from within outward by transfixing its base with the narrow blade of a small scalpel. The contents of the cyst are removed, and each half of its wall is successively seized by a fine forceps and excised by small curved scissors. Upon the removal of the lid clamp there is a free oozing of blood, which, however, is easily checked by pressing a compress gently upon the lid; next the lid is cleansed and the wound covered with iodoform; a bandage is not necessary. As these transverse incisions, following the natural creases of the lid skin, have no tendency to gape, it is not strictly necessary to use sutures; but if the wound is very large, it is perfectly proper to close it by one or two sutures.

If the chalazion is to be removed by an incision through the conjunctiva, the position of the lid clamp is reversed, its plate being put upon the outer side and its ring upon the conjunctival side of the lid (Fig. 341).

If the chalazion is very small, the clamp may be omitted, and the operation still be made almost bloodless if the lid is everted and firmly pressed against the handle of a scalpel or the nail of an assistant's finger.

The clamp being screwed down the lid is everted; the cyst, marked by a dark red, prominent patch in the conjunctiva, is opened by an incision; a small curet is introduced and the contents are scraped out. Overhanging edges of the cartilage may be trimmed off without fear of producing a contraction and malformation of the tarsus. The cartilaginous walls of the chalazion often contain small pockets filled by the same granulation tissue; these side pockets should always be searched for and thoroughly scraped out, for if overlooked they form the nucleus of a new tumor, and often account for the recurrence of the chalazion at the site of the operation.

When the clamp is removed the cyst cavity fills with blood, producing more or less tumefaction of the lid; but in a few days the blood is absorbed and the lid swelling is gone. No special dressing is needed, except perhaps the application of a warm wet compress for a few hours to allay pain.

Dr. Agnew's method of removing the contents of the chalazion through an intermarginal incision has no material advantage over the other methods.

To remove chalky deposits in the Meibomian glands, the lid is everted and the conjunctiva over the white deposit is punctured, and the chalky grain picked tip on the point of a Graefe cataract knife.

Polypoid granulations on the conjunctiva, warty excrescences at the lidborder, and similar growths are excised with curved scissors if necessa my, the small wound is touched with liquid chromic acid at the end of a probe.

3. Operation for Making a New Canthus; Canthoplastic Operations. The object of these operations is either to reduce or to increase the transverse diameter of the palpebral aperture.

(a) The Operation for Shortening the Palpebral Fissure (Tarsorrhaphy or Blepharorrhaphy). This accomplishes its object by uniting the opposing lid borders for a short distance at the outer or inner canthus (external or internal tarsorrhaphy). The operation, as applied to the outer canthus, is performed as follows:

The surgeon seizes the border of the lower lid with a forceps near the outer canthus, and transfixes it with a narrow scalpel 2 mm. below the eyelashes in such a manner that the back of the blade is turned toward the canthus and its point emerges from the intermarginal. surface of the lid border just in front of the orifices of the 'L%Ieibomian glands; pushing the blade along the lid border by a steady sawing movement, the operator cuts from it a narrow strip, from 4 6 min. in length, which must contain all the eyelashes. In the same way a similar flap is removed from the opposite border of the upper lid; the two opposing denuded surfaces (Fig. 342) are carefully united by two or three fine silk sutures, and the lid., are kept immobilized by a bandage for two or three days, when the sutures are removed.

Internal Tarsorrhaphy. In a case of paralysis of the orbicularis muscle, causing eversion of the lower tear point, Dr. Arlt' has relieved the troublesome epiphora by a tarsorrhaphy at the inner canthus. From the tear points toward the inner canthus a narrow strip of cutis was pared off and the wounds were united by two sutures.

Dr. H. D. Noyes operated for the same purpose in the following manner: " I dissected tip a parallelogram of skin above and below the canaliculi for a space which reached from the commissure to 3 mm. beyond the puncta. I turned the raw surfaces of the little flaps, raised from the respective lids, against each other and stitched through them. The puncta were thus turned inward and out of sight."

(b) The operation for enlarging the palpebral fissure (canthotomy or blepharotomy) is performed at the external canthus only.

