|Year : 1964 | Volume
| Issue : 2 | Page : 82-84
Surgical considerations in trachoma cases in India
Trachoma Research Centre, A.M.U. Institute of Ophthalmology, Aligarh, India
|Date of Web Publication||14-Feb-2008|
B R Shukla
Trachoma Research Centre, A.M.U. Institute of Ophthalmology, Aligarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shukla B R. Surgical considerations in trachoma cases in India. Indian J Ophthalmol 1964;12:82-4
Complicated trachoma cases form a complex problem, as the sum total of ocular involvement is generally the result of multiple factors and not exclusively due to the trachoma virus. Surgical treatment required in such cases is essentially the treatment and cure of these complications. The severity and morbidity of such complications and sequelae differ from case to case, so much so that no one routine surgical procedure can be the answer to all cases. Naturally, greater discretion is required to determine the plan of surgical intervention for the cure of the different complications.
Trachoma surgery is wrongly classed under minor surgery. On the contrary the planning and execution of surgery of varying degrees of complications in trachoma should rest in the mature experience and skilled hands of seasoned operators, if results are to be permanent, relapses are to be prevented and blindness from ill-conceived surgery in trachoma is to be minimised.
At this stage it is necessary to lay stress on proper training courses for junior services in this special branch of ophthalmic surgery so that the tyro is made conscious to the fact that it is as important and delicate as other forms of ocular surgery.
| Classification|| |
Surgical considerations in respect of complicated trachoma cases have to be viewed under two headings.
1. Surgery of complications resulting from long standing trachoma.
2. Ocular surgery-cataract, glaucoma, keratoplasty, oculoplastic etc.-in trachomatous eyes.
I. Surgery in Trachoma
Under the first caption the clinical entities requiring surgical treatment are entropion, trichiasis, mechanical ptosis, obliterated fornices, conjunctival pockets, symblepharon, corneal opacities, submucous fibrosis xerosis and total xerophthalmia.
Entropion and Trichiasis
These complications are corrected surgically either through a cutaneous or conjunctival approach, the latter being certainly preferable. Under the cutaneous approach for the various eponymous operations, viz. Snellen-Streatfield, Hotz - Anagnostakis, Beardo Panas, Stallard's, Kettesy's are invariably better under our conditions. However, while selecting any operation through the cutaneous route one must rigidly avoid wide excision of skin, placing an incision too near to the lid margin and passing sutures through it. Excluding cosmetic blemishes, we have seen thousands of lids mutilated and eyes rendered blind through disregard of these vital principles.
If trichiasis is an isolated condition and there are many misaligned cilia, without an element of spasm, Hughe's operation wherein tarso-conjunctiva is employed in preference to skin (Waldhauer) or buccal mucosa (Van-Milleingen) may be decided upon. In cases of trichiasis at the angles, with or without entropion, Spencer Watson's operation of transplanting the lid border is satisfactory. In some cases mere resort to galvanic (electrolysis) or diathermic epilation may suffice.
Although the different operations through the skin produce satisfactory results for cosmetic reasons, the ideal procedure would be one of operations performed through the conjunctival approach. Of the three common operations, viz., Lagleyze's, Webster's and Trabout's, the last two are quite satisfactory. The conjunctival incision must be placed in the area of deep scarring of the subtarsal sulcus. In the case of Webster's operation the buccal mucosal strip should be about 5-6 mm wide and one and a half times larger than the linear incision to be covered. In all these operations both the wound margins must be adequately undermined, the distal one to 1 mm from the ciliary roots and thus freed from the pull towards the subtarsal sulcus.
While keeping the essential principles of correct surgery in entropin and trichiasis cases in mind (hairline properly replaced, deformed tarsus adequately straightened, and contracted conjunctiva restored) one must also be aware of the late complications, like surgical lagophthalmos, inadequate blink reflex and gradual worsening of corneal lesions due to inadvertent vertical shortening of lids.
In established cases tarsectomy corrects the pseudo-ptosis adequately. In cases of recurring trachoma where cornea is also greatly involved, tarsectomy sometimes aggravates the corneal disease. Tarsectomy, in such cases, should be combined with peritomy and coverage of the raw scleral limbus with buccal mucosa (Denig's operation). In some cases Blaskovicz's operation is preferable.
Obliterated Fornices, Conjunctival Pockets and Symblepharon
In chronic and recurring cases treated earlier by irritant drugs, these sequelae are not so uncommon. The basic cicatrisation process undergoes excessive proliferation and contracture. These findings, however, do not constitute serious disability. If these conditions become symptomatic or cause recurring conjunctivitis, plastic repair with buccal mucosa or auto-peritomeum may be required.
Majority of these cases are suitable for lamellar keratoplasty without untoward results. Optical iridectomy, as customarily done, should be given up in preference to keratoplasty.
Submucous Fibrosis Conjunctiva and Total Xerophthalmia
Sometimes a long standing trachoma with or without perverted secretion of Meibomian glands leads to intractable and unresponsive photophobia and congestion. These are accompanied by diffuse subconjunctival fibrous tissue proliferation, xerosis and absence of lacrimal secretion. Best results have been obtained by us by transplantation of Stenson's duct in the lower fornix in these cases. In total xerophthalmia with or without symblepharon, we have successfully created new epithelial surface and fornices by auto-peritoneum transplants. These cases subsequently need cicatricial entropion correction and parotid duct transplants. In one such case we have been able to obtain 6/24 vision from a previous 'hand movements'.
Pathogenesis of trachoma pannus manifesting pleomorphic morphology is still not very clear. We feel that corneal trachoma as is evident clinically in this country, is not entirely a trachomatous process but probably a result of a complex mechanism requiring further elucidation. In recurring cases of corneal trachoma, medical treatment may not be sufficient. Combined technique of peritomy, massage of corneal blood vessels, thermocautery of pannus and coverage of exposed limbus with buccal mucosa would be more rewarding. The worst cases of this type would do better subsequently and would be saved from frequent relapses by the use of contact lenses. Cases suffering from recurring attacks of corneal trachoma need regular follow up and sooner or later may require therapeutic keratoplasty in addition.
| II. Ocular Surgery on Trachomatous Eyes|| |
Under this consideration, long standing cases of trachoma in a trachomatous country, when they have to be operated for cataract or glaucoma or any other ocular operation need more elaborate operative planning and also Greater post-operative care to prevent trachomatous conjunctivitis. Trachomatous eyes of course are no contraindications to these operations, provided they are performed in the correct perspective of trachoma.
In cataract cases we would recommend either corneal section with sutures or limbal section with a larger limbal based conjunctival flap. A complete iridectomy is preferable to a peripheral button-hole particularly if the section is scleral.
In glaucoma operations, where good subconjunctival filtration is the aim, a large conjunctival flap with undermining of the upper fornix conjunctiva is desirable. After completing the operation, Decadron solution 2 mg. should be left under the limbal conjunctiva.
In all intra ocular operations with a trachomatous background there is a greater incidence background post-operative conjunctivitis under the effect of the bandage. Ophthalmic ointments do not suit some of these cases and collyria should be preferred. In addition the bandage should be removed after the seventh day if otherwise permissible. These cases, in our opinion, do better if administered in addition, some of the long acting sulphonamides for about a fortnight after the operation.
| Summary|| |
Operative surgery in trachoma is discussed under two categories, (1) surgical correction of sequlx of trachoma and (2) ocular surgery on trachomatous eyes.