18 WEEKS: Operative Treatment of Entropion. be left on the posterior portion, cilia would be very likely to sprout up through the incision. The formation of granulomata is not so common as when the tarsal incision is left uncovered by mucous membrane. When they appear in the line of the divided tarsus, they may be removed by curette, knife, or scissors. Puck- ering of the lid margin may follow, as in the simple tarsal in- cision; this may be remedied later by making one or more deep vertical incisions, as practiced by Dr. Green, or it may be left to take care of itself. I have usually found that in time it straight- ens out of .its own accord with advantage to the desired eversion. The method differs from that of Dr. Green only in the applying of the quill suture, and in covering a portion of the incision with mucous membrane. A combination of a form of quill suture with the tarsal incision has, I am told, been used by Professor Voelckers in the University at Kiel for a number of years.

OPERATIVE TREATMENT OF ENTROPION BY THE TRANSPLANTATION OF A FLAP OF MUCOUS MEMBRANE.

BY JOHN E. WEEKS, M.D.,

NEW YORK CITY. Shrinkage of the palpebral conjunctiva from whatever cause may produce entropion, but by far the most common cause is trachoma. The long-continued congestion of the tarsus occa- sions .some hypertrophy of that body. The traction of the shrink- ing tarsal conjunctiva lessens the vertical dimension of the tarsus, causing it to become more concave on its posterior surface and more convex on its anterior surface. The same condition is found in the lower as in the upper tarsus, but the former is so much narrower and thinner that the deformity is much less. WEEKS: Operative Treatment of Entropion. I9 The photophobia occasioned by the superficial keratitis which usually accompanies trachoma in the second stage causes more or less tonic spasm of the orbicularis palpebrarum muscle, which results in forcing more than the normal number of muscle fibers to the margins of the lids, aiding in a thickening of the margins of the lids and in crowding the lashes against the cornea. In all cases of marked contraction of the palpebral conjunctiva the pal- pebral fissure is shortened, from the external commissure. .In not a few cases of entropion the intermarginal space is narrowed; also the ducts of the Meibomian glands are so curved that their orifices are constantly in contact with the eyeball. The writer has operated in many ways for the correction of entropion. He has found that the Anagnostakis-Hotz operation produces permanent, satisfactory results in only the mildest cases of entropion. The Jaesche-Arlt operation is inelegant. The Green and Burow operations are too often followed by relapse, and the Streatfield-Snellen operation is sometimes insufficient when used alone. A study of the conditions present in entropion has impressed the writer with the necessity for the reconstruction of the margin of the lid in many cases, and he now employs a modification of the Streatfield-Snellen operation combined with the Van Millingen operation. If the palpebral fissure is much shortened, a canthoplasty is first performed. In all pronounced cases of entropion, either of the upper or lower lid, the margin of the lid is reconstructed by the Van Mil- lingen method. When the lower lid is the seat of the entropion, reconstruction of the margin of the lid alone is sufficient. In operating on the upper lid (after having performed cantho- plasty if that is necessary), the lid is split along the intermarginal space, the incision extending to a depth of 2.5 mm., and so made that all of the lashes are in the anterior flap and the tarsus in the posterior flap; the groove thus formed is wedge-shaped and measures about 2.5 mm. in width at its base. This groove is made in the early part of the operation, so that the bleeding will 20 WEEKS: OperWive Tret*te of Entrop4rn. have ceased when the other parts-of the operation are complete. The lid is then fixed with a Knapp clamp and an incision made through the integument 3 mm. from the margin of the lid and parallel to it, extending the whole length of the tarsus. If the integument is redundant, a narrow strip is dissected from the upper flap. A strip of subcutaneous tissue is now dissected out, exposing the upper two-thirds of the tarsus. The tissue imme- diately beneath the lower flap is left in situ. By means of a scalpel, or Beer's knife, a wedge-shaped strip of the tarsus is removed, the groove formed running parallel to the lid margin, its apex almost reaching the tarsal conjunctiva; the strip is taken from the thick- est part of the tarsus. Four sutures are applied, each passing