If the enlargement of the fissure is required only temporarily for relieving the eyeball of the pressure of excessive lid swelling in acute blennorrhea, or for the removal of an enlarged globe or a retrobulbar tumor, the operation consists simply in a horizontal incision through the commissure, the wound being allowed to close up again (temporary cauthoto )

But if the enlargement of the fissure is to be permanent, the reunion of the wound edges must be prevented by lining them with conjunctiva (permavent canthotomy). The steps of the operation are as follows:

An assistant draws the temporal portions of the lids apart to make the external commissure stand out as a firm vertical ridge. The surgeon inserts the one blade of blunt pointed straight scissors between the commissure and globe, and pushes it in a horizontal direction toward the wall of the orbit; next the scissors are shut, and with one firm stroke the entire thickness of the commissure is cut through. The bleeding is usually profuse, but easily controlled by pressure; sometimes, however, it is necessary to use torsion upon a small artery. Owing to the traction of the assistant upon the eyelids, the transverse incision is immediately changed to a vertical rhomboid wound (Fig. 343), whose temporal side is represented by the skin and the bulbar side by the conjunctiva. Skin and conjunctiva are then united by sutures to keep the palpebral fissure permanently enlarged. Three sutures are applied one uniting the center of the wound where the new canthus is to be, and one suture above and one below it.

Before these sutures are passed it is necessary to loosen the conjunctiva from the underlying tissues. Seizing the conjunctival border of the wound with forceps, the surgeon draws upon it until be distinctly feels the resistance of the ligament; then, passing the closed blades of curved scissors into the Wound, he feels for the ligament, and when he has found it opens the scissors just far enough to get the ligament between the blades, and cuts it by one quick stroke. As soon as the ligament is cut the conjunctiva is so movable that it can easily be united with the skin borders of the enlarged fissure. The sutures should be tied rather loosely, lest they cut through the swollen tissue too soon. Bandaging is not necessary. On the third or fourth day the sutures can be removed.

Operation for Epicanthus. The best results are obtained by the modified v. Ammon's operation, devised by Dr. Knapp' in 1873.

A rhomboidal piece of skin, over an inch in length and nearly two thirds of an inch in width at its broadest part, is excised on the root of the nose. The skin at both sides of the wound is carefully undermined, and when the bleeding has subsided the wound is united by silk sutures. Dr. Knapp covers the wound with plaster strips to protect it from the child's hands, for immediate union is of the greatest importance to avoid unsightly scars on the nose.

MAJOR OPERATIONS.

This group comprises operations

1. For the correction of malposition of the eyelids (entropion and ectropion); 2. For the reconstruction of the partly or totally destroyed lid 3. For the relief of ptosis.

I. Operations for Entropion and Trichiasis.' Instruments.

Small scalpels, curved scissors, mouse toothed forceps, needles, needle bolder, and silk Nos. I and 3. The lid clamp and lid plate are not absolutely required, though used by manv operators.

The chief object of all entropion operations is to remove the offending eyelashes from contact with the eyeball. This can be accomplished in two ways: either the whole inverted lid border is turned tip and secured ill its normal position by a permanent tension from a fixed point above, or tile eyelashes alone are turned up to their normal direction and supplied with a support below to prevent their reinversion.

1. The principle of relieving entropion by permanent tension upon the lid border finds its most correct and successful application in the operation of Anagnostakis and Holz.'

The operation is performed on the upper lid as follows:

While an assistant fixes the skin at the supra orbital margin the operator, seizing the center of the lid border with fingers or forceps, draws the lid downward to put its skin well on a stretch, and makes a transverse incision through skin and orbicularis muscle from a point 2 or 3 mm. above the punctum lachr vmale to a point 2 or 3 min. above the external canthus. This incision (Fig. 344, A) divides the lid skin in a line parallel to and a little below the upper border of the tarsal cartilage, and is therefore from 4 to 8 mm. distant from the free border in the center of the lid. The skin and muscular layer are now dissected from the incision down to the roots of the eyelashes, and, while an assistant is holding the edges of tile wound well separated, the operator seizes with forceps and excises with curved scissors the muscular fibers running transversely across the upper border of the tarsus. Next the sutures are inserted. Three sutures are usually sufficient one in the center of the wound and one at each side of the central suture. The curved needle, armed with black silk No. 3, is first passed through

