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Trichiasis, Entropion and Tinea Tarsi - Semantic … ENTROPION AND TINEA TARSI. By HENRY SMITH, m.d.. M.ch. Major, i.m.s., Civil Surgeon, Jullundur, Punjab. The terms trichiasis, and

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Page 1: Trichiasis, Entropion and Tinea Tarsi - Semantic … ENTROPION AND TINEA TARSI. By HENRY SMITH, m.d.. M.ch. Major, i.m.s., Civil Surgeon, Jullundur, Punjab. The terms trichiasis, and

TRICHIASIS, ENTROPION AND TINEA TARSI.

By HENRY SMITH, m.d.. M.ch.

Major, i.m.s.,

Civil Surgeon, Jullundur, Punjab.

The terms trichiasis, and entropion, are used in all the text books in a most confusing way ; in a way in which I defy any student to define for an examiner, on an actual case, which is which. Each may be either and the student will fare according to the personal equation of' the Examiner.

1 define trichiasis as a condition in which more or less of the lashes are faulty in their

direction, some coming towards the eyeball, and in which the lashes are often erratic in their

positions of eruption, with or without incurva- tion of the lid. The inner ones may point inwards while the outer ones point outwards. In some cases they appear to erupt on no plan or system such as we see in health?unsystem- atically as the bristles in a brush, This is not

a congenital condition. The cause of trichiasis as thus defined is obscure. It is said to follow

hordeolum, tinea tarsi and other such conditions; but in my experience it so seldom follows those conditions that I have grave doubts as to their causative influence. Trichiasis proper is chiefly confined to the upper lid.

Entropion, I define as incurvation of the tarsal cartilage including its border. In both

entropion and trichiasis the lashes ultimately impinge on the eyeball.

Entropion of the upper lid is caused, I think, almost entirely by the contraction of its under surface following trachoma, assisted by the

hypertrophy of the orbicularis muscle which is caused by its continued over action from the

conjunctival irritation of trachoma. There is a

spastic entropion, seen most commonly in chil-

dren, due to chronic conjunctival irritation of a severe nature?mostly trachoma and cornea] ulceration. In this condition the fibres of the orbicularis muscle seem to act more strongly near the border of the lids and undoubtedly become hypertrophied in that situation. This same action of the orbicularis in adults and more especially in aged people is the cause of

entropion of the lower lid in them. According to my definition it is the altered direction of the lashes and the altered system of their eruption which constitutes trichiasis. It is the simple incurvation of the lid which constitutes entro-

pion. It is plain we may have both conditionly combined.

Treatment.?The treatment of trichiasis and

entropion are pretty much the same apart from spastic entropion. Entropion, and trichiasis if it exists, should be treated before trachoma as thejT

Page 2: Trichiasis, Entropion and Tinea Tarsi - Semantic … ENTROPION AND TINEA TARSI. By HENRY SMITH, m.d.. M.ch. Major, i.m.s., Civil Surgeon, Jullundur, Punjab. The terms trichiasis, and

Nov., 1905 ] . THE TREATMENT OF TRICHIASIS. 423'

are botli vapidly and certainly curable, whereas trachoma is one of the most obstinate of human affections as far as treatment is concerned. Trichiasis and entropion only call for treatment when the cilia impinge on the eyeball. We now hear little of electrolysing the hair bulbs

compared with what was the fashion 15 years ngo. Electrolysis of the hair bulbs and Wilde's operation (the scalping operation) should be put on the same footing. The result of the one

looks just as barbarous as that of the other. The result of both is highly disfiguring. Both should be relegated to a place in the history of barbarous operations. When the hair bulbs are electrolysed the whole cilia-bearing portion of the tarsal cartilage, atrophies and the border of the lid thins down to a condition much like the border of the third eyelid of a bird. Neither of the above operations is necessary as the worst case can be satisfactorily dealt with by a plastic operation which does not disfigure the patient. Besides electrolysis is a painful operation and a painfully tedious operation. Snellin's operation is designed to render the curve of the lid normal, as well as to alter the direction of the lashes, by talcing a V shaped piece out of the tarsal

cartilage, the angle of the V pointing towards the eyeball, and bringing the limbs of the V together by stitches. Do we really thus render the curve of the lid better than it was before ? I consider that we do not. We leave a ridge on the interior of the cartilage at the point of the V where there was none before and while we do not otherwise alter the original curve

in other respects we add an additional curve.

This operation does not sufficiently alter the incurvation at both ends of the lid and the

patient has not long left hospital when he returns with lashes impinging on the eyeball at both ends. This insufficiency to permanent- ly retain the lashes in position ut both ends of the lid is the grave objection to all the standard operations in severe ca><es?I presume we see more severe cases at our Indian hospitals than are seen in Europe and America where patients sensibly go under treatment much earlier in the history of their maladies. In severe cases, the different operations which do not involve the

complete division of the tarsal cartilage from end to end and the complete division across the ends of the cilia bearing strip of cartilage, leaving that strip attached only to muscle and skin and the

removal of a small ellipsoidal piece of skin from the outer surface of the lid, and the excising of a portion of the overgrown orbicularis muscle and thus reducing its power, are in my

experience imperfect operations and will have to be repeated sooner or later. Scott's opera- tion and- the various other operations consist-

ing of partial slitting of the cartilage and depending on the tension of stitched up skin to retain the hair bearing border in position are, in my experience, only trifling with the condition.