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through the integument of the lower flap I.5 mm. from its edge, then through the epitarsal tissue at the upper margin of the tar- sus, emerging on the surface 8 mm. above the margin of the upper flap. These sutures are of No. 3 silk and are tied firmly. The groove in the edge of the lid is now freed from clots, making it ready for the reception of the flap. One-half of the lower lip is now engaged between the blade of a Knapp clamp, the plate lying against the integument, and pressure applied. The clamp acts as a hemostat, and also puts the mucous membrane on the stretch.' A strip of mucous mem- brane 2 to 2.5 mm. in width and as long as the groove in the in- termarginal portion of the lid- is now removed by means of a WEEKS: Operative Treatment of Entropion. .. Graefe knife. If this knife is made to cut along the entire length of its edge, two strokes will be sufficient to excise a wedge-shaped strip of the lid of sufficient length. Scissors and forceps may be required for the final separation of the flap. The flap is imme- diately transferred to the groove in the lid and pressed into place. The plastic lymph is sufficient to retain the flap. No sutures are required. The operated lid and the opposing margin of the lower lid are covered with bichloride vaseline I/5000, moist gauze, cotton, and a bandage. The dressing is not disturbed until forty-eight to seventy-two hours have elapsed. At the expiration of seventy- two hours the flap is quite firmly adherent and the bandage may be dispensed with. As a rule the bandage is replaced and per- manently removed on the fourth or fifth day. The margin of the lid is smeared with borated or sublimated vaseline for a few days longer. The stitches employed in the modified Streatfield-Snel- len operation are removed on the seventh to ninth day. The wound in the lip is closed by a continuous silk suture and heals by first-intention; the stitch is removed on the fifth day. In all operations in which the transplantation of a flap of skin or mucous membrane is involved, the question of shrinkage must be considered. My experience in some twenty cases in which I have employed the method described is that flaps transplanted from the lip shrink less than flaps of integument. Some of the cases have been under observation for a number of years; in none has there been a relapse of the entropion. In cases where the union between lid and flap is rapid, the flap of mucous membrane does not lose its epithelial layer, as is almost always the case when integument is employed; its sur- face remains smooth and is restored to a normal condition sooner than that of integument. There is no irritation to the cornea from the exfoliation of corneous epithelium, and no trouble from the growth of fine hairs. The Tiersch graft does not possess sufficient substance to give perfectly satisfactory results in re- constructing the margin of the lid. 22 22Discussion.

DISCUSSION. Dr. H. KNAPP. I want to say that I have long practiced ex- actly the same method and described it six or seven years ago with skin flaps, and also every now and then with mucous mem- brane, and I can endorse all that Dr. Weeks says, except that I have not found any great advantage in mucous membrane over skin flaps. If we take the skin flap from the upper border of the lid wound, or from behind the ear, we secure a good mem- brane free from hair. The operation of implanting a flap of skin belongs to the late Dr. Waldhauer, who published it about twenty or thirty years ago. Of all the methods that I have used I have found this the most satisfactory in the generality of cases, but I must say, how- ever, that of late I have seen some very excellent results attained by a pupil of Panas' with the latter's operation. Dr. THEOBALD. I should like to say just a word on this sub- ject in regard to senile entropion of the lower lid. Perhaps some of the members may remember that several years ago I read a paper on the use of caustic potash in the treatment of this form of entropion. It is a very simple operation, and can be repeated a second time if necessary. The results have been very satis- factory, and because the operation is so simple and so readily per- formed I am led to speak of it here. The operation is not orig- inal with me, but was practiced by my grandfather, Professor N. R. Smith. The crayon of caustic potash is sharpened to a point and is moved back and forth across the lid at about 4 mm. from its margin. An extension or spreading of the caustic action of perhaps 2 mm. from the line of application is to be allowed for. By simply causing the potash to act upon this little strip of tissue parallel to the lid margin, and moving it back and forth gently, perhaps a dozen times, you secure a very marked caustic action upon the tissue, and, when desired, you can check this action by the application of vinegar and water. As a rule the lid will im- mediately stay out in good position. A slough takes place, and the cases in which a complete cure is not effected in senile entro- pion are very unusual in my experience. I have sometimes em- ployed it in cases of entropion the result of trachoma. The method is not adapted to entropion of the upper lid. Dr. LIPPINCOTT. I have also used the method described by Dr. Weeks with very happy results, but I also, as Dr. Knapp has done, have used the skin flap. I have had no disagreeable re- Discussion. 