To the former belongs the credit of having been the first (Annale,3 d'Oeuhstique, 1857) to declare that in order to be effective, uniform, and lasting the skin tension applied to the lidborder must proceed from a fixed point so located that it maintains the same distance from the lid border in all the various positions and movements of the lid, and the only point which fulfils these anatomic conditions is the opposite border of the tarsal cartilage. but this valuable suggestion and the operation based upon it did not find among the ocolists the recognition they deserved. Twenty years later Dr. Holz was led by his own independent investigations to adopt the same views (Arch. of Eighth., via. p. 249), and to suggest an operation in its chief features identical with that of Anagnostakis.

The wound border of the lid skin (Fig. 344, a) ; then it is thrust through the upper border of the tarsus and returned through the tarso orbital fascia just above this border; and finally it is carried through the upper wound border (Fig. 344, b). When these sutures are tied the skin is drawn upward and fixed to the upper tarsal border (Fig. 345, B), and this slight traction is sufficient to turn the inverted lid border and eyelashes to their normal position; and, as the skin becomes firmly united with the tarsal border, the tension thus produced upon the lid border is permanently secured.

The sutures should, of course, not be tied until all bleeding has ceased and the wound is thoroughly cleansed; they may be removed on the third day, Under aseptic dressings the wound heals by first union, even if, as sometimes occurs, secondary hemorrhage or edema causes considerable swelling for several days. Should, however, suppuration occur, the sutures should at once be taken out to give free exit to the pus; and if the suppuration is promptly subdued, a fair result may still be hoped for, because the contraction of the cicatrix unites the skin with the tarsal border.

This operation can be performed also on the lower lid; only that on account of the smallness of the tarsus the sutures are passed entirely below it through the tarso orbital fascia.

In the higher degrees of entropion (trichiasis) additional surgical measures are often necessary : if the palpebral fissure is abnormally contracted, canthotomy should be done in connection with the entropion operation ; and if the tarsus is much shrunken and rigid, the reposition of the lid border cannot be accomplished without grooving the cartilage (Strea~feild snellen's operation).

Just above the roots of the eyelashes a transverse, Darrow wedge shaped strip is removed from the cartilage; the resulting groove makes it easy for the lid border to turn up under the traction Of the skin when it is sutured to the upper border of the tarsus.

2. The second principal method of relieving entropion may be called the reconstruction of the lid niargin. It consists in turning up the inverted eyelashes alone, and supporting them in their normal position by a new lidmargin. This operation, first suggested in 1873 by Spencer Watson's complicated double transplantation, has gone through numerous changes before it was evolved into the present simple procedure.

The inverted lid border is split by the intermarginal. incision, great care being taken that all cilia are contained in the anterior laver. This incision is deepened so much that the anterior laver with the lashes can easily be everted, thereby converting the intermarginal incision into a gaping wound (Fig. 346) several millimeters in depth.

This groove is to be filled either by a strip of mucous membrane or a skin graft. The graft must be of the same length and width as the intermarginal wound.

The strip of mucous membrane is cut out with a few clips of a pair of curved scissors from the inner surface of the under lip, and placed at once on the wound and pressed into position with a pledget of cotton wool or gauze.

The skin graft is cut out from the integument behind the ear, the incisions penetrating obliquely just into the corium. It is at once transported to the lid and pressed into the groove. If the graft should he too large, it should be trimmed down with a pair of small curved scissors until its edges are even with the margin of the wound. Sutures are unnecessary, but both eyes should be bandaged for twenty four or forty eight hours, until the graft is adherent.

The writer prefers skin grafts, because the normal intermarginal space is lined by skin, not by mucous membrane; because skin grafts are less likely to mortify; and because filling the entire depth of the wound makes a more substantial new lid border. The use of' skin grafts is often objected to on the ground that the fine hairs in the transplanted strip would irritate the eye, but if the grafts are cut as described above, they never gro%v any hairs. If subsequently any hairs are found in the newly made lid margin, a careful inspection will prove that they grow from the posterior edge of the lid margin, or, in other words, they are cilia which the operator when making the intermarginal incision has left in the posterior margin of the wound.

