|Year : 1969 | Volume
| Issue : 3 | Page : 99-102
Entropion operation of upper lid in trachoma - a modification of 'inversio tarsi' operation
PK Mukherjee, PC Jain
Department of Ophthalmology, Medical College, Jabalpur, India
P K Mukherjee
Department of Ophthalmology, Medical College, Jabalpur
|How to cite this article:|
Mukherjee P K, Jain P C. Entropion operation of upper lid in trachoma - a modification of 'inversio tarsi' operation. Indian J Ophthalmol 1969;17:99-102
|How to cite this URL:|
Mukherjee P K, Jain P C. Entropion operation of upper lid in trachoma - a modification of 'inversio tarsi' operation. Indian J Ophthalmol [serial online] 1969 [cited 2013 May 25];17:99-102. Available from: http://www.ijo.in/text.asp?1969/17/3/99/38521
Trachoma is one of the commonest causes of corneal blindness in India. It is involved in one of there ways.
i. as superficial punctate epithelial and subepithelial keratitis due to the primary attack of virus on cornea.
ii. vascularisation and pannus formation.
iii. in the third stage, the stage of complications. Here again the corneal lesions result either as sequela of deformity of lid, or from dryness of the eye from partial to total destruction of secretory elements of the conjunctiva and partially to keratinisation of the epithelium.
Entropion and trichiasis are contributory factors in keeping the eye irritable due to constant rubbing against the already diseased, scarred and opaque cornea. Correction of the deformed lid therefore is an essential step for relief of constant pain, intractable lacrimation and photophobia, if not for restoration of vision.
The success of surgery of entropion of upper lid depends upon a clear understanding of genesis of formation of entropion and trichiasis. According to Kettesy  the turning of the tarsus appears late in trachomatous process preceded by a long and often stationary period during which the intermarginal surface gradually merges with the conjunctival surface of tarsus. Entropion is the end result of cicatricial contraction of the tarsal conjunctiva pulling the intermarginal strip upwards in inwards causing rounding off of the sharp inner edge. This in turn pulls the skin also. The cornea is rubbed by the rounded intermarginal strip along with the skin. It is but natural that the lashes are also misdirected. The change in the direction of the lashes begins in the hindermost row first. The thickness of the tarsal plate does not contribute much in genesis of entropion Goel  Torgersruud. 
Result of surgical correction of entropion of upper lid depends on the ability to undo the above process as far as possible and on maintaining a relative: position of ectropion.
The operations that are practised to correct trachomatous entropion of upper lid are divided into two groups
i. Correction from skin surface.
ii. Correction from conjunctival surface.
The latter is superior to the former Shukla.  The pathophysiology involved suggests that it is the conjunctiva and nearest part of the tarsal plate in which scarring process is located(Torgersruud) 
The operation 'Inversio tarsi' of Blaskowicz for entropion of upper lid is the key operation for various modifications of the conjunctival approach to entropion correction. ,,,
Kettesy  in 1948 used mattress sutures, Torgersruud  used modified sutures and called them `controlling sutures' to improve the 'inversio operation. Goel  utilised both types of sutures alternating with each other and attained better results.
The authors have been practicing Goel's modification for the last five years and have achieved excellent results. The modification which has been evolved is as follows. Rotation of the distal (lash bearing,) end of the tarsal plate by undermining it with the wedge of proximal (towards the fornix) end of the tarsal plate and keeping it in place by continuous suturing of the proximal tarsal plate to the undersurface of the skin bearing the lashes.
| Technique of Operation|| |
Lid spatula, needle holder, Bard - Parkar handle with knife, curved pointed conjunctival scissors, curved needle with cutting edges, fixation forceps, mosquito artery forceps, hypodermic needle, 2 ml. syringe and no. 1 silk.
1% anaethaine or 4% xylocaine is used to anesthetize the conjunctiva. 4% novocaine or 2% xylocaine with adrenaline is used to infiltrate the lids. Use of hyalase with xylocaine facilitates better spread of the anesthetic. One ml. of anesthetic is infiltrated in the lid from the skin surface infiltrating upto the tarsal plate through the orbicularis. Another ml is injected in the tarsal plate from one end to the other through conjunctiva after averting the lid.
