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ARTICLES
Year : 1981  |  Volume : 29  |  Issue : 4  |  Page : 385-387

Some observations on the common procedure of tarsal wedge resection for cicatricial entropion of the upper eyelid


Dr. Rajendra Prasad Centre for Ophthalmic Sciences. A.I.I.M.S. New Delhi, India

Correspondence Address:
S Ghose
Dr. Rajendra Prasad Centre for Ophthalmic Sciences. A.I.I.M.S. New Delhi
India
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Source of Support: None, Conflict of Interest: None


PMID: 7346465

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How to cite this article:
Ghose S, Sood N N, Dayal Y. Some observations on the common procedure of tarsal wedge resection for cicatricial entropion of the upper eyelid. Indian J Ophthalmol 1981;29:385-7

How to cite this URL:
Ghose S, Sood N N, Dayal Y. Some observations on the common procedure of tarsal wedge resection for cicatricial entropion of the upper eyelid. Indian J Ophthalmol [serial online] 1981 [cited 2019 Dec 11];29:385-7. Available from: http://www.ijo.in/text.asp?1981/29/4/385/30937

Trachoma is widely prevalent in India and cicatricial entropion is unfortunately a fairly common sequel, often presenting a challenge to the ophthalmic surgeon.

The most commonly practised primary operation for correction of entropion still remains that of tersal paring and wedge rese­ction with tarsoplasty.

Basically, for the operation to succeed, the amount of tarsal wedge resection must be judged well, the lateral limits of this wedge must be correctly placed, and the extent of skin muscle excision, if any, should be estimated carefully.

Skin- Incision

The skin incision should be at least 3mm above the upper lid margin to spare the roots of the cilia. It should extend parallel to the lid margin, 2mm beyond the line of cilia at the medial and lateral ends.

Problems with the entrotion clamp

It will be obvious that with the entropion clamp it is virtually impossible to include the medial and lateral ends of the lid, and thus, the tarsal paring falls short of the corners of the lid, often leaving an uncorrected entropion of these areas.

The clamp is usually placed after infiltra­ting the lid with local anaesthetic, and the tendency to some the force the clamp into position is to be avoided. It is better to first massage the infiltrated lid to reduce its boggi­ness to allow easy and correct placement of the clamp.

The correct size of the clamp is to be chosen. Too large a clamp has its obvious problems, and too small clamp leaves the corners inaccessible to surgery. If the superior fornix is not deep, it may be difficult to place the clamp.

With the clamp in place, the amount of skin muscle excision can be judged only very approximately. As the tissue planes do not slide and adjust spontaneously, the surgeon does not have any true indication as to whether the skin muscle excisipn is too little or too much. It is easily possible to err in either way, with too little an excision tending to produce undercorrection, and too much lead­ing to overcorrection, notching, and even vertical shortening of the lid.

Unduly excessive pressure of the clamp is to be avoided. At the same time, if the clamp is not tightened adequately, the tissue planes of the anterior and posterior laminae of the lid tend to slip and slide over one another, producing further difficulties in judgment of amount of tissues to be excised. It is to be emphasized that the clamp should not be allowed to get displaced during surgery, inten­tionally or otherwise. The clamp must not be loosened and then displaced laterally so as to make a corner of the lid accessible.

Tarsal paring

After the incision is completed, and the tarsus exposed adequately, tarsal paring is done, with due care so as not to perforate the tarsus. The instrument of choice is a small rounded blade. The deepest part of the wedge should be preferably near the lid margins. The lower border of the wedge should be placed 3 mm above the lid margin-a higher place­ment will reduce the efficacy of the correction. The upper border of the wedge should be approximately 3 mm higher in the centre, and lower down in the corners. After the wedge is fashioned, it is possibly easier to strip off the wedge working from both the ends and com­pleting it in the middle. A single-toothed fine forceps is used to grasp the corner of the wedge, and then to gradually shave it off. It is often useful to remember that the width of the wedge in different parts of the lid can be tailored according the variation of degree of entropion along the to length of the lid.

After the wedge has been removed, the edges of the grooved tarsus can be approxima­ted to check for the degree of correction achie­ved-if necessary, some more tarsal tissue can be pared off to give adequate correction. A slight overcorrection may be desirable, but a gross overcorrection should be strictly avoided. This important step of approximating the edges of the grooved tarsus to assess correction is more difficult with the clamp in position.

Suturing the tarsal groove

3 to 4 mattress sutures to unite the grooved edges may be evenly placed as a separate layer with 4.0 chromic catgut. If necessary, a few more interrupted catgut sutures may be used. The needles must be small and sharp enough to work on the tarsus smoothly without lacera­ting it.

If silk is used for the tarsus and the ends are passed out through the skin, care must be taken that they pass out above the line of cilia. It must be noted that, if such silk sutures are used, they should be cut late, about the 10th to 14th day, to allow sufficient time for the low grade tarsal tissue to heal well.

Operating without the Entropion Clamp

It is our experience that the operation can be efficiently performed without the use of the clamp. Local infiltration of xylocaine is a great help in stopping troublesome oozing.

After infiltration and massage, 3 equidi­stant traction sutures are passed through the full thickness of the lid at the lid margin, and pulled down to gently stretch the upper lid, keeping a lid spatula underneath for support. The sutures together with the other end of the spatula can be clipped to the eye-towel after adjusting the tension, thus not necessitating the need of an assistant merely to hold these sutures. If the spatula has perforations at its sides, the traction sutures may be passed through these, and secured to the eye-towel.

These sutures can be released from the eye-towel at any desired stage of the operation, so that the tarsal wedge resection can be correctly gauged. The whole length of the tarsus can be uncovered end to end, thus making the corners also freely accessible to surgical correction.

Only after the tarsal paring is completed and the chromic catgut mattress sutures placed, should the amount of redundant skin muscle to be excised be assessed on the lax lid, without the clamp hampering in any way. The skin muscle is closed with silk in a separate layer. If deemed necessary, the lower skin muscle edge can be anchored to the upper tarsus, to leave the skin near the lid margin taut.

The skin sutures may be removed within a week, and the separate deeper tarsal layer of chromic catgut sutures takes eare of the hea­ling of the low grade tarsal tissue.

It may be felt that with a clamp in place, bleeding is less of a problem. It should be remembered that when the clamp is taken off, generalised oozing is often troublesome.

In our experience, without a clamp, bleeding has not been a problem, no more than in any lid surgery where no clamps are used, specially if a little adrenaline is also infiltrated.


  Summary Top


Tarsal wedge resection for cicatricial entropion of the upper eyelid is an operation very commonly left to be taken care of by relatively inexperienced ophthalmic staff in large hospitals.

In this paper, we have tried to point out the various problems and pitfalls of this `minor' operation, especially when done with the entropion clamp, and to make some observations on steps which should be taken to obviate these.

We feel that operating without the clamp, and suturing in two layers, not only give more satisfactory results, but would also go a long way to prevent the problems of mismanaged cicatricial entropion of the upper eyelid.




 

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