The two methods of entropion operation here described can relieve all degrees of entropion ; in the worst forms the best results are obtained by the combination of both methods.

This latter plan is certainly superior to the Jaesche Arlt operation, in which also skin tension is combined with the transplantation of the cilia.

The lid margin is split by the intermarginal incision; next a second incision is made 5 mm. above and parallel to the ciliary edge, and a third incision is carried in a curve from one end of the second incision to the other end, and the semilunar piece of skin is removed. The bridge containing the eyelashes is detached from the underlying cartilage by careful dissection, so that when the margins of the gaping skin wound are drawn together by fine sutures the bridge is shifted upward. This produces along the lid margin a gap which is covered by a piece of skin (Waldense's in edification).

The objectionable features of this operation are that the new intermarginal space is abnormally broad, and that the excision of the lid skin seriously disturbs the natural appearance and movements of the lid. In many instances the shortening of the lid skin has made the closure of the lids impossible.

Burow, Green, and others, believing in an incurvation of the tarsus as the chief factor in the production of entropion, practise a transverse incision from the conjunctival side through the entire thickness of the tarsus to straighten the supposed incurvation. These operations are seldom permaneritly successful, and leave on the conjunctival surface a thick sear which is often the source of a persistent irritation to the eye.

II. Operations for Ectropion. The eversions of the lid calling for operative correction are the senile ectropion and the various forms of eversion from the contraction of cicatrices following extensive tissue destruction in the lid and its vicinity (cicatricial ectropion).

Senile ectropion occurs only in the lower lid from a relaxation of its tissues associated with a lengthening of its free border. Unless the lid border is shortened, the reposition of the everted lid cannot be successfully accomplished. This accounts for the unsatisfactory results attained by the suture operations (Suellen, Argyll Robertson, and others) which attempt to overcome the eversion by the traction of sutures carried from the conjunctiva near the fornix through the entire thickness of the lid, and tied upon the cheek over a piece of small rubber tubing.

Shortening the lid border is accomplished by Adams's operation:

A wedge shaped piece is excised from the entire thickness of the lid, and the margins of the wound drawn together by sutures. If, as originally practised, the piece is excised from the center of the lid, the contraction of the scar produces an unsightly notch in the lid border: this disfiguration is avoided by making the excision at the external canthus (Fig. 347).

The Kuhnt Miller Operation. A very neat operation for the same purpose was designed by Prof. Kuhnt in 1883, and modified by L. Miller in 1893.

A deep incision is made by an iridectomy knife into the center of the lid margin to split the lid substance into two portions the one portion containing the Conjunctiva and tarsus, and the other portion containing the soft tissues and the skin. From the first portion a triangular piece is dissected out by two incisions (Fig. 348, A, ac and be) converging toward the fornix. The two portions of the lid are further separated toward the external canthus by carrying the lance from and under the margin be toward d. Now the V shaped wound of the tarsus is closed by one or two sutures, and then the long stretch of the skin margin (da) is "gathered up" with the much shorter margin A of the tarsus by sutures, the proper mode of their application is best understood by a reference to Fig. 348, B. Where these sutures are tied the skin puckers a little between each suture, but the process of cicatrization will efface everY trace of this unevenness and restore a perfectly smooth lid margin.

In the operations for cicatricial ectropion the first step should always be to liberate by careful dissection the everted lid from all cicatricial adhesions so thoroughly that its reposition is possible without the least restraint or resistance.

Cicatricial ectropion of the lower lid presents two problems:

1. Its border, being stretched and abnormally lengthened, must be reduced to the proper size.

2. The replaced lid must be provided with a solid support below to bold it in its normal position.

In many instances these problems can be successfully solved by Arlt's operation (Fig. 349, A and B).

The incisions ab and bd are made so that they form at b an acute angle. These incisions are carried right through the cicatricial tissues; the flap abd is carefully dissected up to the lid border, and the lid released from all cicatricial restraints, so that it can easily be brought into its normal position. Next the lid border is shortened at the external canthus by removing the piece coed, making an incision co along the edge just behind the eyelashes on the conjunctival side and the crosscuts cd and oe. If now the lid border is lifted up into its proper position, the wound margins oe and cd are brought in apposition and held together by two sutures.