23 sults from the few thin hairs. The malposition of the lid is cer- tainly very beautifully corrected by this method and the patient's comfort increased correspondingly. In one case of marked en- tropion existing for eight years, with an opaque cornea, the oper- ation was followed very shortly by decided clearing of the cornea and improvement of the vision. Dr. WILDER. I have found that a canthoplasty is necessary in many of the cases that I see in my service at the Illinois Eye and Ear Dispensary. I think it is well also to emphasize the im- portance of removing those bundles of muscular fibers that re- main in the lower flap when' the incision is made for the ordinary entropion operation. If this bundle is allowed to remain it nat- urally contracts just as it did before, and the entropion recurs. This is one of the important features of the operation of Dr. Hotz, who showed that in extreme cases if these muscle fibers are re- moved there is much less liability to recurrence than there other- wise would be. In addition, there may be combined with this operation the planting of an intermarginal graft, and in my ex- perience the skin flap has been more satisfactory than the mucous membrane. I have often taken a strip of skin from the hairless portion of the hand with very good results. I have found the correction of the deformity of the cartilage a very difficult point, and have devised an instrument for the purpose. With it a wedge-shaped piece can be taken out of the cartilage at any point. It has also proved useful for cutting a skin flap that will exactly fit into the little groove made by split- ting the edge of the lid. Dr. GREEN. My name has been mentioned in cQnnection with an operation which was evolved in the course of my opera- tive work over 25 years ago. I had tried, as I think I may fairly say, all the operative methods then in vogue for the cure of entropion, with trichiasis, of cicatricial type; that is, the type char- acterized by cicatricial contraction of the cdnjunctiva and tarsus following trachoma. I have uniformly found the operation of Arlt unsatisfactory. I believe, however, that the supplementing of his procedure by the insertion of a strip or wedge of integu- ment or mucous membrane into the lid-margin obviates one great defect in that operation. My old Arlt operations were en- tirely successful as judged by their primary results, but when I saw the patients six months or a year later, as I often did, with their condition scarcely at all improved as compared with that 1Qswcvssion. existing before the operation, I became disheartened. In a large number of cases of cicatricial entropion there is such alteration of the lid-margin that the cilia lie flat against the eyeball, and the ducts of the Meibomian glands also open backwards against the. eve. In my attempts to devise some means to correct the incur- vation of the tarsus I finally hit upon a plan, which was to me original, which consisted in making an incision from end to end of the lid through conjunctiva and tarsal tissue, down to the muscle, but leaving the muscle intact. The operation was com- pleted by the removal of a narrow strip of skin from the front of the eyelid, near the line of the cilia, and closing the wound by sutures. Having had abundant experience from my own operations, and also from seeing the results of operations by others in which very broad pieces of skin had been removed, I had learned that in these cases there was nothing to be gained from the excision of a large flap of skin. I had even seen cases in which the lids could not be closed, as the result of such mutila- tion, but in which, nevertheless, the position of the lid-margin was not greatly improved. Comparing this operation with other historical methods that had preceded it, I discovered that a mine of information was contained in Himly's Krankheiten und Missbildungen des menschlichen Auges. I found operative procedures there de- scribed;which must have given good results, in which the entire thickness of the eyelid was cut through, so that the whole margin of the lid could be freely tilted forwards, as indicated in one of Dr. Ewing's diagrams, and as accomplished also in my own opera- tions. Such an operation was the tarsotomia horizontalis of von Ammon (I833), as modified and improved by Rosas (i835). The obvious weak point in that method is the danger that the lid- margin may possibly slough, and more or less serious deformity result. The original Jaesche operation also involved the de- tachment of the tarsal margin from the rest of the lid, but it was an operation originally proposed for partial trichiasis, confined to a portion of the length of the eyelid. I learned also that an operation closely resembling mine had been described by Burow some two or three years before I made any public mention of my method. This led me to look a little further into the