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ORIGINAL ARTICLE
Year : 1984  |  Volume : 32  |  Issue : 3  |  Page : 157-160

Management of large lid colobomas following entropion surgery


Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
S M Betharia
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences. New Delhi-110 029
India
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Source of Support: None, Conflict of Interest: None


PMID: 6519731

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How to cite this article:
Betharia S M, Kalra B R. Management of large lid colobomas following entropion surgery. Indian J Ophthalmol 1984;32:157-60

How to cite this URL:
Betharia S M, Kalra B R. Management of large lid colobomas following entropion surgery. Indian J Ophthalmol [serial online] 1984 [cited 2020 Aug 6];32:157-60. Available from: http://www.ijo.in/text.asp?1984/32/3/157/27410



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The large colobomas produced after entro­pion surgery are not very common in present era. The purpose of this communication is to present 4 such cases of large colobomas seen and to highlight the genesis of their occurren­ce. the severity of the complications produced and the surgical management by plastic repair of lid.


  Materials and methods Top


Four cases of large colobomas of lids following entropion surgery were operated upon (Table 1).


  Operative technique Top


The operation done for the repair of large colobomas present in these cases was a two stage procedure utilizing lower lid for reconstruction of upper lid. The standard method described by Cultler & Beard[1] was used in all cases. In the first stage the margins of the colobomatous defect were made raw converting the semilunar defect into a rectangular one. A full thickness flap of the lower lid was fashioned leaving about5 mm of the area below the lid margin in the form of the handle of the bucket and giving 2 vertical incisions on the sides. The full thickness flap was brought into the area of the defect by slid­ing it beneath the handle after its mobiliza­tion. It was sutured in 2 layers. The tarsoconjunctival layer was sutured with 5-0 chromic catgut and the skin muscle lamina with 4-0 black silk. The skin of the handle was undermined and a continuous 5-0' black silk suture was passed so that no raw area remained in the handle. During second stage of surgery the flap is cut in the middle with the convexity downwards after supporting the flap by iris repositor so that the cornea is not injured. The lower edge of the handle is made raw and is attached to the lower flap. We have not done cilia transplantation in these cases.


  Discussion Top


The most common type of operation done for cicatricial entropion of upper lid is the wedge resection of tarsal plate. The large coloboma of lid produced in such an opera­tion is due to inadvertent excision of the lid margin.

Irregular lid margin and small lid notches are commonly seen after entropion surgery. The Snellen's entropion clamp used routinely for this surgery though is self retaining, haemostatic and gives support to the lid tissue to facilitate the wedge resection and protects the globe, suffers from the various disadvan­tages[2] that is (1) the complete length of the lid margin cannot be tackled (2) the Exact amount of wedge required for proper correc­tion cannot be judged (3) can cause ischaemic necrosis if the screw is tightened too much or if the -surgery is prolonged. The adrenaline mixed with xylocaine adds to the factor of ischaemia due to vasoconstriction (4) the clamp if slips during surgery is difficult to reapply again. The type of colobomas seen in our cases were however quite large and we feel that apart from the usual causes of pressure necrosis or infection in the postoperative period or very tight sutures, [ 3] advertent chop­ping of the affected lid margin seems to be a possible cause. All these colobomas had typi­cal appearance that they were semilunar in shape, situated in the central part of lid involving almost whole of lid except the extreme corners where the lid margin was showing entropion and trichiasis without any scar on the skin above the lid margin.

The management of these patients posed various problems specially in 2 cases where there was bilateral colobomas. All these patients have presented to us within 2 to 6 months period after the entropion surgery by which time severe exposure keratitis causing marked diminution of vision even upto the extent of perforation of corneal ulcer in one case (case no. 1) has occured. Secondary infection was the second problem as shown by case I and 3 where staph. aureus was cultured from conj. sac of both eyes. The bilaterality of coloboma posed another pro­blem in 2 cases (1 and 3) because as the plastic repair needed for these cases required closure of the globe for at least 6 weeks at the same time protection of the other globe and allow­ing some visual function so that patient can remain mobile during that period of 6 weeks when the second stage of the Cutler Beard operation can be taken up in one eye along with stage I in the other eye during the same hospital stay. To solve this problem in bilateral cases we have advocated bandage lens with inverse Frost suture in case no. I to allow the corneal ulcer to heal and parame­dian tarsorrhaphy to protect the globe at the same time maintaining the visual function.

To avoid this major complication the blood supply of lid coming from marginal arcade must he taken care of and the dissec­tion lower down towards the lid margin should he careful so as to avoid the damage to the marginal arcade.


  Summary Top


Four cases of large colobomas of upper lid following entropion surgery are presented to highlight their possible etiopathogenesis, the serious complications caused by them and their surgical management. The emphasis is laid on the preservation of the blood supply of lid coming from marginal arcade which seems to be of major importance in causation of such large colobomas.[3]

 
  References Top

1.
Cutler N.L., and Beard C., 1955, A method for partial and total upper lid reconstruction. Amer. Jour. Ophthalmol.' 39: 1.  Back to cited text no. 1
    
2.
Ghose S., Sood N.N., and Dayal Y., 1981, Indian J. Ophthalmol. 29:385-387.  Back to cited text no. 2
    
3.
Weiner M. Surgeiy of the eye, 1949, Grune and Strat• Strat­ton, New York. 210:247.  Back to cited text no. 3
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1]



 

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