The reposition of the lid leaves below it the open wound abdg (Fig. 349, B), which must be filled with some solid material to furnish a good support to the lid according to the second indication stated above. If the adjacent integument is sound and elastic, the support of the replaced lid can be furnished by drawing the margin ag and gd together from g upward, and by uniting also a portion of the margin ag with ab and gd with bd to a Y shaped cicatrix.

If this plan cannot be adopted, Molfe's method of grafting a skin flap without a pedicle upon the wound should be practised.

The edges of the lower and upper eyelids are united by three ligatures, and the ends of the ligatures are drawn up and fixed upon the forehead by strips of adhesive plaster. The shape and size of the skin required must be carefully cut out in lint. A piece of lint is then laid upon the forearm and the shape traced by the point of the knife, making it one third larger all around to allow for shrinking. This flap is excised and spread out on the left forefinger to remove from it with sharp scissors all areolar tissue to leave a white surface. The flap so prepared is put upon the wound and moulded into position. No sutures are used; several pieces of lint or gauze wrung out of hot water are laid upon the flap and secured by a bandage. new eye should not be disturbed for the first three days, after which the dressing should be carefully removed, the last layer being well soaked with hot water in order that it may be removed easily without deranging the flap. It may then be dressed every twenty four hours. The ligatures of the eyelids should not be removed before six weeks.

This operation is superior and preferable to all the numerous ingenious methods of transplanting flaps with pedicles from the face, for it is free from the serious disadvantage they possess to wit, that if the flap sloughs the disfiguration of the face is worse after the operation than before.

Operation for cicatricial ectropion of the upper eyelid presents an additional problem of great interest namely, to restore its mobility. On this account the selection of a proper material to replace the lost skin of the lid is of the greatest importance. This material should be so thin as to mould itself to the surface of the lid, and so light and pliable as not to impede the movements by its weight and thickness. For these reasons the transplantation of skinflaps from the temporal region cannot be recommended. Wolfe's flaps have been used with fairly good results, but the lid always looks heavy and cannot be elevated to the full extent.

Thiersch's method of skin grafting yields better cosmetic results.

The lid, being completely liberated from the cicatricial adhesions, is drawn down and fastened to the check by three ligatures passed through the lid border. The wound is temporarily covered with a gauze compress wrung out of a warm solution of sodium chlorid (_1 per cent.) while the grafts are being cut from the flexor side of the arm. The surgeon grasps the arm between the thumb and fingers of the left band to draw the skin tense, and, holding the razor in his right hand, be lays its blade flat upon the wellwetted surface of the arm, and presses it down just enough to make its sharp edge bite into the skin, but no deeper than the papillary layer. By slow and short sawing motions the blade is steadily pushed on in the papillary layer until a piece of epidermis of the desired size has been gathered on the razor blade.

During this “shaving process " an assistant drops salt solution upon the blade and pushes with a probe the skin shaving back from the edge of the razor. To cut the shaving off, the edge of the knife is turned up, while the assistant presses the probe flat down upon the shaving near the edge of the razor blade. Now the compress is removed from the lid, the wound is carefully cleansed of all coagulated blood, and the skinshaving is transferred directly from the razor to the lid surface. For this purpose plenty of salt solution is dropped on the razor to keep the graft floating: if, now, the edge of the razor near its point is brought in contact with the border of the wound, the solution will run off from the razor and carry the graft with it; but as soon as the solution begins to flow and the edge of the graft has come in contact with and clings to the woundborder, the razor is drawn from under the graft across the wound, by which maneuver the skin graft floating from the razor is at once spread out smoothly over the lid surface. It is not difficult to cut shavings from 11 to 2 inches in length and from I to 1 1 inches in width if only the knife blade is operated by a steady hand and moved in the same plane. When the whole wound is well covered with these skin shavings two layers of strips of silk protective, moistened with the salt solution, are placed in position. They should be half an inch wide and long enough to lap over the wound border on both sides; one layer is placed in a transverse direction and the second layer in a longitudinal direction. These strips are covered with a compress which is to be kept wet with salt solution. The sound eye should also be bandaged.