litera- ture, and I found that this writer too had been anticipated, namely, by Celsus, by Aetius, and by Paulus AEgineta. All these authors refer to a condition which is clearly to be identified as true cicatricial entropion such as follows trachoma, but they. also employ language clearly descriptive of another Dixu.Tsio,L and different condition, namely spastic entropion, which almost always occurs in the lower lid, and which yields readily to dif- ferent operative methods, including that mentioned by Dr. Theo- bald. The ancient operation, which in the upper lid is called avappao, and in the lower lid araraq3paa, consists of two dis- tinct procedures, namely, the &va paq7 orwarapao7, proper, whicb consists in the excision of a rather large flap of skin from the eyelid and closure of the wound by sutures, and the 'vrorop', or subsectio, which is a long and deep incision carried through the conjunctiva and tarsus parallel to the line of the cilia. All thi writers mentioned state, however, that the vnroroupi may be suffi- cient, without the excision of the flap of skin from which the operation derives its name. My first insistance upon some modification of this ancient method was on restricting the width of the strip of skin to be re- moved, and, secondly, on a better way of applying the sutures, which, while not exactly that of Dr. Ewing, is much like it. Presently, however, having occasion to operate upon cases in which no skin could be spared, it occurred to me to try a sub- stance not known to the ancients, namely collodion. After making the tarsal incision from one end of the lid to the other, making it deep, so that the lid margin could be easily turned out, and painting a strip along the entire length of the lid with con- tractile collodion, I was able to evert the lid-margin without pre- viously excising any skin or using any sutures. Now while I do not hesitate to remove a strip of skin whenever it appears to be redundant, I nevertheless limit myself to removing a very narrow strip, and in the majority of cases I do not excise any skin at all. In the process of healing, the gaping incision in the tarsus fills rapidly by granulation and is soon covered by smooth conjunctiva. The increase in the height of the tarsus, by this formation of new tissue, is generally not less than two millimeters, and this gain in height and also the restoration of the lid-margin and the correction of the direction of the cilia are permanent. This operation is essentially one adapted to the cure of cica- tricial entropion of the upper lid. When the operation is per- formed on the lower lid the results are less satisfactory. I be- lieve the modification described by Dr. Ewing will prove valu- able. So far as I have had an opportunity of observing the cases in which he has employed this method in operating for true cicatricial entropion of the lower lid, the results have been ex- cellent. 26 Discussion. Dr. TORRANCE. As I come from the home of trachoma and trichiasis, perhaps I may be allowed to say a few words. Prob- ably from sixty to eighty visitors a day come to my hospital suf- fering from this terrible disease, which causes more blindness than people are aware of. I find that eyes differ very much and that no one method of operating will suit them all. It is very im- portant to consider the thickness of the tarsal cartilage and how the hairs grow out. Sometimes you will find the glands. coming right out on the surface, and it is difficult to make this incision and keep all the hairs of the anterior flap out, and the cause of failure I believe in many of these cases is that you do not get all the hair bulbs in your anterior flap. Where you have a thick cartilage, my experience is that the best operation is the old Snel- len method. I find that in at least fifty per cent. of all cases you can get a very good result with the old Jaesche-Arlt operation. There is no danger whatever of sloughing in the old cases. I have never seen one. You know how vascular everything about the eye is, and even though you have a very small flap it will heal and grow. I have tried the so-called Van Millingen operation, but I may say that as a matter of fact I try to adapt the operation to the case in hand and do not know when I begin an operation how I am going to end it. Dr. WEEKS. I am very much pleased to have listened to the extended discussion of this subject, for it is really, to my mind, an important one. The operation that Dr. Green has so well described has certainly proven unsatisfactory in the hands of some others than Dr. Green, for a number of cases have presented themselves to me with relapses. In regard to dissecting out the sub-cutaneous tissue in the lower flap, if the tissue is very abundant and bulges into the wound, I excise some of it; if. we should excise all of this sub- cutaneous tissue we might jeopardize the nutrition of the lower flap. I do not think the operation referred to by the last speaker, that of scalping, should be done at all.