The only operation 1 now do, after a fair trial of the multiplicity of operations in vogue, is as follows:?I catch the lid (upper lid) close to the border with a Bryant's artery for-

ceps and turn it out. I then insert a Graefe's knife just outside the lachrymal punctura in the intermarginal space, taking care to be rathe1!- behind it than to run any risk of cutting the hair bulbs across?no evil result follows cutting across the ends of the miebomian gland ducts? and stick the cartilage clean through from that

point to the external commissure. I then turn the edge of the knife forwards at each end and cut the strip of cartilage clean across leaving it attached only to the skin and muscle. I then take off the forceps and insert between the lid and the e\7ebull a horn spatula and excise an

ellipsoidal piece of skin from the lid?the lower incision parallel with the border of the lid and about -Jth of an inch from its margin. From the

space thus exposed in the middle I take out a

liberal piece of the orbicularis muscle down to the cartilage, so as to reduce its power, and unite the edges of the skin with a few stitches. When I have gone thus far I observe that th6; ends of the cilia bearing stripe stand out as a

pair of unsightly points. These points I trim with a sharp pair of scissors. At tins stage, any one can see that I have caused the cilia bearing border to slide up as a whole from end to end on the sliced border of the base of the cartilage. I do not insert a piece of skin or rtiueons

membrane graft in the gap: there seems to

be no gap as the one is slid upon the top of the other. The after result is about as

perfect as any operation is perfect. The piece of skin removed is smaller than is necessary to remove in Arlts' operation. The cilid

bearing border I have never seen necrosing. In the case of only a few in-growing hairs I, in the same manner detach the piece of carti- lage bearing the hairs at fault and stitch in with a steeple stitch a piece of mucous membrane from the lip running the two tails of the stitch, on separate needles, up through the incision and out through skin about A-rd of an inch above the

? l

border and tie them there over a small roll of

gauze. This graft always grows if the \Veeping of blood from the wound has completely ceased before it is inserted. Inventions in the forth of forceps to render the slitting easy and to

prevent loss of blood are incumbrances. They prevent the operator from cutting out right to the ends. The loss of an ounce of blood is of no

importance. In entropion of the lower lid?trichiasis of

the lower lid is exceedingly rare ?the excision

of a small ellipsoidal piece of skin from the lower lid and a large piece of the whole thickness of the orbicularis muscle and stitching the skin

edges together is all that is necessary. Care must be taken not to excise too much skin as it is bettei- to have to excise a second piece on accoiirit of insufficiency than to have to do att ectvopioii

Page 3: Trichiasis, Entropion and Tinea Tarsi - Semantic … ENTROPION AND TINEA TARSI. By HENRY SMITH, m.d.. M.ch. Major, i.m.s., Civil Surgeon, Jullundur, Punjab. The terms trichiasis, and

424 THE INDIAN MEDICAL GAZETTE. [Nov., 1905.

..operation on account of having done too much?

conjunctival irritation has caused the orbicularis muscle to become hypertrophied in the con-

tinued effort* to shut off light and the hyper- trophied muscle in turn causes the entropion ; hence the importance of dealing with that muscle in entropion of the lower lid. The methods of

controlling entropion, by stitches, alone are in

my experience not,satisfactory. In addition to

the above operations for entropion,, it is often

necessary to elongate the palpebral fissure it

haying from some cause become very short?by cutting the, external commissure and uniting the bulbar conjunctiva with three stitches to

the skin, one in the angle and one above and below, so as to prevent it reuniting. A form of entropion, most common in children,

is due, to the continued blepharo-spasni in the efforts of nature to shut off light from an eye affccted", with- corneal ulceration or conjunctival inflammation of a somewhat- lasting character. The consequent irritation induces a hypertrophy of the orbicularis .muscle,from over action which again induces the entropion of both lids. It is

commonly held and, I think correctly, that the fibres become .shifted towards the borders ot the lids. The teatment of this condition consists in

elongating the palpebral fissure and, if it be

already long enough, the conjunctiva should not be stitched to.theskin, so as to allow it to, resume its.original length. It is also advisable at the

.same, time to slip a Graefe's knife between the skin and the muscle of both upper and lower lids find with (the finger or spatula beneath the lid

to cut the orbicularis right across. Snellen's

stitches can then be applied if,, seen necessary. The conjunctival or corneal condition or both must be treated at the same time. ?

....

linen. Tarsi, whether this condition be

parasitic or not the result of treatment with the 'usual' ointments is very unsatisfactory I have seen cases go on for years under 'treatment, bv

repeated epilation?clearing off the scabs with soda solution, daily and daily application of

yellow oxide of mercury 8 grains to the omipe .without the .slightest, improvement. I have used ?it as much as 50.grains to the ounce without,in- convenience to the patient and 110 apparent benefit. With such ointments it is a most

pbstinate condition to cure. I, now when the case pomes before me, clear off the scabs and as soon

as weeping from the raw surface has ceased I

slightly turn out , the margins of the lids,

peeping the eye closed at the same time, and rub the margins heavily with a solid nitrate of ?silver stick. In a few days the nitrate of silver slough is ready to drop off and with it most of the lashes. The remainder I extract and repeat the nitrate of silver stick application a second time and.a,third timt* similarly.. I find that this is

generally sufficient to ^completely- cure the malady, : Jn my experience it is incomparably, '^e.4iiu8^^p^.ai)(l t

the most certain of all the

purpose;,; ?< ? ;