This first dressing should remain undisturbed for two days. To remove it the compresses and strips of protective are thoroughly soaked with salt solutions; the grafts are rinsed with the same solutions, and fresh strips and compresses are applied. After four or five days the bandage may be removed from the sound eye, at the end of one week the ligatures may be cut, and during the second week the grafted lid needs only to be daily rubbed over with iodoform ointment. After the second week no further treatment is required. The grafted skin undergoes a gradual contraction of about one fourth of its area, but if this shrinkage has been anticipated by the operator, it will not affect the perfect cosmetic success of the operation.

Transplantation of Cicatricial Skin to Replace the Integument of the Lid.For cases where the eyebrow is partially destroyed and the supraorbital region largely covered by cicatricial tissue the author has made the new skin of the replaced lid from this cicatricial skin.

In case of complete ectropion of the upper lid (Fig. 350) the procedure was as follows:'

The border of the everted upper lid of the left eye was drawn up and fixed to the temporal portion of the supraorbital margin, and above it a large stretch of cicatricial skin extended far into the frontal and temporal region. The absence of the temporal half of the brow made the following operation possible: From a point (a, Fig. 351) near the inner canthus an incision was carried obliquely upward past the end of the eyebrow well up into the cicatricial skin above the supraorbital margin, and then continued at a considerable distance from the lid border in a curved line downward to a point (c) about 6 mm. from the external canthus. The large skin flap (abc) mapped out by this incision was carefully dissected from the underlying sear tissue down to the lid border, with which it was left connected. The lid then was released from all cicatricial adhesions and replaced in its normal position.

The cicatricial skin flap (abc, Fig. 351) contracted considerably as soon as it was detached from its basis; but as this shrinkage was anticipated by cutting the flap of very large dimensions, it was still sufficiently large to cover the whole surface of the lid. It was spread over this surface, and its margin (ac, Fig. 352) was fixed by four sutures to the upper border of the tarsus, and the resultant wound (abc) above the lid was covered by a skin flap (bed) from the temporal side, the margin be being united to ab, and A to the margin ac, Fig. 353.

The great advantage of this operation lies in the fixation of the new lidskin to the upper tarsal border. This union makes the new skin an integral part of the lid, and constitutes a protective barrier to prevent tissue contraction, which may take place in the supratarsal region, from disturbing the position of the lid .

Ill. Operations for the Restoration of the Lid (Blepharoplasty). If the lid is partly or totally destroyed (b " i nj uries, extirpation of tumors, ulcerations, etc.), the defect is repaired by the trans lantation of skin flaps from the vicinity. The operative procedures are as numerous as the lesions vary in character and extent, and each case must be studied well to designate the method best suited for its conditions. In general, it may be said that the results of blepharoplasty present a far better appearance on paper than in flesh.

The following methods may serve as working patterns:

Eversbusch's Method for Making an Entire New Lid. A skin flap of suitable shape and size is cut in the vicinity, and the wound as well as the under surface of the flap is covered with Thiersch skin shavings. A piece of silk protective being placed upon the wound, the flap is put back in its original place, and left there tinder proper aseptic dressings until the Thiersch grafts are adherent. Then the cicatrix along the orbital margin is excised, and the skin flap being laid across the eyeball, its edge (which has been previously freshened up) is sutured to the wound along the orbital margin.

If a portion of the conjunctiva is preserved, this is carefully dissected up from the cicatricial adhesions and used for lining the transplanted flap.

For the reconstruction of the upper lid a tongue shaped flap is taken from the temporal region Fricke's method (Fig. 354). The lower lid can be restored by Dieffenbach's method of sliding a flap taken from the cheek upon the triangular wound (Fig. 355), or by

Landoll's Method (Figs. 356, 357). Two parallel incisions (ab and ed), which at both ends reach a few millimeters beyond the canthi, are made through skin and orbicularis of the upper lid, and this bridge, being dissected from the tarsus, is drawl] down to take the place of the lost lower eyelid. The lower edge of the flap is sutured to the skin along the infraorbital margin,* and its upper edge is united with the conjunctiva. After union has taken place the connections of the skin bridge with the upper lid are divided.