The lid is everted over the lid spatula by means of two sutures passed on the border of the lid just above the lashes. Incision by a sharp knife is given on the sulcus subtarsalis along the whole length of tarsal plate parallel to the lid margin. [Figure - 1] A single firm stroke by a B.P. knife is sufficient to slice the tarsal plate, otherwise it can be completed with snips of the scissors. Care should be taken not to cut either the orbicularis or to buttonhole the skin. Bleeding if any is stopped by artery forceps.
Once the tarsal plate has been cut into two, proximal and distal parts, the next step is to undermine the distal edge of the proximal part of the tarsus by separating it from the orbicularis. This is achieved by holding the cut edge of the proximal part with fixation forceps and lifting it. Then the pointed ends of the scissors are introduced between the tarsus and the orbicularis. Simple spreading of the blades will separate the fibres of orbicularis from the tarsal plate. The dissection is carried out all along the length of the tarsal plate extending upto the skin bearing the lashes. Care should be taken not to damage the roots of the lashes. The proximal end is separated from the orbicularis for about a 2 mm distance along the whole width of the tarsus.
Suturing is started from the lateral edge from the skin surface of the lid. The thread bearing needle is passed through the skin amidst the lashes in such a way that the tip emerges between the distal part of the cut tarsus and the orbicularis. The needle traverses the space between the two cut edges of he tarsus over the orbicularis without picking it up.
On reaching the edge of the proximal tarsus the needle is passed through the tarsus 1 min away from the cut edge from the orbicularis surface to the conjunctival surface, perpendicular when it emerges on the conjunctival surface. The direction of the needle is then reversed and a similar bite is taken in the tarsus 2 mm. medial to the first bite and the needle is passed from the conjunctival surface to the orbicularis surface. It then passes over the orbicularis under the distal tarsus and emerges on the skin surface among the lashes. [Figure - 2].
Such three more sets of sutures are passed continuous with each other like a running stitch [Figure - 3]. The two ends of the thread are now pulled in a manner of purse-string resulting in drawing of the proximal tarsus under the distal edge and averting it sufficiently to cause correction of entropion and to produce relative ectropion of the lid margin [Figure - 4]. The two ends of the thread are tied together over the skin surface. The eye is dressed with antibiotic ointment and a pad and bandage are given for 24 hours. Thereafter the eye is left open with antibiotics only.
Sutures are removed on the seventh day by cutting the knot on the nasal side and pulling the thread out by a jerk from the temporal side.
| Advantages|| |
Only one needle and suture is required and it does away with the four sets of double armed sutures.  Since the knot is tied on the skin surface, it does not irritate the eye. The suture is removed with ease. Time consumed is less than ten minutes. The results are as good as any other modification for entropion of upper lid.
| Summary|| |
Genesis of trachomatous entropion of upper lid has been discussed. Various modifications of Blaskowicz's `inversio tarsi operation have been reviewed and a modification of the same has been described in detail.
| References|| |
|1.||Duke Elder W. S.: System of Ophthalmology. Vol. VIII. p. 278. Henry Kimpton, London (1965). |
|2.||Goel I.: Entropion Operation of the Upper Eyelid in Trachoma. Proc. AllIndia Ophthal. Soc. 17, 181-187, (1957). |
|3.||Kettesy A.: Genesis and Operation of Cicatrical (Trachomatous) Entropion of the Upper Lid. Brit. J. Ophthal. 32, 419-423 (1948). |
|4.||Larmande A. M.: Operation for Trachomatous Entropion-Trichiasis by Way of Conjunctiva - Trabut's Technique. Proc. All-India Ophthal. Soc. 17, 192-202 (1957). |
|5.||Torgersruud T.: Operation for Entropion of the Upper Lid in Trachoma. Brit. J. Ophthal. 34, 555-558 (1950). |
|6.||Shukla B. R.: Surgical Consideration in Trachoma Cases in India. J. All-India Ophthal. Soc. 12, 82-84 (1964). |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]