If only a portion of the lower lid is lost, the remaining portion may be moved over into the defect, and, if the defect is very large, a skin flap can be drawn over from the opposite side to be joined with the transplanted lidportion Knapp's method (Fig. 358).

For partial destruction of the upper lid Landolt has devised the following ingenious method (Fig. 359) :

The nasal portion of the upper lid being lost, the surgeon splits the remaining lidportion in its entire extent into two layers, the anterior layer containing the skin and muscle, the posterior layer containing the tarsus and conjunctiva. An incision made through the anterior layer from the external canthus obliquely upward to the eyebrow allows the anterior layer to be shifted toward the nasal side, where it is united by sutures with the nasal margin of the original lid defect; sutures are also put into the lid margin from a to d to reunite the transplanted anterior layer with the posterior laver. The triangular wound (abc) resulting from the sliding of the anterior layer is covered by Thiersch's skin grafts.

Operations for Coloboma of the Lid. Congenital and traumatic colobomata of moderate extent can usually be rectified by a careful union of the freshened edges. Extensive lacerations of the lid, however, often produce so great a displacement of the severed lid portion that its reposition requires a regular transplantation, as, for instance, in the following case:

In September, 1886, a young man received a deep cut by a piece of glass, completely dividing the temporal third of the upper lid of the left eye. In November he presented himself with a long oblique sear in the upper lid, with its temporal portion so displaced that its edge ran straight upward. To relieve this deformity the scar was excised from a to c, and a flap was formed by the deep incisions ce and eg. This flap, being well mobilized, was then turned so as to bring the lid edge be into its normal position ; the wounds were then closed by uniting the edges ce with ac and the neighboring skin with ge. The result was very satisfactory.

IV. Operations for Ptosis. Patients suffering from paralysis of the levator palpebrarum instinctively learn to elevate the lid to a certain degree by the aid of the frontalis muscle. Its contractions, drawing the eyebrow and the integument between the brow and eyelid upward, exert indirectly a traction upon the lid by which a moderate elevation of the lid is accomplished. To increase this vicarious action of the frontalis muscle upon the upper lid is the aim of the following ptosis operations:

Panas's Operation. The upper lid being stretched upon a horn plate, a transverse incision, following the furrow above the lid, is made through skin and muscle to expose the tarso orbital fascia. From near either extremity of this incision a vertical incision (Fig. 362) is carried downward to a point 2 or 3 mm. below the upper border of the tarsus, where the one incision is continued in a horizontal direction to terminate near the tear point, and the other one horizontally outward to terminate near the external canthus. The rectangular flap thus mapped out is dissected up from above downward, so as to expose the upper tarsal border. Next a transverse incision, slightly convex upward and about 2 cm. in length is made just above the eyebrow. This incision is carried through all the tissues down. to the periosteum. The cutaneous bridge between the two horizontal incisions above and below the brow is undermined, and the rectangular skin flap is pushed under this bridge upward and attached by sutures to the upper edge of the upper incision. In order that the traction of these sutures shall not produce ectropion, an additional suture is applied at each side. These lateral sutures are passed through the tarso orbital fascia and conjunctiva near the upper tarsal border but do not include the skin, and carried under the skin upward to emerge from the upper margin of the frontal incision. The wound is dressed with antiseptic dressing, and the sutures are removed after four or five days.

The effect of the operation depends on the length of the rectangular flap If it is too long, the elevation of the lid will be insufficient; if too short, a marked degree of lagoplithalmos is produced. '

Wilder's Operation (Fig. 364). Dr. W. H. Wilder of Chicago has in a number of cases relieved the ptosis by folding upon itself the tarso orbital fascia (" the suspensory ligament of the upper lid") and by establishing a firm adhesion between the fascia and frontalis muscle :

An incision 11 inches in length is made a little above and parallel with the orbital margin through all the tissues down to the periosteum, and should be so placed that the resulting sear will be concealed by the eyebrow. Retractors being used to draw down the lower lip of the wound, the skin and orbicularis muscle are separated from the fascia by careful dissection until the tarsus is brought into view. Two time sutures of sterilized catgut or silk, armed at each end with a curved needle, are then passed in the following manner: the needle is introduced deep enough into the tarsus to secure a firm hold at a point about at the junction of the outer and middle third and a little distance from its upper edge. It is then drawn through, and several gathering stitches are taken upward in the tarso orbital fascia, after which the needle is made to pass through the muscle and connective tissue of the upper lip of the wound. The other needle on the same suture traverses a parallel course in the same manner, entering the tarsus about 3 mm. from the point of entrance of the first, and emerging in the tissue above, thus making a loop by which the lid may be drawn up. The second suture is passed in the way, making a loop at the junction of the middle and inner thirds of the tarsus. The requisite elevation of the lid may be now secured by drawing on the loops and tying the sutures, after which the ends may be cut off. The lower lip of the wound is now replaced and united to the upper with fine sutures. The slight sear that remains after healing is almost entirely hidden when the eyebrow grows again. As the buried sutures become capsulated additional strength is' given to the bands that hold up the lid.

The various operations aiming at increasing the effect of the frontalis muscle by subcutaneous ligatures are unreliable and uncertain in their effect, like all operations done in the dark. But the excision of an oval piece of skin should never be practised for this purpose, because it produces a hideous lagophthalmos.

If the action of the levator muscle is not entirely lost, the principles of tendon advancement and tendon resection as practised in squint operations may be employed, and are made the basis of the methods of Eversbusch, Suellen, and Wolff.

In Eversbusch's ope) ation the advancement is produced by folding the tendon upon itself, like the advancement of Tenon's capsule.

Midway between the lid margin and the eyebrow a horizontal incision is made through all the tissues down to the fascia. The edges of the wound are dissected up to expose well the tendon, which there is blended with the tarso orbital fascia. Four mm. above the upper border of the tarsus a small vertical fold of the center of the tendon is then taken up in the loop of a double armed thread, and both needles are passed vertically downward between the tarsus and orbicularis, brought out at the lid margin 2 mm. from each other, and tied over a small bit of rubber tubing. A similar suture is passed through the nasal and temporal portions of the tendon respectively; the skin wound is closed by sutures before the tendon sutures are tied.

Snellen's operation' is a tendon resection.

The upper border of the tarsus is exposed by a transverse incision and the orbicularis fibers are pushed upward and downward. The exposed fascia is then incised at some distance above the tarsal border, and three or four needles are thrust through the tendon and passed from above downward to emerge again through the upper border of the tarsus. But before the needles are drawn out the piece of tendon between the tarsal border and the point of entrance of the needles is excised. Then the needles are drawn through and the threads tied.

Wolff's operation 2 combines tendon resection with tendon advancement, and is a decided improvement over Suellen's method.

The surgeon makes an incision through all the tissues along the upper border of the tarsus, and, lifting up in a vertical fold the central portion of the tendon expansion on the anterior surface of the tarsus, he cuts at each side a vertical buttonhole, through which two strabismus hooks are slipped under the tendon, so that the one hook is placed close to the insertion and the other hook so far above it that the distance between the two books represents the piece of tendon to be resealed. Two double armed catgut sutures being put through the tendon just below the upper hook, the tendon is cut transversely below the sutures. Both ends of each suture are then carried behind the tendon stump and passed through the line of insertion, tied, and cut short; the skin wound is closed over them by silk sutures.

The success of the operation depends upon the accurate dosage of the tendon resection; the resected piece should measure exactly as many millimeters as the vertical diameter of the palpebral aperture of the affected eye is smaller than that of the normal eye.

Operation of Ptosis Adiposa or Atonica. In this affection the lid shows neither any superabundance of adipose tissue nor any imperfect action of the levator muscle; but the skin has lost its connection with the aponeurosis and the upper border of the tarsus, and therefore is not drawn back with the tarsus when the lid is opened, but falls down over the lid border like a heavy curtain (Fig. 366). To relieve the deformity by cutting away this skin curtain would be a grave mistake, because it would leave the skin so short that the lid could not be closed. But the deformity can be perfectly relieved by reattaching the skin to the Tipper border of the tarsus by means of the sutures employed in the author's operation for entropion (see page 549).

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